Every finding on record at Maple Lawn Medical Care Facility

Based on observation, interview, and record review the facility failed to implement interventions to prevent accidents for two residents (#2, #6) of three resident reviewed for accidents resulting in major injury (fracture and brain bleed) and hospitalization for resident #2.Findings Included: Resident #2 Review of the medical record demonstrated R2 was admitted [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), dementia, repeated falls, constipation, psychotic disorder with delusion, hypothyroidism (low thyroid hormone), vitamin D deficiency, chronic kidney disease, depression, gastro-esophageal reflux, osteoarthritis (arthritis that occurs when flexible tissue at the end of bones wears down), chronic pain, hyperlipidemia (high fat content in blood). Review of the medical record revealed a recent hospital leave on 06/30/2025 and a readmitted on [DATE] with new diagnoses that included displaced fracture of lateral end of left clavicle, intercranial injury, and fall on same level. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) for 07/28/2025 revealed a Brief Interview for Mental Status (BIMS) 7 (severe cognitive impairment) out of 15. Review of the medical record revealed progress note 06/30/2025 at 09:15 (a.m.) Note Text: (Physician name) made aware of resident fall, hematoma to L lateral head, pain to L shoulder/neck, and discoloration/lack of ROM to L arm. DRR completed, new order received: Send to ER for eval and treat.Call placed to (name of ambulance company) at 0847.EMS arrived at 0855. R2's medical record also revealed progress note 06/30/25 at 10:46 (a.m.)Note Text: Called to residents room by staff at approx. 830am, resident was noted laying on bathroom floor on right side with head near toilet and feet near the door. Upon assessment resident noted with skin tear to L elbow approx. 0.5cm in diameter, LUE noted discoloration to length of arm. Area was cleansed with NS pat dry and CDD applied. Resident also noted with hematoma to L side of head measuring approx. 5cm in diameter. Resident denied pain at first, but when trying to move LUE resident c/o pain to neck and shoulder. HS called and down to assess. Unable to assess residents other extremities at this time d/t going to hospital. Neurological assessment WNL for resident. VS: 97.5, 66, 22, 111/60, 90%RA. BG. 138. Review of R'2s medical record revealed a progress note 07/03/2025 at 15:43 (03:43): Received report from (nurse at hospital). Resident admitted to hospital with a brain bleed (has resolved), and left clavicle fracture. Review of R2's plan of care revealed a problem statement written 04/7/2025 which stated: I am at a risk for falls r/t impaired mobility, incontinence, hx of falls at home, diagnosis' (dementia, CVA), potential medication adverse effects (antidepressant, antiplatelets, antiHTN, diuretic). I am impulsive (sp) and self-transfer despite reminders/education which increases risk. R2's care plan also revealed a written intervention with an initial written date of 04/7/2025 I need a safe environment with non skid footwear, paddle call light left within reach, FWW left within reach, safety frame to toilet, bed control out of my reach, facility WC with anti roll back, B standard footrests and standard cushion, Wide bed with Raised perimeter overlay to mattress, Safety reminder sign to bed side table. Safety reminder sign to bedside wall. Res. to have fan on in room as tolerates. Res. to have urinal at bedside. Safety reminder sign to FWW. Low to floor bed with fall mat. My preferred method of transfer from bed is to put knee's onto bedside mat prior to getting up. **15 Minute checks** . Review of provide incident report revealed R2 was found on the floor on 06/30/2025 at 08:30 a.m. and had experienced an unwitnessed fall. The same incident report included a section entitled, any other information or specific factors that may have contributed to this fall? which revealed, 15 min checks not done during time. The same incident report included a section entitled, root cause of fall, which stated, Poor safety Awareness. During an interview on 08/27/2025 at 01:04 p.m. Director of Nursing (DON ) B reviewed the facility investigation file regarding R2's fall on 06/30/2025. She explained that the root cause of R2's fall was reviewed by the Interdisciplinary team and was to be determined that the cause was R2's poor safety awareness and lack of interventions that had been implement that were listed on his plan of care. DON B explained that disciplinary action had been conducted because 15 min check had not been completed, as specified on the plan of care, since 07:45 a.m. and the fall occurred at 08:30 a.m. DON B provided a document entitled Written Record of Written Warning that had been provided to Certified Nursing Aide (CNA) H. The same document revealed the name of CNA H, the date of 06/30 and stated Summary of event and education provided to staff member(s): Staff to make sure to follow care plan & 15 min checks. If unable , to communicate with staff on hall so we can do the check. *3 day suspension. On 08/27/2025 02:37 p.m. during an attempted interview R2 was observed lying down in bed. It was observed that his bed was against the wall, a perimeter mattress was in place, the bed was in a low position, a fall mat was on the floor next to his bed and his pressure pad call light was within reach. Resident did not respond to verbal stimuli and appeared to be sleeping. During a telephone interview on 08/27/2025 at 02:43 p.m. Certified Nursing Aide (CNA) H explained that she had been providing care to R2 on the date of 06/30/2025. CNA H explained that she was in a room assisting another resident when she was notified that R2 was found on the floor. CNA H explained that she had last completed R2's 15-minute checks at 07:45. CNA H explained that she had been received disciplinary action for not following R2's plan of care and had also received a 3-day suspension. Resident #6 (R6) Review of the Resident #6 (R6) clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident #6 (R6) had long and short-term memory impairment and severely impaired decision-making skills for daily living. R6 was admitted to the facility with diagnoses that included dementia and resided in the facility secure unit. On 08/25/2025 10:54 AM, R6 was observed in the facility's secured memory care unit, attending a music program. A large purple bruise was observed to R6's right eye, along scrap/small abrasion to the nose. On 08/25/2025 at 11:37 AM, during a phone interview with R6's representative, family member L reported being made aware that R6 fell on 8/21/25 while walking with a new Certified Nursing Assistant (CNA.) but was not exactly sure or how the fall occurred. On 08/26/2025 at 10:27 AM, video footage of R6's fall was observed in the Nursing Home Administrator (NHA) A office with NHA A and DON B present. NHA A explained the CNA on camera walking with R6 was a high school student and part of the OJT, NHA A explained OJT stood for On the Job Training, and the local high school had a career center program and the facility hired from there. The camera footage showed unidentified CNA from the OJT program standing with R6 holding R6's hand and touching residents' side, resident wearing a gown no gait belt was in place. The footage showed R6 by the dining room/living room area and slowly R6 turned and fell. DON B was queried at that time if the facility used gait belts DON B said yes. When queried if R6 was to have a gait belt on while ambulating DON B said yes and the CNA from the OJT had since been educated. Review of R6's care plans did not have the use of a gait belt as an intervention for fall prevention or care. On 08/26/2025 at 1:48 PM, during an interview with DON B she reported the use of a gait belt was not implemented on a care plan because it was standard of practice and the expectation. On 8/26/25 at 2:20 pm during an interview with CNA M she reported R6 ambulated very slowly with no devices (walker, cane) but staff were to always make sure a gait belt was used. When queried if that was something new, CNA M stated no they aways had to use a gait belt with R6. Review of the incident report dated 8/21/25 revealed R6 was ambulating with staff, and a gait belt was not in use at the time of the fall. R6 sustained a 4 by 3-centimeter hematoma and a bump to the right-side of the forehead. The section of the form titled Root Cause was left blank, the section of the form title intervention the box staff education was marked and in all capital, letters read MUST SPECIFY of note, there was no specific education listed.

Based on observation, interview and record review, the facility failed to provide notice of discharges and transfers, to the representative of the Office of the State Long-Term Care Ombudsman.According to an email from the Long-Term Care Ombudsman, received on 8/22/25, the facility had not been sending notices for transfers and discharges and that they did not have any notices on record for 2024 or 2025.On 8/26/25 at 12:03 PM, the Nursing Home Administrator (NHA) was asked who is responsible for notifying the ombudsman of discharges and at 12:32 PM NHA reported that the ombudsman is emailed on a monthly basis either by herself or by the social worker. When asked to provide the monthly emails dating back to their last annual survey, NHA reported that they only had 2 on file. Those emails were provided and were dated 8/14/25 and 8/26/25.On 8/27/25 at 2:25 PM NHA was asked if the facility had a policy related to Ombudsman notification and at 2:36 PM NHA reported that they do not have a written policy regarding Ombudsman notification.On 8/27/25 at 2:39 PM, during an interview with Social Service Director (SSD) N, they reported that they were responsible for notifying the Ombudsman of discharges and transfers. SSD N further reported that notification should be done monthly. When asked if that had been occurring SSD N reported that it is sometimes done. When asked why it wasn't done consistently each month, they reported that they forget.

Based on observation, interview and record review, the facility failed to ensure clinical rationale was documented by the provider for ongoing use of an as needed (PRN) anti-anxiety medication beyond 14 days, for one resident (resident #6) of four residents reviewed.Findings include: Review of the clinical record revealed R6 was admitted to the facility on [DATE] with diagnosis of that included Alzheimer's dementia. R6 's Minimum Data Set with an Assessment Reference Date (ARD 5/24/25 reflected R6 had long and short-term memory impairment and severely impaired cognitive skills for daily decision making. Further review of the clinical record reflected R6 was prescribed Ativan on 7/25/25 0.5 milligrams as needed three times a day for restlessness and anxiousness, a urinalysis was also ordered R6 on 7/25/25 and an anti-biotic was ordered on 7/26/25. Further review of the clinical record did not include rationale from the Physician/ provider for continued us of the PRN Ativan beyond 14 days of the mediation being ordered. On 08/26/2025 9:57 AM, during an interview with the Director of Nursing (DON) B the concern of the ongoing use of the PRN Ativan was discussed and DON B stated the facility still used paper charts as well. Review of the hard/paper copy of R6's medical record contained a most recent visit by Psychiatry on 2/6/25 and a Physician visit dated 6/26/25. On 08/27/2025 10:25 AM, during an interview with Social Worker (SW) K she reported that the Nurse contacted the Physician on 7/25/25 regarding R6 having increased agitation/restlessness and that was why the Ativan was ordered PRN, when queried why there was no stop date for the Ativan SW K stated she was not sure, but R6 had a lot of anxiety and agitation. When quired about R6 simultaneously having had a urinalysis done on 7/25 and an antibiotic prescribed the following day to treat a urinary tract infection, it was asked of the infection could cause or contribute to agitation/restlessness. SW K responded that R6's family member got married in the facility's courtyard on 8/8/25 and the family member wanted R6 to be able to participate in the wedding but was now considering comfort care. A request for documentation from the attending physician/prescribing practitioner for rationale to extend the use of the Ativan was requested and not received by the end of the survey. A follow up interview was conducted with DON B who reported the Ativan continued beyond 14 days due to the family member getting married and now that that has occurred R6 will now be changed to comfort care, and the Ativan order will change.

Based on observation, interview, and record review the facility failed to complete a Significant Change in Status Assessment (SCSA) for one resident (#91) of 15 resident's Minimum Data Set (MDS) reviewed.Findings Included:Resident #91 (R91)Review of the medical record demonstrated R91 was admitted to the facility 01/31/2025 with diagnoses that included atrial fibrillation, hypothyroidism (low thyroid hormone), gastroesophageal reflux, chronic pain, sacral pressure ulcer, osteoarthritis (arthritis that occurs when flexible tissue at the end of bones wears down), hyperkalemia (high level of potassium in blood), bradycardia (heart rate below 60 beats per minute), history of pace maker, and urinary retention. Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/07/2025 revealed a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact) out of 15. Review of R91's medical record revealed that an Unstageable pressure wound to his coccyx had been identified on 07/10/2025. The most recent completed skin evaluation completed on 08/25/2025 revealed that the coccyx wound had progressed to a stage 4. Review of the medical record revealed R91 had a recorded weight (wt) of 168 lbs. (pounds) on 07/03/202 and a recorded weight of 153 lbs. on 08/07/2025. Review of progress notes dated 08/25/25 revealed: Note Text: WT:153# (8/7) wt. is down 9% x 30 days, down 16% x 90 days & down 15% x 180 days.Review of the most recent completed MDS (quarterly MDS), with an assessment reference date (ARD) of 08/07/2025, revealed section M-Skin Conditions was documented as having one unstageable pressure ulcers. Review of section K-Swallowing/Nutritional Status, with the same ARD, revealed documentation that R91 had greater than 5% weight loss in the last 30 days.Review of R91's Minimum Data Set history did not demonstrate that the facility had completed a Significant Change in Status Assessment (SCSA). Review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1 dated October 2024 revealed Some Guidelines to Assist in Deciding if a Change is Significant or not: Decline in two or more of the following: .-Emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days). -Emergence of a new pressure ulcer at Stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status.In an interview on 08/26/2025 at 10:58 a.m. MDS Nurse D was asked review R91's last MDS, with an ARD of 08/07/2025. MDS Nurse D confirmed that the quarterly assessment revealed that R91 had an unstageable pressure ulcer and a 5% weight loss in the last 30 days. When asked why a Significant Change in Status Assessment (SCSA) MDS was not completed, MDS Nurse D could not explain why it had not been completed.

This citation pertains to intake number MI00152699. Based on interview and record review the facility failed to ensure one out of three residents (Resident #2) was able to exercise resident rights and be treated with respect and dignity. Findings Included: Review of the facility documents revealed Resident #2 (R2) had resided at the facility since [DATE], and had a diagnosis of dementia and behavior disturbances. R2 was deceased at the time of the onsite investigation. Review of a facility investigation revealed that on [DATE] Medical Assistant (MA) C reported that Licensed Practical Nurse (LPN) D entered R2's room while she was in the room to administer medications to R2. MA C reported that R2 was lying flat in bed when LPN D gave R2 a pill, and told R2 that was a new stomach pill that he needed to take. MAC further reported that LPN D used vulgar language and told R2 that he must swallow the pills. MA C reported that R2 told LPN D that she was killing him. The investigation concluded that R2 had no recollection of the incident when Social Worker (SW) E followed up with him. In an interview on [DATE] at 9:30 AM, MA C stated she was in the room when LPN D entered to give R2 his medications. MA C said R2 had to swallow a pill which was a new pill that, and was the only pill that could not be crushed so he had to take it whole. MA C said R2 was not able to swallow the pill, and told LPN D he could not swallow the pill over and over multiple times. CNA C said R2 was lying flat, and water was running out of his mouth down to his chest, while LPN D kept telling him that he needed to swallow the pill. MA C said R2 just kept saying several times, that he could not. MA C said LPN D used vulgar language and told R2 to take his pill. An attempt was made on [DATE] at 10:04 AM to contact LPN D but was not successful. Review of LPN D's education revealed that LPN D had been education in resident rights in 2022, 2023, and 2024. LPN D was terminated from the facility on [DATE]. The reason for termination was mistreatment of resident.

This survey pertains to intake MI00146629. Based on observation, interview and record review, the facility failed to develop and implement person-centered care approaches for one resident (Resident #1) with dementia of three reviewed. Findings include: Review of the medical record reflected Resident #1 (R1) admitted to the facility on [DATE], with diagnoses that included Alzheimer's. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/17/24, reflected a Brief Interview for Mental Status (BIMS-a cognitive screening tool) should not be completed, as R1 was rarely/never understood. The same MDS reflected R1 had short-term and long-term memory impairments and severely impaired cognitive skills for daily decision making. On 9/5/24 at 12:08 PM, R1 was observed seated in her room, in a Broda chair (specialty chair). A staff member was observed to propel R1 to the dining room, while seated in the Broda chair. A hoyer (mechanical lift) lift sling was observed beneath R1. She was wearing padded arm protectors on both arms. On 9/6/24 at 9:26 AM, R1 was observed seated in a Broda chair, in her room. A hoyer lift sling was beneath her. She was wearing a long sleeve shirt, and a padded arm protector was observed on her right arm. R1 did not verbally respond when spoken to and kept her eyes closed. The left side of her bed was observed against the wall. A nightstand was observed approximately one foot away from the right bedside, near the head of the bed. An Incident Report, dated 8/26/24 at 7:50 AM, reflected staff was providing morning care, and R1 became combative and began hitting and squeezing her arm. When staff was putting R1's shirt on, blood was observed. The report reflected a skin tear injury to the right forearm, measuring 4.5 inches in length by 4 inches in width and 1.5 centimeters deep. An emergency room note for 8/26/24 at 9:16 AM reflected R1 presented with an extremity laceration. The documentation reflected the tissue was avulsed (torn away) to the subcutaneous fat (beneath the skin), and muscle was exposed. The note further reflected, .Given the depth of the laceration, concern was it needed repaired . An emergency room note for 8/26/24 at 1:10 PM reflected R1 was seen in the Emergency Department with a large laceration/avulsion to the right forearm. The wound was cleansed and closed using a combination of deep sutures, which would dissolve on their own, and sutures on the skin that were to be removed in 10 days. During an interview on 9/6/24 at 9:52 AM, Certified Nurse Aide (CNA) I reported R1 required total assistance from staff for care. She reported R1 had behaviors of being combative with care, swatting at staff, twisting the arms of staff, as well as twisting her own arms. CNA I stated she went in to provide care around 7:35 AM to 7:40 AM (on 8/26/24). While washing R1, she began swatting at CNA I and hitting and twisting her own right arm, using her left arm to do so. CNA I reported she had visualized R1's skin prior to the start of care, and no skin tears were noted. While putting R1's shirt on over her right arm, she observed blood. When she pulled R1's sleeve back, she noticed a huge skin tear, then went to the hall to get the nurse. CNA I reported seeing muscle tissue and bright red blood. CNA I stated she did not see R1's injury occur but observed R1 twisting her arm while care was being provided. CNA I reported she would normally call a second CNA in to help but could not find anyone to help her with care. When R1 became combative, CNA I stated she tried to reassure her that she was getting washed up for breakfast, that it was ok, and she (CNA) was trying to help her. CNA I reported she continued providing care to R1 that morning as she exhibited behaviors throughout the care. CNA I stated she did not stop performing R1's care that morning but probably should have, per her report. CNA I reported R1 exhibited behaviors with care pretty much daily, each time care was performed. She stated other shifts also reported the same behaviors. CNA I stated she had reported behaviors to the nurses but was unsure if anything was documented. During an interview on 9/6/24 at 12:00 PM, Registered Nurse (RN) G reported being the charge nurse the morning of 8/26/24. She reported CNA I was providing perineal care to R1, while R1 held a stuffed dog in her arm. She was notified by CNA I that blood was observed on R1's arm protector. RN G reported observing a softball sized saturation of blood and stated R1's arm was still bleeding and dripping onto her sheets. RN G reported R1's right hand was on her stuffed dog, and her left hand was squeezing her right forearm. Blood was observed around the cuticles, fingernails and under all five fingers of R1's left hand. Upon assessment, RN G stated adipose (fatty) tissue was noted on the skin flap. Under the deepest part, muscle and tendon were visible. According to RN G, CNA I did not know what happened and stated the injury was not present at the start of care. RN G reported the Physician assessed R1's arm and ordered for her to be sent to the emergency room . RN G reported R1 could become aggressive and liked to grab onto herself, such as her thumb, fingers, pant legs, shirt, bed sheets or the clothing of staff. She stated she always made sure R1 had something to hold onto to calm and soothe her. If that did not work, she would reapproach. In an interview on 9/6/24 at 12:17 PM, Social Worker (SW) H stated staff had not reported physical behaviors during care to her, for R1. She reported she previously stopped having staff chart behaviors on a sheet (behavior log) for R1 because they were all blank, but behaviors would be documented in the medical medical record. During an interview with Nursing Home Administrator (NHA) A and Director of Nursing (DON) B on 9/6/24 at 1:23 PM, it was reported that staff training for the care of residents with dementia and behaviors included, if a resident was refusing or if there were issues during care, staff should ensure resident safety, leave, reapproach them or have other staff reapproach them and possibly having the resident hold onto something soothing. Record review reflected CNA I completed training related to dementia care, including but not limited to, Handling Difficult Behaviors in Residents with Dementia on 5/22/24.

Based on interview and record review the facility failed to provide appropriate infection surveillance for all residents (100 current residents) and take appropriate actions to track, trend, and formulate corrective actions to decrease the spread of nosocomial infections in the facility. Findings Included: During an interview on 08/15/2025 at 09:32 a.m. Infection Control Preventionist (ICP) C explained that he had been in his current position since February of 2024 and was responsible for the data collection and review of information regarding infections in the facility. ICP C explained that he reviewed the data and would identify trends that potentially required interventions to prevent further spread of infection. ICP C explained that the Infection Control Committee met a monthly, through the Quality Assurance Committee, and a report was provided to the committee monthly. ICP C was asked for the latest monthly report that was presented to the Infection Control Committee. ICP C explained that the last written report that was completed was February 2024. When asked why the other months were not available ICP C explained that he had been busy and had not had time to complete the reports but had verbally reported to the Infection Control Committee and Quality Assurance Committee for each month since February 2024. When asked if there were any trends for facility acquired infections ICP C explained that he had not identified any trends. Review of the facility Line Listing of facility use of antibiotics demonstrated nosocomial (infections acquired in the facility) infections rates of 11.63% for February 2024, 3.27% for March 2024, 5.72% for April 2024, 7.74% for May 2024, 7.36% for June 2024, and 10.2% for July 2024. No report was provided for the root cause of increase in nosocomial infections. The same line Line Listing demonstrated urinary tract infections with out catheters to be 3 in March 2024, 7 in March 2024, 6 in June 2024, and 10 in July 2024. No report was provided for the root cause of increase in nosocomial urinary tract infections in resident without catheters. No report was provided to identify actions taken by the facility for the increase in nosocomial infection rates or for increase in nosocomial urinary tract infections in resident without catheters. Review of the facility provide maps of infections by location demonstrated a legend that include C=Community Acquired and I=In-House Acquired. Review of infection maps for March 2024, April 2024, May 2024, and June 2024 did not demonstrate and C or I on the map. Review of the Quality Assurance Minutes for April 2024, May 2024, June 2024, and July 2024 each demonstrated Reports present for (date) meeting. Each month demonstrated under the above section demonstrated Infection Control- (Name of ICP C presented this report. In an interview on 08/15/2024 at 11:18 a.m. Director of Nursing (DON) B explained that it was the expectation that ICP C provide a monthly report that is to be provided to the Infection Control Committee and the Quality Assurance Committee. DON B explained the report should include nosocomial infection rates, trends, and identified corrective action to prevent the further spread of infection. DON B explained that she was aware of the increase in nosocomial urinary tract infections without catheters and explained that she had identified the concerns on the one of the units. DON B could not provide any education or actions that were taken in response to the increase in identified concerns. DON B could not explain why the provided facility maps did not include they type of infections, as listed in the map legend as 'C-Community Acquired or I-In House Acquired. DON B could not explain why the Quality Assurance Minutes demonstrated Infection Control- (Name of ICP C presented this report was recorded in the minutes even though no report was completed for each month after February 2024.

Based on interview and record review, the facility failed to ensure adequate staffing to provide restorative/mobility services and choice of shower frequency, in a sample of 20 residents and a census of 100 residents, resulting in resident choices not honored, unmet goals, and the likelihood for functional decline. Findings include: In review of the Facility assessment dated [DATE], the facility had 114 licensed beds and the average daily census was 104. The same assessment revealed services and care offered were based on resident needs and preferences; and 102 residents required assistance with bathing. The same assessment indicated specific mobility program was offered per individual resident needs that included transfers, ambulation, contracture prevention/care. The same facility assessment indicated there were zero restorative nursing assistants and would add two staff once staffing levels were reached. Mobility Registered Nurse (RN) D was interviewed on 8/15/24 at 9:37 AM and stated she was pulled from restorative/mobility care to work as the floor nurse approximately twice a week and there were residents that had not received mobility services as recommended by therapy due to staffing. 45135 During an interview on 08/15/24 at 10:54 AM, DON B stated they did not on the restorative plan, they haven't have a restorative program since January 2024. DON B also stated they have a mobility program but had to step away from it because they needed to have the Certified Nursing Assistant (CNA) working on the floor taking care of residents' DON B stated they encourage staff to walk residents right now. During an interview on 08/15/24 at 1:19 PM, Registered Nurse (RN) and mobility coordinator D, stated she works alone in the mobility program. RN D also stated she can get eight to ten residents seen in one day. RN D stated that staffing had been so bad that she got pulled to the floor once to twice a week, sometimes three times in a week. RN D stated ideally, they could have had 30-40 residents in the mobility program a week. RN D added that the restorative program stopped the end of last year sometime. RN D stated she had no backup, so when she is pulled to the floor, the CNA's try to walk residents if they had time. 49103 On 08/13/24 at 11:07 AM an anonymous resident was interviewed and was asked about choices concerning bathing. The anonymous resident said two showers per week would be preferred and explained that staff have said there is not enough staff . to provide two showers per week. Review of the Electronic Medical Record (EMR) for a period going back of 30 days confirmed the days of the week resident said the showers occur and that they have been documented as having been given only once per week. On 08/13/24 at 2:13 PM an anonymous resident was interviewed and talked about showers. I get one shower a week. I have said I would like two showers a week. The anonymous resident then explained the person spoken to was a shower attendant who said there was not enough staff to give two showers per week. According to Electronic Medical Record (EMR) on 8/13/24 the anonymous resident has a Brief Mental Status Interview score of 15/15 indicating intact cognition. The EMR review of a 30-day period confirmed documentation of once a week tub baths on 4 separate dates, not showers. On 08/15/24 08:47 AM during interview with Registered Nurse (RN) Supervisor J staffing was discussed. RN J explained that normally there are two staff members scheduled for day shift to work on the baths and showers. RN J said if they can't complete required showers/baths on that shift then the showers or baths get placed for the next shift. RN J also said those scheduled to work on baths and showers are not on the unit taking an assigned group for general care. They are scheduled to focus on the baths and showers. When asked about residents who would like more than one bath per week RN J said, If there is a request and if we have the extra space we do our best to accommodate them. And added that is especially true if the resident has an event of some kind like a family event or something going on. and added, We have had a few residents who get more than 1 shower a week due to infections.

Based on observation, interview, and record review the facility failed to allow one out of two residents (R9) to relocate to a chosen room of 2 residents reviewed for choices resulting in emotional distress manifested as frustration, anger, and depression. Findings include: On 8/13/24 at 12:15 PM R9 was resting in bed, awake and able to participate in an interview. R9 was asked how things were going and responded, Not good! R9 talked about his wife who was a resident on another hall. I was supposed to be able to move to a room across from her R9 explained. R9 said that during the time the move was anticipated the Administrator canceled the plan and I was never told why. R9 said he sees his wife (R27) and when they are together . we cry every day. R9 went on to describe a marriage of [AGE] years with deep commitment and bonding that leaves him feeling empty without her near presence. On 8/13/24 record review of the Electronic Medical Record (EMR) revealed R9's admitted as 2/6/23 and with pertinent diagnosis of Major Depressive Disorder (Recurrent, unspecified). According to the Brief Mental Status Interview (BIMS) documented 5/14/2024 R9 has a score of 15/15 indicating intact cognition. On 8/14/24 at 9:10 AM R27 was observed resting upright in bed ready for breakfast. R27 was smiling and establishing strong eye contact; able to participate in an interview. During interview R27 said the only concern is to be with my husband. R27 talked about the fact they are both getting older. If we are closer, I can keep an eye on him, and he can keep an eye on me. and added We love each other so much! R27 talked about the many enjoyable times the two spend together. According to EMR review R27 had an admitted [DATE]. On 8/14/24 at 1:23 PM an interview was held with the Nursing Home Administrator (NHA) A of the facility who recalled the previous plan to move R9 to a room across from wife (R27). NHA A explained the plan was canceled due to protestations of the family of R27 when the plan was talked about and during this period R27 decided in agreement with family. On 8/14/24 at 3:07 PM, an interview with the Social Worker (SW) E during which there was discussion of R9's unhappiness with the cancellation of a plan to move. SW E explained R27 had at one point been okay with the plan to move him closer. R27 then conferred with family, and both decided to not recommend him to be closer. SW E talked about the fact the two spend significant time together. On 8/14/24 record review of the EMR disclosed a psychiatry note entered 3/11/24 by Nurse Practitioner (NP) G which contained the following: Resident was evaluated while laying in bed in the dark and quoted resident as saying he had been lied to having been told he could have the room across from his wife and it was given to someone else. Resident stated, I'm worse than I've ever been. It was documented that resident missed his wife and was not sleeping well. In the Assessment and Plan portion of the note, NP G documented that Some of the sadness is situational and would benefit from weekly psychotherapy. I encouraged him to visit his wife daily. On 8/15/24 at 12:35 PM a subsequent interview was held with SW E and the question was asked if aside from voiced family concerns about the previous proposed move, if R9 had a right to the choice to move into the room he wanted. SW E responded, Yes, technically he had the right and added he would not have had the end result (to be near his wife) he was seeking. We would have moved his wife to another room the same day. Record review disclosed a Behavior Note entered 2/26/24 which stated the following: Resident states he wants to move to room closer to wife and that he has spoken to management regarding this desire. Resident assured that his requests would be forwarded. Further review of EMR did not disclose any documentation of negative interactions between R9 and R27. On 8/15/24 at 1:00 PM R9 was observed sitting on the side of his bed with a tray of food in front of him. Flat affect noted; little eye contact; and the room was dark with lights off and shades closed. Not good; never good he said in response to the question of how he was doing. I will never feel good until I can be near my wife he stated. R9 talked about feeling bitter about the situation and added that the Administrator will not speak with him about the situation.

Based on observation, interview, and record review, the facility failed to provide restorative services to maintain mobility, in two of two residents reviewed for mobility (Resident #98 & #44), resulting in anxiety and unmet goals. Findings include: Resident #98 (R98) R98 was observed sitting in a wheelchair in her room on 8/13/24 at 11:37 AM. R98 stated during an interview that she was so anxious she could barely stand it. R98 stated her therapy services ended last week because she could not bear weight on her leg; she stated therapy explained she would receive restorative nursing services, but services had not started and she felt there was a lack of communication. R98 pointed to a daily activity flyer she had received and stated she wondered if she was supposed to attend range of motion (ROM, movement at each joint) exercise program scheduled at 4:00 PM; and staff had not told her she should attend the activity. R98's Minimum Data Assessment (MDS) dated [DATE] revealed she was admitted to the facility on [DATE]; and had a Brief Interview for Mental Status (BIMS, cognitive screener) score of 15 (13-15 cognitively intact). The same MDS revealed R98 had a functional limitation of range of motion (limited ability to move a joint that interfered with daily functioning or placed resident at risk of injury) on one side of her lower extremity (hip, knee, ankle, foot). Physical Therapy (PT) Discharge Summary Dated 8/08/24, indicated R98 had the diagnosis of a left femur fracture repair following a motor vehicle accident. R98 was unable to continue making progress on her goals due to toe touch weight bearing status on her left lower extremity. Prior to R98's accident, she was living independently in a home. The plan was for PT to re-assess when R98's weight bearing status was upgraded. The same PT summary included recommendations for a ROM program with 2-pound weight to the left lower extremity and 4-pound weights to the right lower extremity. R98's same summary indicated prognosis to maintain current level of function was good with consistent staff follow-through. Occupational Therapy (OT) Discharge Summary dated 8/08/24 revealed R98 had reached her maximum potential with skilled services given her current weight bearing restriction and would be reevaluated once her status was upgraded. R98's OT summary included recommended exercises to both upper extremities using 3-pound hand weights or arm bike as tolerated to maintain current therapeutic strength gains. R98's same summary indicated prognosis to maintain current level of function was good with consistent staff follow-through. Mobility Registered Nurse (RN) D was interviewed on 8/15/24 at 9:37 AM and confirmed R98 was not currently on restorative/mobility program because there was not enough staff. RN D stated she was pulled from restorative/mobility care to work as the floor nurse approximately twice a week. RN D stated R98 had not attended the exercise group activity that was scheduled 3 times a week at 4:00 PM. 45135 Resident #44 (R44) Medical record reflected R#44 was admitted to the facility on [DATE] and readmitted on [DATE] following a fall with major injury. Diagnoses of dystonia, psychotic disorder with delusions, severe vascular dementia, anxiety, depression, age-related osteoporosis without current pathological fracture, chronic pain, disorientation, and adult failure to thrive. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/18/2022, revealed R#44 had a Brief Interview of Mental Status (BIMS) of 01 (severely impaired) out of 15. Under section GG0130, Activities of Daily Living (ADL) assessment revealed R#44 is dependent of all care including being toileting, repositioning and getting dressed. During an interview on 08/14/24 at 04:05 PM, family member I stated she was told R#44 was found on her floor in her room trying to get to the bathroom on 04/13/24. Family member I also stated this had happened before. Family member I stated it was after midnight when she received the call, and she was out of state for work. R#44 had fractured her left hip. Record review revealed R#44 had the following test on 04/13/24. Right hip magnetic resonance imaging (MRI)- No fractures. Left hip computed tomography (CT)-Acute impacted sub-capital left hip fracture with mild displacement. CT- cervical spine without contrast. No fractures, CT of the brain, no bleed, no fracture. Record review also revealed that R#44 had to have a surgical repair on 04/14/24 with an abductor pillow in place, hip precautions to be maintained. R#44 did clench her mouth and was non-verbal. Unable to follow verbal cues and tended to push back. Record review revealed R#44 returned to the facility on [DATE] at 13:20PM. R#44 was assisted to the recliner following therapy evaluation. Occupational therapy (OT) evaluation has been completed to assess safety and functional performance during self-care, transfers and mobility. R#44 will receive skilled OT five times a week for two weeks. Physical therapy (PT) evaluation completed, and R#44 will be receiving skilled PT services 5 times per week for 2 weeks to address strength, balance, gait, and transfer deficits. ADL's/Functional Status as of 04/17/24: Eating -Limited Assistance, Meal (s) acceptance -75%, res was feeding self, pleasant mood and having a conversation with staff.360ml, Bed mobility - Extensive Assistance x2, Transfers - Extensive Assistance x2, Toileting - Extensive Assistance x2, Ambulation in room- Did not occur. Ambulation in hallway Did not occur, R#44 is a WBAT with assist x2. ADL's/Functional Status as of 04/24/24: Eating -Extensive assistance, Meal (s)acceptance - No meals given at this time., 0ml, Bed mobility - Total Assistance x2, Transfers - Total Assistance x2, Toileting - Total Assistance x2, Ambulation in room- Did not occur, Ambulation in hallway Did not occur. R#44 followed up with orthopedic doctor, discontinued physical therapy and occupational therapy on 04/29/24. Restorative program started up after therapy programs were discontinued. Record review revealed nurses note dated 05/03/24 stated R#44 required extensive assist of 1 to 2 staff for ADL's, dressing, bathing, toileting. Resident requires extensive to total assist for dining. Dines in hall dining room. Propelled in wheelchair by staff, ambulates with assist of 2 people with gait belt. During an interview on 08/15/24 at 10:54 AM, DON B stated R#44 was not on the restorative plan, they haven't have a restorative program since January 2024. DON B also stated they have a mobility program but had to step away from it because they needed to have the Certified Nursing Assistant (CNA) working on the floor taking care of residents' DON B stated they encourage staff to walk residents right now. During an interview on 08/15/24 at 1:19 PM, Registered Nurse (RN) and mobility coordinator D, stated she works alone in the mobility program. RN D also stated she can get eight to ten residents seen in one day. RN D stated that staffing had been so bad that she got pulled to the floor once to twice a week, sometimes three times in a week. RN D stated ideally, they could have had 30-40 residents in the mobility program a week. RN D added that the restorative program stopped the end of last year sometime. RN D stated she had no backup, so when she is pulled to the floor, the CNA's try to walk residents if they had time.

Based on observation, interview, and record review the facility failed to include daily nursing total numbers and actual hours worked on the posted Daily Nurse Schedule, which was available for 100 current residents and family/visitors. Findings Included: During an interview on 08/15/2024 at 12:49 a.m. Nursing Staff Scheduler F was asked where the facility daily nursing hours were posted in the facility. Nursing Staff Scheduler F explained that a nursing staff schedule was posted outside of the nurse managers office. Nursing Staff Scheduler assisted surveyor locating the posting of the facility daily nursing hours. During that time, it was observed a document was posted entitled Daily Nurse Schedule, dated 08/15/2024. The document demonstrated names and shifts of person that were to work that date. The document did not include total hours to be worked, only demonstrated the total number of persons that were to work. Nursing Staff Scheduler was asked where are the total number of hours to be worked for each shift and where was the total number of hours worked for previous shifts. Nursing Staff Scheduler F could not answer and suggested that Director of Nursing (DON)B would know the answer. During an interview on 08/15/2024 at 01:06 p.m. Director of Nursing (DON) B was asked to observe the Daily Nurse Schedule for 08/15/2024 which was posted outside of the Nurse Managers Office. After review of the above documents DON B was asked where the actual hours worked, for previous shifts and dates was posted. DON B could did not know the answer and suggested that we talk with Nursing Home Administrator (NHA) A. During an interview on 08/15/2024 at 01:10 p.m. Nursing Home Administrator (NHA) A was asked where the posting for actual nursing hours worked, and hours scheduled was posted. NHA A explained that a Daily Nurse Schedule was posted outside of the nurse managers office. NHA A was asked if the Daily Nurse Schedule included total hours worked and she responded that the person reviewing the hours would have to add the hours on their own as the schedule only listed total number of persons working. NHA A explained that she was not aware of the requirement to post actual worked hours and requested location of that requirement. NHA A was provided the requested information.

This Citation Pertains To Intake MI00140863 Based on observation, interview and record review the facility failed to ensure one resident (Resident #3) was free from abuse of three reviewed, resulting in Resident 3 being abused by a staff member. Findings include: Review of the facility reported incident dated 10/27/2023 reflected Resident 3 was handled roughly be two Certified Nursing Assistants (CNA's) F and G on 10/24/23 when putting R3 to bed for the evening. The facility reported incident also included the allegation of CNAF engaging in an aggressive manner with R3 on the same day after dinner. According to the clinical record Resident 3 (R3) was an [AGE] year old female admitted to the facility with diagnosis of dementia. The Minimum Data Set (MDS) dated [DATE] R3 scored 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. On 10/30/2023 R3 scored 5 on the BIMS indicative of severe cognitive impairment. Of note, R3 resided on the facility's secured dementia unit. Further review of the facility reported incident documents reflected CNA D reported allegations of abuse perpetrated by CNA's F and G toward R3 to the house supervisor on 10/27/23. Review of the documents reflected CNA E was assigned to the secured dementia unit with CNA F and G, CNA E alleged she witnessed R3 being mocked, and handled roughly, covering R3 eyes, holding her down by her shoulders and throwing her in bed. On 11/14/2023 review of the facility video footage dated 10/24/23 revealed CNA F in the common area, R3 was sitting on a walker and CNAF was observed on camera trying to get R3 to move, R3 began swatting at CNA F and grabbed her name badge and lanyard, camera footage revealed CNA F swatting back multiple times at R3. Additional camera footage was viewed dated 10/24/23 at 6:00 pm, this footage showed CNA E entering the common area with R3, CNA F was observed a few feet away. R3 then raised and dropped her arms and CNA F then mimicked the movement over and over and over, CNA E was transitioning R3 into a chair at which point CNA F was observed talking, making multiple hand gestures including but limited aggressively pointing her finger at R3. Additional camera footage dated 10/24/23 at 9:55 pm showed CNA E, F and G exiting R3's room. Review of CNA E's witness statement reflected on 10/24/23 she observed CNA F and CNA G forced R3 into bed, covered her eyes and put their hand over R3's mouth. CNA E's witness statement reflected CNA F and G laughed about the incident like it was a joke. Multiple attempts were made to interview CNA E messages were left and text messages sent with no response. On 11/14/23 at 2:43 during a phone interview with CNA G she reported she helped R3 in bed along with CNA E and F, she elaborated the her and CNA F did all the work and R3 tried to get up, CNA G stated they were not rough but R3 needed to be pushed back down to lay down. CNA G stated CNA E was confused about what she saw. On 11/14/23 at 3:21 pm during a phone interview with CNA F she denied all allegations of abuse, when queried about the video footage that was viewed dated 10/24 where she was observed swatting at R3 and then later mocking R3, CNA F stated her behavior was justified because R3 threatened to kill her earlier that day. Of note all three CNA's E, F and G were terminated at the conclusion of the facility investigation on the grounds of abuse. According to the facility policy and procedure titled Abuse Prevention and Investigation Program dated 4/2020 Policy Statement It is the policy of Maple Lawn Medical Care Facility to maintain and right of each resident to have an environment free of abuse, neglect misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident 's medical symptoms. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members or legal guardians, friends or other individuals.

This Citation Pertains To Intake MI00140863 Based on observation, interview, and record review, the facility failed to report allegations of abuse for one (Resident #3) of 3 reviewed for abuse reporting, resulting in known allegations of abuse that were not reported timely to the facility Administrator and/or Director of Nursing . This deficient practice leaves the potential for further allegations of abuse to go undetected and unreported, allowing the opportunity for further abuse to continue. Findings include: Review of the facility reported incident dated 10/27/2023 reflected Resident 3 was handled roughly be two Certified Nursing Assistants (CNA's) F and G on 10/24/23 when putting R3 to bed for the evening. The facility reported incident also included the allegation of CNAF engaging in an aggressive manner with R3 on the same day after dinner. According to the clinical record Resident 3 (R3) was an [AGE] year old female admitted to the facility with diagnosis of dementia. The Minimum Data Set (MDS) dated [DATE] R3 scored 10 out of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. On 10/30/2023 R3 scored 5 on the BIMS indicative of severe cognitive impairment. Of note, R3 resided on the facility's secured dementia unit. Further review of the facility reported incident documents reflected CNA D reported the allegations of abuse that involved R3 by CNA F and G to the house supervisor on 10/27/23. Review of the documents reflected CNA E was assigned to the secured dementia unit with CNA F and G. CNA E alleged she witnessed R3 being mocked, and handled roughly, covering R3 eyes, holding her down by her shoulders and throwing her in bed on 10/24/23. On 11/14/2023 review of the facility video footage dated 10/24/23 revealed CNA F in the common area, R3 was sitting on a walker and CNAF was observed on camera trying to get R3 to move, R3 began swatting at CNA F and grabbed her name badge and lanyard, camera footage revealed CNA F swatting back multiple times at R3. Additional camera footage was viewed dated 10/24/23 at 6:00 pm, this footage showed CNA E entering the common area with R3, CNA F was observed a few feet away. R3 then raised and dropped her arms and CNA F then mimicked the movement over and over and over, CNA E was transitioning R3 into a chair at which point CNA F was observed talking, making multiple hand gestures including but limited aggressively pointing her finger at R3. Additional camera footage dated 10/24/23 at 9:55 pm showed CNA E, F and G exiting R3's room. Of note, none of the camera footage has volume. Review of CNA E's witness statement reflected on 10/24/23 she observed CNA F and CNA G forced R3 into bed, covered her eyes and put their hand over R3's mouth. CNA E's witness statement reflected CNA F and G laughed about the incident like it was a joke. Multiple attempts were made to interview CNA E voice mail messages were left and text messages sent with no response. On 11/14/23 at 2:43 during a phone interview with CNA G she reported she helped R3 in bed along with CNA E and F, she elaborated the her and CNA F did all the work and R3 tried to get up, CNA G stated they were not rough but R3 needed to be pushed back down to lay down. CNA G stated CNA E was confused about what she saw. CNA G elaborated she became aware of the allegations against her and CNA F on 10/26 situation because her friend CNA J, belongs in a group chat with CNA E, D, H, I, J and K, and all 6 of the CNA's were gossiping about it on a group chat. On 11/14/23 at 3:21 pm during a phone interview with CNA F she denied all allegations of abuse, when queried about the video footage that was viewed dated 10/24 where she was observed swatting at R3 and then later mocking R3, CNA F stated her behavior was somewhat justified because R3 threatened to kill her earlier that day. On 11/14/23 at 3:45 pm during an interview with CNA H she acknowledged she was part of a group chat with E, D, I, J, K, CNA H further reported that the group chat and became aware of the allegations of abuse that involved R3 and CNA F and G on 10/26/23 at approximately 11:00 am. CNA H stated she did not report the incident because there were so many people in the group chat she assumed one of them would report it and thought it was taken care of. On 11/14/23 at 4:00 pm during an interview with CNA I, she too reported she was aware of the abuse allegations prior to the group chat via facility gossip but also acknowledged partaking in the group chat on 10/26/23. When queried why she didn't notify the Nursing Home Administrator (NHA) A of the abuse allegations, CNA I stated she did not see abuse first hand , therefore considered it hearsay, and she does not and would not report hearsay to NHA A. On 11/14/23 at 5:30 pm, a portion of the 10/26/23 group chat was reviewed, CNA E had written And ever since that day, which is two days ago, I've been thinking like what the f**k do I do after I witnessed that and They should never let those two (CNA F and G) work 400 I saw how they treated them I was shocked. I didn't even tell you guys cuz that's how bad I feel about. There were voice recording on the group chat thread (which were not audible) along with question from CNA K as to why they covered R3's eyes. On 11/15/23 at 8:40 am, during an interview with NHA A she reported CNA E, F and G were all terminated related to the incident. NHA A reported despite the CNA's all being trained in abuse she could not account for why the allegations were not reported immediately after they were made. According to the facility policy and procedure titled Abuse Prevention and Investigation Program dated 4/2020 read in part In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin and misappropriation or resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation in-volve abuse or result in serious bodily injury, or not later than 24 hours in the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency) in accordance with State Law.

Based on observation, interview, and record review the facility failed to inform and or have ongoing communication with residents regarding their rights as expressed during the confidential group meeting held on 06/07/23 for 15 of 15 of the participants resulting in the potential for rights to be violated, misunderstood, and the inability of the Residents to make informed decisions regarding their rights Findings Included: During a confidential resident council meeting with the state surveyor on 6/27/2023 at 2:00 PM, 15 out of 15 residents who were in attendance stated that they did not know where they could find the information on resident rights, and all 15 residents concurred that they did not know where it was posted. All 15 residents concurred that staff had not ever gone over resident rights with them. In an an interview on 6/27/2023 at 2:48 PM, Activity Director (AD) H stated that she regularly attended the monthly resident council meetings, and said the Ombudsman has come and talked to the residents during their meetings. AD H said every year in July she held a Quality Assurance (QA) resident council meeting, and the last one held was July of 2022. AD H stated that during this meeting all subjects were discussed with the residents in attendance, and included resident rights, information about who the Ombudsman was and contact information, and grievances. AD H was informed that during the confidential group council meeting all residents who were in attendance were not aware of how to fill a grievance and where to find the grievance forms, where to find out who the Ombudsman was and contact information, did not know where to find the list of resident rights, did not know where to find the state agency contact information, nor the state survey results. AD H stated that her yearly QA resident council meeting was due to be conducted in July of 2023, and said because it had been since last July of 2022 that she held the last meeting, the residents probably forgot that she went over their resident rights, the Ombudsman information, because it had been a year ago. AD H stated that she was not involved with the grievance forms, and said Administrator A was in charge of those. Review of resident council meeting minutes for the Months of January, February, March, April, May and June of 2023 revealed no discussions regarding resident rights, and their rights to the Ombudsman name and contact information, where grievance forms were located and the purpose of the grievance forms, nor was there any documented discussion that informed the residents, who were in attendance of all six months of council meetings, of their resident rights to know where to locate the posting of the state agency contact information and the facility's survey results. Observation on 06/27/2023 at 2:30 PM, of the Resident Reception room revealed a document holder on the wall that contained resident grievance forms, the state agency survey results, and the Ombudsman name and contact number. No poster was observed on the wall that contained the contact information for the state agency, including how to file a complaint with the state agency. During the observed the state survey results binder was opened, and revealed a two page form in the front of the binder that was titled, Nursing Home Complaint Form, and was dated October of 2003. The form was for residents to fill out with their complaint and submit the form to the state agency. The form had the name of the state department as, Michigan Department of Consumer & Industry Services, Bureau of Health Systems, Complaint Investigation Unit. Page two of the form instructed residents to, Sign this form when completed and submit it to the Bureau of Health Systems by mail or fax to: Michigan Department of Consumer & Industry Services Bureau of Health Systems, Complaint Investigation Unit P.O. Box 30664, [NAME], Ml 48909. Per www.michigan.gov the Department of Consumer & Industry Services was only in place from 1996 to 2003, the state agency complaint investigation unit no longer exists, and the Bureau of Health Systems is the incorrect Bureau information were residents can submit a complaint with the state agency. Record review of the QA resident council meeting minutes from July 2022 revealed the topics of state agency contact information, resident rights and where to find the information, grievances, and information about the Ombudsman was documented as discussed. Upon further review of the minutes for the July 2022 QA resident council meeting revealed that only one resident out of the 15 who were in attendance at the confidential resident council meeting on 6/27/2023 at 2:00 PM, was also in attendance at the July 2022 QA meeting. The remaining 14 resident had not been in attendance at the QA July 2022 meeting. Record Review of the facility's Resident Council policy and procedure dated January 2003, revealed Resident Council, Policy Statement In an effort to promote the residents right to organize and participate in resident groups in the facility for the purpose of self determination, the Activity Department will facilitate and assist in the maintenance of Resident Council. Procedure .#9. The use of resources to enhance residents' understanding of facility functions and/or issues that affect them are facilitated. Resources can include utilizing department heads, the long-term care ombudsman, or others, as guest speakers upon approval or request of the Resident Council. In an email received on 6/28/2023 at 4:56 PM, Administrator A wrote, Resident Rights, Grievance, and Ombudsman information are listed in the Welcome to (name extracted) Booklet that is in the Admissions Packet. Concerns and Complaints on Page A-7, A-8. The Resident Rights are on page A-1 and A-2 and the Ombudsman and Complaint information is all listed on page A-15 and A-16. These items are all listed on the bulletin board in the showcase in the front hallway as well as in the Resident Reception room. We review these with residents in July Resident Council Meetings and during our July QA Meeting. Review of the 15 residents, who were in attendance at the confidential resident council meeting on 6/27/2023 at 2:00 PM, admitted s revealed that eight out the 15 resident had the following years of admission: 2019 times four residents, 2020 times two residents, 2021 times one resident, and 2022 times one resident, in regards to how many years it had been since they received their admission packet. The remaining seven resident all had admitted s in 2023, however the seven resident concurred during the confidential council meeting that they had no knowledge of where to find the information regarding resident rights, and their rights to know the Ombudsman's name and contact information, where grievance forms were located and the purpose of the grievance forms, and the state agency contact information and the facility's survey results. Observation of the showcase in the front hallway revealed it was located in the lobby/front hall at the entrance of the facility. The front hall/lobby had double doors that were observed during the onsite survey from 6/26-6/28/2023 to always be closed, putting the showcase out of resident's view, and was located outside of the residents living area. During the onsite survey residents were not observed to frequent the front hall/lobby area, and furthermore the showcase had to glass sliding doors that were locked and not accessible at will to the residents, and was not at a visual level for resident who require the use of a wheelchair. Another observation was conducted on 6/28/2023 at 1:51 PM, of the Resident Recreation room which again revealed that the state agency contact number was not posted in view of residents, but was rather in the survey results binder.

Based on observation, interview, and record review the facility failed to ensure 15 out of 15 resident, who attended a confidential group meeting, were knowledgeable of their resident rights regarding the Ombudsman contact information, state agency contact information, how to file a complaint with the state agency, and the state agency survey results, resulting in the potential for resident to not be able to exercise their rights. Findings Included: During a confidential resident council meeting with the state surveyor on 6/27/2023 at 2:00 PM, 15 out of 15 residents who were in attendance stated that they did not know where they could find the information on resident rights, and all 15 residents concurred that they did not know where it was posted, and that staff had not ever gone over resident rights with them, regarding their right to the Ombudsman, the Ombudsman's name and contact information, where to find the state agency contact information including the process to file a complaint with the state agency. In an an interview on 6/27/2023 at 2:48 PM, Activity Director (AD) H stated that she regularly attended the monthly resident council meetings, and said the Ombudsman has come and talked to the residents during their meetings. AD H said every year in July she held a Quality Assurance (QA) resident council meeting, and the last one held was July of 2022. AD H stated that during this meeting all subjects were discussed with the residents in attendance, and included resident rights, information about who the Ombudsman was and contact information, and grievances. AD H was informed that during the confidential group council meeting all residents who were in attendance were not aware of where to find out who the Ombudsman was and contact information, did not know where to find the state agency contact information, nor the state survey results. AD H stated that her yearly QA resident council meeting was due to be conducted in July of 2023, and said because it had been since last July of 2022 that she held the last meeting, the residents probably forgot that she went over their resident rights, the Ombudsman information, because it had been a year ago. AD H stated that she was not involved with the grievance forms, and said Administrator A was in charge of those. Review of resident council meeting minutes for the Months of January, February, March, April, May and June of 2023 revealed no documented discussions regarding resident rights to the Ombudsman and contact information, nor was there any documented discussion that informed the residents, who were in attendance of all six months of council meetings, of their resident rights to know where to locate the posting of the state agency contact information and the facility's survey results. Observation on 06/27/2023 at 2:30 PM, of the Resident Reception room revealed a document holder on the wall that contained the state agency survey results, and the Ombudsman name and contact number. No poster was observed on the wall that contained the contact information for the state agency, including how to file a complaint with the state agency. During the observed the state survey results binder was opened, and revealed a two page form in the front of the binder that was titled, Nursing Home Complaint Form, and was dated October of 2003. The form was for residents to fill out with their complaint and submit the form to the state agency. The form had the name of the state department as, Michigan Department of Consumer & Industry Services, Bureau of Health Systems, Complaint Investigation Unit. Page two of the form instructed residents to, Sign this form when completed and submit it to the Bureau of Health Systems by mail or fax to: Michigan Department of Consumer & Industry Services Bureau of Health Systems, Complaint Investigation Unit P.O. Box 30664, [NAME], Ml 48909. Per www.michigan.gov the Department of Consumer & Industry Services was only in place from 1996 to 2003, the state agency complaint investigation unit no longer exists, and the Bureau of Health Systems is the incorrect Bureau information were residents can submit a complaint with the state agency. Record review of the QA resident council meeting minutes from July 2022 revealed the topics of state agency contact information, resident rights ,and information about the Ombudsman was documented as discussed. Upon further review of the minutes for the July 2022 QA resident council meeting revealed that only one resident out of the 15 who were in attendance at the confidential resident council meeting on 6/27/2023 at 2:00 PM, was also in attendance at the July 2022 QA meeting. The remaining 14 resident had not been in attendance at the QA July 2022 meeting. Record Review of the facility's Resident Council policy and procedure dated January 2003, revealed Resident Council, Policy Statement In an effort to promote the residents right to organize and participate in resident groups in the facility for the purpose of self determination, the Activity Department will facilitate and assist in the maintenance of Resident Council. Procedure .#9. The use of resources to enhance residents' understanding of facility functions and/or issues that affect them are facilitated. Resources can include utilizing department heads, the long-term care ombudsman, or others, as guest speakers upon approval or request of the Resident Council. In an email received on 6/28/2023 at 4:56 PM, Administrator A wrote, Resident Rights, Grievance, and Ombudsman information are listed in the Welcome to (name extracted) Booklet that is in the Admissions Packet. Concerns and Complaints on Page A-7, A-8. The Resident Rights are on page A-1 and A-2 and the Ombudsman and Complaint information is all listed on page A-15 and A-16. These items are all listed on the bulletin board in the showcase in the front hallway as well as in the Resident Reception room. We review these with residents in July Resident Council Meetings and during our July QA Meeting. Review of the 15 residents, who were in attendance at the confidential resident council meeting on 6/27/2023 at 2:00 PM, admitted s revealed that eight out the 15 resident had the following years of admission: 2019 times four residents, 2020 times two residents, 2021 times one resident, and 2022 times one resident, in regards to how many years it had been since they received their admission packet. The remaining seven resident all had admitted s in 2023, however the seven resident concurred during the confidential council meeting that they had no knowledge of where to find the information regarding their right to know the Ombudsman's name and contact information, and the state agency contact information and the facility's survey results. Observation of the showcase in the front hallway revealed it was located in the lobby/front hall at the entrance of the facility revealed a state survey report, Ombudsman information, and state agency contact information to be inside. The front hall/lobby had double doors that were observed during the onsite survey from 6/26-6/28/2023 to always be closed, putting the showcase out of resident's view, and was located outside of the residents living area. During the onsite survey residents were not observed to frequent the front hall/lobby area, and furthermore the showcase had to glass sliding doors that were locked and not accessible at will to the residents, and was not at a visual level for resident who require the use of a wheelchair. Another observation was conducted on 6/28/2023 at 1:51 PM, of the Resident Recreation room which again revealed that the state agency contact number was not posted in view of residents, but was rather in the survey results binder.

Based on observation, interview, and record review the facility failed to ensure 15 out of 15 resident, who attended a confidential group meeting, were knowledgeable of their resident rights on how to file a grievance and complaint, resulting in the potential for residents grievances and complaints to go unresolved. Findings Included: During a confidential resident council meeting with the state surveyor on 6/27/2023 at 2:00 PM, 15 out of 15 residents who were in attendance stated that they did not know where they could find the information on resident rights regarding how to file a grievance, where the grievance forms were located, what the process was to file a grievance. All 15 residents concurred that staff had not ever gone over resident grievance rights with them in regards to their right to file a grievance and complaint, nor the contact information of the state agency and Ombudsman to whom the residents had the right to file a grievance or complaint. In an an interview on 6/27/2023 at 2:48 PM, Activity Director (AD) H stated that she regularly attended the monthly resident council meetings, and said the Ombudsman has come and talked to the residents during their meetings. AD H said every year in July she held a Quality Assurance (QA) resident council meeting, and the last one held was July of 2022. AD H stated that during this meeting all subjects were discussed with the residents in attendance, and included resident rights, information about who the Ombudsman was and contact information, and grievances. AD H was informed that during the confidential group council meeting all residents who were in attendance were not aware of how to fill a grievance and where to find the grievance forms, where to find out who the Ombudsman was and contact information, did not know where to find the list of resident rights, did not know where to find the state agency contact information, nor the state survey results. AD H stated that her yearly QA resident council meeting was due to be conducted in July of 2023, and said because it had been since last July of 2022 that she held the last meeting, the residents probably forgot that she went over their resident rights, the Ombudsman information, because it had been a year ago. AD H stated that she was not involved with the grievance forms, and said Administrator A was in charge of those. Review of resident council meeting minutes for the Months of January, February, March, April, May and June of 2023 revealed no discussions regarding resident rights to file a grievance and complaint, where the grievance forms were located and the purpose of the grievance forms. No documented discussion about resident rights to file a grievance with the Ombudsman and/or state agency, and were to find the contact information. Observation on 06/27/2023 at 2:30 PM, of the Resident Reception room revealed a document holder on the wall that contained resident grievance forms. During the observed the state survey results binder was opened, and revealed a two page form in the front of the binder that was titled, Nursing Home Complaint Form, and was dated October of 2003. The form was for residents to fill out with their complaint and submit the form to the state agency. The form had the name of the state department as, Michigan Department of Consumer & Industry Services, Bureau of Health Systems, Complaint Investigation Unit. Page two of the form instructed residents to, Sign this form when completed and submit it to the Bureau of Health Systems by mail or fax to: Michigan Department of Consumer & Industry Services Bureau of Health Systems, Complaint Investigation Unit P.O. Box 30664, [NAME], Ml 48909. Per www.michigan.gov the Department of Consumer & Industry Services was only in place from 1996 to 2003, the state agency complaint investigation unit no longer exists, and the Bureau of Health Systems is the incorrect Bureau information were residents can submit a complaint with the state agency. Record review of the QA resident council meeting minutes from July 2022 revealed the topics of state agency contact information, resident rights and where to find the information, grievances, and information about the Ombudsman was documented as discussed. Upon further review of the minutes for the July 2022 QA resident council meeting revealed that only one resident out of the 15 who were in attendance at the confidential resident council meeting on 6/27/2023 at 2:00 PM, was also in attendance at the July 2022 QA meeting. The remaining 14 resident had not been in attendance at the QA July 2022 meeting. Record Review of the facility's Resident Council policy and procedure dated January 2003, revealed Resident Council, Policy Statement In an effort to promote the residents right to organize and participate in resident groups in the facility for the purpose of self determination, the Activity Department will facilitate and assist in the maintenance of Resident Council. Procedure .#9. The use of resources to enhance residents' understanding of facility functions and/or issues that affect them are facilitated. Resources can include utilizing department heads, the long-term care ombudsman, or others, as guest speakers upon approval or request of the Resident Council. In an email received on 6/28/2023 at 4:56 PM, Administrator A wrote, Resident Rights, Grievance, and Ombudsman information are listed in the Welcome to (name extracted) Booklet that is in the Admissions Packet. Concerns and Complaints on Page A-7, A-8. The Resident Rights are on page A-1 and A-2 and the Ombudsman and Complaint information is all listed on page A-15 and A-16. These items are all listed on the bulletin board in the showcase in the front hallway as well as in the Resident Reception room. We review these with residents in July Resident Council Meetings and during our July QA Meeting. Review of the 15 residents, who were in attendance at the confidential resident council meeting on 6/27/2023 at 2:00 PM, admitted s revealed that eight out the 15 resident had the following years of admission: 2019 times four residents, 2020 times two residents, 2021 times one resident, and 2022 times one resident, in regards to how many years it had been since they received their admission packet. The remaining seven resident all had admitted s in 2023, however the seven resident concurred during the confidential council meeting that they had no knowledge of where to find the information regarding resident rights, and their rights to know the Ombudsman's name and contact information, where grievance forms were located and the purpose of the grievance forms, and the state agency contact information. Observation of the showcase in the front hallway revealed it was located in the lobby/front hall at the entrance of the facility. The front hall/lobby had double doors that were observed during the onsite survey from 6/26-6/28/2023 to always be closed, putting the showcase out of resident's view, and was located outside of the residents living area. During the onsite survey residents were not observed to frequent the front hall/lobby area, and furthermore the showcase had to glass sliding doors that were locked and not accessible at will to the residents, and was not at a visual level for resident who require the use of a wheelchair. Another observation was conducted on 6/28/2023 at 1:51 PM, of the Resident Recreation room which again revealed that the state agency contact number was not posted in view of residents, but was rather in the survey results binder.

Based on interview and record review, the facility failed to ensure accurate completion of advance directive information for 1 (Resident #30) of 1 resident reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) resulting in the potential for a resident's preferences for medical care to not be followed by the facility. Findings include: Review of the medical record revealed that Resident #30 (R30) was admitted to facility 5/12/2023 with diagnoses including hydronephrosis, malignant neoplasm of bladder, and hemiplegia following cerebral infarction. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/16/23 revealed that R30 had adequate hearing, clear speech, was usually understood by others, and was usually able to understand others. Section C of same MDS revealed that R30 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 12 (moderately impaired cognition). Review of R30's medical record completed with the following findings noted: Order dated 5/12/2023 at 2:16 PM stated, DNR (Do Not Resuscitate). Document titled Maple Lawn Medical Care Facility Resident Medical Decision Identification Form dated 5/12/23 indicated that R30 was capable of making his own medical treatment decisions. R30's DO-NOT-RESUSCITATE ORDER reflected R30's signature and corresponding date of 5/12/23 within the section titled DECLARANT CONSENT; the section titled ATTESTATION OF WITNESS, within the same form, reflected 2 witness signatures with a corresponding date of 5/ /23 for both (the month and year was indicated but the day was omitted). Document titled Maple Lawn Medical Care Facility Activation of Durable Power of Attorney for Healthcare dated 6/20/23 revealed that R30 was deemed unable to make his own decisions by two physicians. R30's Durable Power of Attorney for Health Care (DPOA-HC) paperwork, indicated that R30 named his son as DPOA-HC, and to make decisions for R30, when he was no longer able to make his own decisions, as determined by two physicians or a physician and a psychiatrist. Document titled Maple Lawn Medical Care Facility Code Status reflected R30's date of admission as 5/12/23 with a handwritten date beneath which reflected updated 6/20/23. Director of Social Services (DSS) F initialed on line that indicated, This code was prepared by the resident's legally appointed and appropriately activated Patient Advocate, as this resident has been determined as being incapable of participating in their own health care decisions by two physicians in a written medical determination . with R30's activated POA (Power of Attorney) noted to have initialed on the line that indicated No Code - Do not resuscitate. R30's POA was noted to sign on the line that indicated Signature of Resident (or Resident Advocate/Guardian) with two witness signatures noted beneath. The corresponding lines which indicated the dates for both the POA and witnesses' signatures were noted to be blank. A second DO-NOT-RESUSCITATE ORDER reflected R30's POA signature within the section titled PATIENT ADVOCATE CONSENT with the corresponding line that reflected the date of the signature noted to be blank; the section titled ATTESTATION of WITNESS, within the same form, reflected 2 witness signatures with the corresponding lines that reflected the date of each signature noted to be blank. A Psychosocial Note dated 6/23/2023 at 8:51 AM, completed by DSS F stated, Resident's DPOA (Durable Power of Attorney) has been activated. Call placed to DPOA and message left asking to come in and sign advance directives. In an interview on 6/27/23 at 3:21 PM, DSS F stated that a residents advance directive information was completed upon admission, and at other times deemed warranted, by the admissions nurse, admissions coordinator, or herself and included completion of the Resident Medical Decision Identification form, Maple Lawn Medical Care Facility Code Status form, and the Maple Lawn Medical Care Facility DO-NOT-RESUSCITATE ORDER form if the DNR option was chosen. Per DSS F, when the DNR option was chosen, both the Maple Lawn Medical Care Facility Code Status form and the Maple Lawn Medical Care Facility DO-NOT-RESUSCITATE ORDER form would be signed and dated by the resident, activated POA, or legal guardian in the presence of two witnesses and that the two witnesses both signed and dated the forms at the same time the resident, POA, or guardian signed. Upon review of R30's Code Status form and DNR Order form, DSS F acknowledged that the dates of the POA and witness signatures were omitted for both. DSS F further stated that she was unsure as to why R30's Code Status form indicated updated 6/20/23, that the updated forms were not completed until 6/23/23 when his POA had come to the facility, and confirmed that both the Code Status form and DNR Order form were incomplete as the POA and both witnesses should have dated the forms at the time of completion. Review of the facility policy titled Maple Lawn Medical Care Facility Advance Directives dated 2/2018 stated, Policy: It is the resident's right to formulate an Advance Directive .Policy Explanation and Compliance Guideline: 1. On admission, the facility will determine if the resident has executed an Advance Directive and if not, determine whether the resident would like to formulate an Advance Directive .3. The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities . Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 (Revised 3-25-14), revealed that, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician. (c) Two witnesses [AGE] years of age or older, at least 1 of whom is not the declarant's spouse, parent, child, grandchild, sibling, or presumptive heir. (3) The names of all signatories shall be printed or typed below the corresponding signatures. A witness shall not sign an order unless the declarant or the declarant's patient advocate appears to the witness to be of sound mind and under no duress, fraud, or undue influence. Further review of this Act revealed, Sec. 4. A do-not-resuscitate order executed under section 3 or 3a shall include, but is not limited to, the following language, and shall be in substantially the following form: DO-NOT-RESUSCITATE ORDER This do-not-resuscitate order is issued by _______________________________________, attending physician for _________________________________________. (Type or print declarant's or ward's name) Use the appropriate consent section below: A. DECLARANT CONSENT I have discussed my health status with my physician named above. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import. _______________________________________ _______________ (Declarant's signature) (Date) _______________________________________ _______________ (Signature of person who signed for (Date) declarant, if applicable) _______________________________________ (Type or print full name) B. PATIENT ADVOCATE CONSENT I authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Patient advocate's signature) (Date) _______________________________________ (Type or print patient advocate's name) C. GUARDIAN CONSENT I authorize that in the event the ward's heart and breathing should stop, no person shall attempt to resuscitate the ward. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Guardian's signature) (Date) _______________________________________ (Type or print guardian's name) _______________________________________ _______________ (Physician's signature) (Date) _______________________________________ (Type or print physician's full name) ATTESTATION OF WITNESSES The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the declarant has (has not)received an identification bracelet. ______________________________ ______________________________ (Witness signature) (Date) (Witness signature) (Date) ______________________________ ______________________________ (Type or print witness's name) (Type or print witness's name) THIS FORM WAS PREPARED PURSUANT TO, AND IS IN COMPLIANCE WITH, THE MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT.

Based on observation, interview, and record review the facility failed to ensure one out of three residents (Resident #40) was assessed for removal of a Foley catheter (tube inserted into the bladder to drain urine into a drainage bag), and document a clinical rational that demonstrated the necessity for the catheter, resulting in the potential for infection and/or long-term urinary incontinence. Findings Included: Per the facility face sheet Resident #41 (R41) was admitted to the facility on [DATE]. Diagnoses included personal history of other diseases of urinary system, and obstructive and reflux uropathy (blockage/trouble urinating). On R41's diagnoses list it was documented that R41 had a nephrostomy tube (drainage tube inserted into the kidney to drain urine) placed into her left kidney by a hospital Radiologist on 7/12/2022 however, on 10/5/2022 the nephrostomy tube was removed by the hospital Radiologist. The list also revealed next to R41's diagnosis PRESENCE OF UROGENITAL IMPLANTS dated 3/8/2023, Chronic Indwelling Foley Catheter per PN (progress note) dated 3/8/2023. Also documented on R41's diagnoses list was a notation, Hx (history) of Polymicroboa; resistant UTI (urinary tract infection) dated 7/21/2022, that was resistant to Vancomycin (used to treat serious infections) Review of R41's care plans that were in place revealed a care plan with a Problem of I (R41) have a Foley catheter and places me at risk for developing UTI or other complications. July '22 Nephrostomy tube placed secondary to obstructive uropathy. 10/5/22-L (left) nephrostomy tube removed, per interventional radiology, does not need to be replaced, improvement noted. 10/12/22--(name redacted-Urologist) to be consulted. The care plan was dated 7/21/2022 for the date the problem was initiated, and 10/27/2022 as the date the problem was revised. The care plan revealed an intervention dated 7/21/2022, Urology consult as ordered. Record review of a physician progress notes dated 3/8/2023, revealed a notation by the physician that R41 was concerned about her Foley catheter still being in place, and was questioning about removing it. Under Plan the note revealed that the staff would discuss with R41 and her family member about follow up with her Urologist regarding the Foley cath. The note also revealed under IMPRESSION, #2 Chronic indwelling foley catheter, and under PLAN .The staff will discuss with the patient's (R41) daughter regarding a follow up urology consultation regarding the indwelling Foley catheter. Record review of all consult progress notes in R41's paper chart revealed no documentation from a Urologist, and upon thorough review of R41's Electronic Medical Record (EMR) and paper chart revealed R41 did not have a Urologist progress note, office visit note, and no written orders, and furthermore no Urologist was listed on R41's face sheet under her care providers. R41's EMR and paper chart revealed no order for a Urologist consult. Record Review of another physician progress note dated 4/4/2023, revealed no documentation regarding the status of R41's Foley catheter, nor the question R41 and her family member had about removing the catheter, no consultation was documented to have been made with a Urologist. The note revealed no documentation of a conversation with R41 and/or her daughter regarding the status of the Urology consult. Record Review of another physician progress note dated 5/3/2023, revealed no documentation regarding the status of R41's Foley catheter, nor the question R41 and her family member had about removing the catheter, no consultation was documented to have been made with a Urologist. The note revealed no documentation of a conversation with R41 and/or her daughter regarding the status of the Urology consult. In an interview on 6/26/2023 at 11:03 AM, R41 and a family member both stated that R41 would like to see her catheter taken out. Family member stated that R41 would probably be incontinent of urine due to the catheter remaining in place for a year now. R41 and family member stated that R41 had a nehprostomy tube removed about one year ago, and has had the catheter in place ever since then. R41 and her family member both stated that they did not know why R41 still had the catheter in place a year later, and had asked several Licensed Practical Nurse (LPN) I about having the Foley catheter removed, but no response had been received. Record review of a physician order dated 7/22/2022, revealed R41 was to have the Foley catheter maintained, and on 9/17/2022 R41 was to have her Foley Catheter changed as needed, and per policy On 6/28/2023 at 9:05 AM, the Director of Nursing (DON) B was asked to provide R41's last Urologist appointment, and the progress notes from that appointment. In an email received from Administrator A on 6/28/2023 at 9:20 AM, of an After Visit Summary dated 10/5/2023 from the hospital, revealed the summary was for a replacement of R41's nephrostomy tube. The summary was documented by a Radiologist due to R41 having a nephrostomy tube replaced. No Urologist notes or visits of R41 being seen were noted on the hospital After Visit Summary. No other Urologist consult or appointment visit progress notes were received. Requested via email reply to above Administrator A's email at 9:24 AM, R41's Urologist consult/appointment progress notes since January 2023 to present. Received via email response from Administrator A, to above request on 6/28/2023 at 9:54 AM, She has not had any other appointments with the urologist since January 2023. Record review of a Minimum Data Set (MDS) dated [DATE], revealed R41 had a Brief Interview for Mental Status (BIMS) of 11 out of 15, which indicated a moderate cognitive impairment. In another interview on 6/28/2023 at 11:46 AM, R41 stated that she always wondered why she still had the Foley catheter. R41 said she did not recall talking to a nurse about it, and did not recall talking to the physician about it in October 2022. R41 stated her daughter may have spoken to them. Stated she had seen the Orthopedic surgeon last week about her knee, which was swollen. R41 said the Orthopedic surgeon told her that he would not do anything about her knee swelling until she saw an Urologist, due to her excess fluid. R41 further stated that the physician had spoken with her that morning and told her the Orthopedic surgeon said she needed to see a Urologist, but stated the physician did not tell her he was going to refer to a Urologist. During the interview R41's daughter arrived in her room. R41's daughter stated that R41 had not been seen since October 2022 by a Urologist or any other physician regarding her Foley catheter, and stated that LPN I had all that information. R41's daughter stated that she had not heard anything about the physician at the facility making a referral to see a Urologist, and she was waiting on him to put in the referral. R41's daughter said that since R41 had seen the Orthopedic surgeon last week she had asked LPN I about the Urologist referral and appointment. R41's said she called a Urologist herself because R41 need the referral, however stated that she was told by the Urologist office that R41 primary physician at the facility had to put in the referral. R41's daughter continued to stated during the interview that R41 has had the Foley catheter in place since July of 2022. R41's Daughter said she asked LPN I numerous times over the lat 6 months about removing the Foley catheter, but said LPN I always just told her that R41's bladder was probably so weak that she would just urinate all over herself and that was why the Foley catheter remained in place. During the same interview R41 stated that she would know when she had to urinate. R41 said she walks to the bathroom herself, and did just that when she had to have a bowel movement. R41 also stated that she would be fine with wearing a brief, and not having the Foley catheter in place. R41's daughter said the physician told her about eight months ago that R41 needed the Foley catheter in place, but had never given a rational for it to stay in place. In an interview on 6/28/2023 at 12:16 PM, LPN I stated that she did not know anything about R41's Foley catheter. LPN I stated that the House Supervisor managed all the referrals and spoke with the physician every time the physician was at the facility in regards to all residents he had seen. During the interview LPN I was asked to provide progress notes form R41's physician and Urologist. Record review of R41's paper chart with LPN I revealed no consult progress notes from a Urologist or the physician regarding R41's request for the Foley catheter to be removed after the 3/8/2023 progress note. LPN I stated that she did not know why R41 had the Foley catheter in place. In an interview on 6/28/2023 at 12:24 PM, Registered Nurse G who was the House Supervisor (RN/HS) stated that R41 and her daughter were offered to be referred to a Urologist in town (this is the same Urologist R41's daughter had called to get a referral), but stated that she thought she recalled R41 and her daughter did not want to be seen by a Urologist at the time. During the same interview RN/HS G was asked to provide documentation of attempts to remove the Foley, document rational for keeping the Foley in place for a year. RN/HS G said she had something and after review R41's diagnoses stated R41 had a bladder perforation, which was why R41 had the nephrostomy tube in place, and stated R41 has a diagnosis of obstructive and reflex uropathy, a urogenital implant (implants for urinary stress incontinence or urinary retention), and on 3/8/2023 the physician had made a progress note regarding R41's Foley catheter, and had written a diagnosis that R41 had urogenital implants-chronic indwelling catheter. Additionally during the same interview RN/HS G stated that she was not able to find documentation of R41 and/or R41's daughter not wanting the Urologist referral. RN /HS G said the reason R41's Foley catheter needed to stay in place was something she would need to look at in R41's EMR or paper chart, because she thought there was something the physician said about the Foley remaining in place. RN/HS G was asked to provide documentation of R41's referral and Urology appointment being scheduled, R41 and her daughter's refusal at the time for the referral, and the reason the Foley catheter remaining in place since July of 2022. RN/HS G also stated that R41 was admitted to the facility with the Foley catheter in place, and said there had been no attempts to remove R41's catheter. As of 6/28/2023 at 2:44 PM, none of the requested documents had been received from RN/HS G. As of 6/28/2023 at 3:10 PM, none of the requested documents had been received from RN/HS G. Record review of the facility's policy and procedure titled Urinary Catheter Maintenance dated December of 2022, revealed under, Policy Statement: Foley catheters will be utilized and maintained in a manner to promote resident comfort while preventing the risk for catheter associated infections in accordance to CDC Guidelines., and under Policy Interpretation and Implementation:, 3. Indwelling catheters should be used only when clinically necessary. When an indwelling catheter is used, it should be removed as soon as possible to reduce the risk of catheter-related urinary tract infections. Upon exit of the survey on 6/28/2023 at 4:00 PM, none of the requested documents had been received from RN/HS G

Based on interview and record review, the facility failed to 1) ensure timely follow up on pharmacy recommendations for one (Resident #66) of six residents reviewed for unnecessary medications and 2) ensure the facility's policy included timeframes for each step of the Medication Regimen Review (MRR), resulting in the potential for unnecessary medications and untimely follow up to pharmacy recommendations. Findings include: Review of the medical record revealed that Resident #66 (R66) was admitted to the facility 1/3/23 with diagnoses including chronic kidney disease stage 4, dependence on renal dialysis, gastro-esophageal reflux disease without esophagitis, and visual loss right eye, normal vision left eye. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/23 revealed that R66 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 13 (cognitively intact). Review of R66's monthly Consultant Pharmacist's Medication Regimen Review since 1/2/23 admission, reflected monthly review with pharmacy recommendations for January and March 2023. Recommendation dated 1/24/2023 stated, (R66's name) is currently receiving Maxitrol (neomycin-Polymyxin-Dexamethasone) (an anti-infective, steroid eye medication used to treat inflammation or treat/prevent bacterial eye infections) to the left eye twice daily. Please clarify - is there a stop date for this order? If this is a chronic order, please update the diagnosis for use, as blindness would not be an appropriate diagnosis for the use of this medication. D/C'd (discontinued) 2/23/23 was handwritten within the Follow-Through section on the report. Nurse's Notes dated 2/23/23 at 8:14 AM stated, Res (resident) seen by (Physician's name) for routine visit .(Physician's name) reviewed .pharmacy recommendations .new orders received to D/C Neomycin eye ointment . Review of R66's medication orders reflected that Neomycin-Polymyxin-Dexamethasone eye ointment was ordered 1/3/2023 and discontinued 2/23/2023. Review of Physician Nursing Home Visit notes dated 1/30/23 and 2/21/23 were not noted to include any mention of or rationale for use of Neomycin eye ointment with documentation noted to indicate, .Physical Examination .HEENT (head, ears, eyes, nose, throat) .Pupils are reactive to light and accommodation. Further review of R66's medical record completed with no indication that the 1/24/23 pharmacy recommendation was reviewed or followed up on prior to the 2/23/23 discontinuation of the eye ointment. Recommendation dated 3/27/2023 stated, (R66's name) is currently receiving Prilosec (Omeprazole) 20mg (milligrams) once daily. This medication is on the Beer's list (a list of potentially inappropriate medications for use in older adults) due to its risk of Clostridium Difficile infections and bone loss/fractures. If a resident is to stay on this medication, risk vs. (versus) benefit documentation should be provided . Within the section titled Physician/Prescriber Response, R66's physician indicated that he agreed with the recommendation, wrote D/C (discontinue), signed, and dated the form 6/5/23. Nurse's Note dated 6/5/23 at 9:51 AM stated, (Physician's name) reviewed pharmacy recommendations. DRR (Drug Regimen Review) completed, new orders received to D/C Omeprazole. Review of R66's medication orders reflected that Omeprazole 20mg was ordered 1/12/2023 and discontinued 6/5/23. Review of Physician Nursing Home Visit notes dated 4/13/23 stated, .Her overall condition has been stable since last evaluation .Her dietary intake has been good .Physical Examination .Abdomen: Soft, nontender . with no indication that 3/27/23 pharmacy recommendation to assess ongoing need of Omeprazole was addressed. Further review of R66's medical record completed with no indication that the 3/27/23 pharmacy recommendation was reviewed or followed up on prior to the 6/5/23 discontinuation of the Omeprazole. In an interview on 6/28/23 at 1:54 PM, Registered Nurse/Nursing House Supervisor (RN/NHS) G stated that the pharmacist generally completed resident chart review and recommendations during the last week of the month, the recommendations were forwarded to her by the Director of Nursing (DON), that she reviewed and placed the recommendation within the designated physician folder for physician review during the next routine visit for the indicated resident, and that once addressed they were forward to the Nursing Secretary to be filed in the resident's closed chart. RN/NHS G stated that she was unaware of any specific time frames for the review, follow-up, and completion of the recommendations and that her goal was to have them completed within a month from the time the recommendation was made but that due to time restraints, this was not always possible. Upon review of R66's January and March 2023 recommendations, RN/NHS G confirmed that she had completed follow-up on both, acknowledged that the 1/24/23 recommendation regarding the Neomycin eye ointment was not followed up on until the eye ointments discontinuation on 2/23/23 (one month after the 1/24/23 recommendation was made), and stated that she had no explanation as to why the March 27, 2023 recommendation for the discontinuation of Omeprazole was not followed up on until 6/5/23 (over 2 months after the 3/27/23 recommendation was made at which time physician provided order to discontinue the medication, per recommendation). In an interview on 6/28/23 at 2:28 PM, Director of Nursing (DON) B stated that the pharmacist reviewed each resident's chart monthly, that she received the recommendations from the pharmacy in a facility packet, and that she forwarded the medication related recommendations to the house supervisors for completion. DON B stated that she was not aware of any specific time frames for the completion of the recommendations, but her expectation was that once the house supervisors received the recommendations that they would review and address them with the physician within a couple week time frame. Upon review of R66's January and March recommendations, DON B acknowledged that the recommendations were not followed up on timely as stated that even if the physician wanted to wait to address the January recommendation for the Neomycin eye ointment until routine rounds, would have expected a timelier diagnosis clarification as the blindness diagnosis was not accurate and stated that the 3 month turn around time to address the March recommendation for discontinuation of the Omeprazole was excessive. DON B further stated that as she recognized that the monthly pharmacy recommendations were not being followed up on in a timely manner, planned to initiate audits to monitor there completion as the goal was for timely discontinuation of unnecessary medications. Review of the facility policy titled Maple Lawn Medical Care Facility Policy Medication Record Review dated 9/2021 stated, Policy Statement: It is the policy of this facility to complete a Medication Regimen review for residents admitted to this facility .Policy Implementation .2. The drug regimen of each resident will be reviewed at least monthly by the consulting pharmacist .4. The consulting pharmacist will report irregularities to the DON, attending physician and the medical director to be acted upon .a. Irregularities may include, but are not limited to, any drug that meets the criteria for unnecessary drugs b. Any irregularities noted by the pharmacist during review will be documented on a written report which will be forwarded the DON, attending physician, and medical director, to include the resident name, relevant drug, and the irregularity identified c. The attending physician will document in the residents' medical record that the identified irregularity has been reviewed and what, if any, action was taken to address .7. Upon completion of the medial record review, the facility designee and/or physician will respond to the recommendations in a timely manner .10. Each residents' drug regimen will be free of unnecessary drugs. An unnecessary drug is any drug when used: a. In excessive doses, including duplicate therapy b. For excessive duration c. without adequate monitoring d. Without adequate indications for its use .

Based on observation, interview, and record review, the facility failed to accurately monitor and document involuntary movements, in one of five residents reviewed for high-risk medications (Resident #35), resulting in an inaccurate monitoring and the potential for unmet needs. Findings include: Resident #35 (R35) On 6/26/23 at 11:00 AM, R35 was observed in activity, lip smacking was noted. 6/28/23 at 12:00 PM, R35 was noted to have lip smacking and chewing. R35's minimum data set (MDS) assessment with assessment reference dated on 6/06/23 revealed she had a brief interview for mental status (BIMS), a brief performance-based cognitive screener, score of 05 (00-07 severe cognitive impairment); R35 did not have any physical, verbal, or other behaviors during the 7-day look-back period. Abnormal Involuntary Movement Scale (AIMS), a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of abnormal movements of the face, limbs, and body in patients with tardive dyskinesia) dated 5/01/23 revealed R35 had no lip and perioral area (e.g., puckering, pouting, smacking) movements or any other involuntary movements during the assessment. Physician's progress note dated 5/24/23 indicated her mental condition was declining. Zyprexa (antipsychotic) 2.5 milligrams (mg) and Lexapro (antidepressant) 5 mg were ordered daily. The plan included to monitor R35's condition closely. The same note indicated R35 had some mid lip smacking and shuffling gait upon examination. The same noted indicated symptoms could be early signs of Parkinson's disease with some extrapyramidal symptoms. Social Worker (SW) F was interviewed on 6/28/23 at 11:03 AM and stated R35's diagnoses included psychotic disorder with delusions. SW F stated R35 had been taking Zyprexa since 4/29/22. SW F stated on 5/24/23 she had noted R35's lip smacking with the physician. SW F stated she did not complete another AIMS assessment after symptoms were noted. SW F stated there was no plan for a neurology consult and stated the nurses assess R35 for symptoms every day and document on the Medication Administration Record (MAR). In review of R35's May and June 2023 MAR's, there was no documentation of antipsychotic side effects including parkinsonism and abnormal involuntary movements documented on day or evening shifts. Nurse Assistant (NA) K was interviewed on 6/28/23 at approximately 11:30 AM and he did not observe R35 lip smacking and that if her lips were dry, she had lip balm. Licensed Practical Nurse (LPN) L was interviewed on 06/28/23 at 12:03 PM she had noticed R35's lip smacking, but not on the day of this interview. LPN L stated R35 had dentures and thought she was moving her dentures around in her mouth. LPN L stated R35 had lip balm. Note to Attending Physician/Prescriber from pharmacist dated 11/22/22 revealed R35 had been taking Zyprexa 2.5 mg since 4/29/22 and was due for a gradual dose reduction (GDR). The physician response dated 11/30/22 indicated disagreement; and noted R35 continued to exhibit periodic episodes of paranoia and delusions. Note to Attending Physician/Prescriber from pharmacist dated 4/25/23 revealed R35 had been taking Zyprexa 2.5 mg once daily since 4/29/22. Per regulations, two reduction attempts/evaluations were due within the first year of initiation. A GDR was denied on 11/30/22. The same recommendation form indicated R35 was due for a dose reduction to comply with regulations. The physician response indicated disagreement with the pharmacist recommendation and noted R35 previously failed GDR attempt, resident was currently stable and dose reduction was not in her best interest. Nursing Home Administrator (NHA) A on 6/29/23 at 12:50 PM indicated the AIMS test was completed upon the instructions on the assessment and did not have a policy or specific training for staff. The social worker was the only staff that completed the AIMS assessment, and the care plan indicated the AIMS assessment was completed every 3 months.

Based on interview and record review, the facility failed to provide adequate supervision and implement appropriate care planned interventions to prevent falls for 2 of 7 residents (Resident #7 and #56) reviewed for falls, resulting in falls with injuries and fractures negatively affecting the residents highest practicable physical, mental, and psychosocial well-being. Findings include: Resident #7: Review of an Admission Record revealed Resident #7 was a male with pertinent diagnoses which included laceration of scalp, traumatic subarachnoid hemorrhage with loss of consciousness (acute [CONDITION(S)] with bleeding in the brain), history of urinary infections, suprapubic catheter (inserted into a hole in abdomen then directly into the bladder), history of falling, and chronic pain. Review of a Minimum Data Set (MDS) assessment for Resident #7, with a reference date of 2/19/22 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of a total possible score of 15, which indicated Resident #7 was cognitively intact. Review of current Care Plan for Resident #7, revised on 2/22/22, revealed the focus, I am at risk for falls r/t (related to) new admit, hx (history) of falls, Rib fx (fracture), impaired mobility, diagnosis', potential medication adverse effects, Antiplatelet increases risk for bruising/bleeding should fall occur . with the intervention .Staff will remind me and reinforce safety awareness .Need a safe environment with bed kept at knee height, nonskid footwear provided, walker kept in reach, commode used on toilet, safety reminder signs, paddle call light, non skid to recliner .My IDT (Interdisciplinary team) will provide/encourage activities that minimize the potential for falls while providing diversion and distraction .use a fall risk assessment to identify my risk factors . Review of Fall Huddle dated 3/20/22 at 11:20 AM, revealed, .Dining room on 100/200 hallway .Resident was at table with magazines .Resident observed laying on the floor near his wheelchair .Res restless, res was previously in recliner in room scooting down, hollering out constantly, not making sense .Remove high traffic area .Resident to wear leg bag when up .impulsive, poor judgment . Review of (Facility Name) Determination of Reportable Incident/investigation Guide for incident on 3/20/22 at 11:20 AM, revealed, .Immediate intervention: Resident in high traffic area for increased safety, increased monitoring for remainder of shift and staff to call activities to help when resident is anxious or offer to take resident for a walk .Falls committee review: Resident was already in a high traffic area - not going to prevent a possible reoccurrence so intervention removed from plan of care. Also, upon further investigation resident with regular catheter bag and tubing in place. New intervention to change resident to a leg bag when up in his wheelchair to allow for ease with mobility and ambulation . Review of Kardex as of 3/21/22 revealed, .**Please assist me with changing my catheter bag to a LEG BAG when I am up** . Review of Progress Notes dated 5/13/2022 at 11:17 AM, revealed, .At approx. 10:50am writer called to 100 dining room and observed res laying on his left side on the floor in front of the table where he was sitting. W/c to Rt (right) of res. Res alert to himself per his norm stating, I was trying to get to my truck. Res able to move all extremities freely and without difficulty. Staff assisting res off of floor with assist of 3 and a gait belt and placed into w/c. Res able to bear weight with no c/o pain or discomfort when standing. Upon assessment res observed with an area of 5.0x4.0cm swelling to Lt (left) forehead with a 4.0x3.0cm abrasion in the center. Ice applied. Skin tear to Lt upper, outer forearm 3.0x0.5cm. Area cleansed with NS, patted dry, steri-strips applied and covered with [MEDICATION(S)] (waterproof, transparent, sterile barrier to external contaminants). Res also with a 5x4.5cm abrasion to Lt mid back left OTA (open to air). Res talking with staff during assessment. Mood pleasant, smiling at staff. Speech clear, non sensical at times per his norm, continues to make comments of getting home to the farm. PEERL with Lt pupil sluggish. T-97.8 P-80 R-22 BP-152/78 spo2 95% on RA. Res removing his O2 multiple times this AM, spo2 maintaining above 90% with no s/sx of respiratory distress or SOB observed. BG 184. House supervisor made aware of the same . Review of Progress Notes dated 5/13/2022 at 11:28 AM, revealed, .Called to room by wing nurse resident observed sitting in w/c alert per norm with confusion and non sensical speech at times per norm. Large hematoma to Lt forehead, laceration to left elbow and abrasion to left back. Denies dizziness, or nausea. Unable to verbalize whether or not he has blurred vision. Knows that he is in (town residing in). When asked what he was doing he stated he was going to his truck. Rt (right) pupil equal round and easily reactive to light at 3 mm. Lt pupil with small abrasion to outer aspect of eye lid pupil 3 mm and very sluggish. Hand grips weak but equal. (Physician) updated with new order received to transport to ER for Eval . Review of Progress Notes dated 5/13/2022 at 11:40 AM, revealed, .Resident transported to (local hospital) ER via (EMS transport company) with transfer packet, code status, DPOA papers, Meds, labs, progress notes and bed hold policy. Report phoned to (local hospital) ER . Review of Progress Notes dated 5/13/2022 at 3:55 PM, revealed, .Report received from (staff member at local hospital) ER. Res is returning. He does have a bleed. Physician and family aware that it could get worse. Steri Strips placed at facility remain in place. Xray to elbow was negative for fx (fracture). [MEDICATION(S)] has been ordered. [CONDITION(S)] updated. Physician aware of above . In an email sent on 5/26/22 at 10:30 AM, revealed, .Regarding the fall on (5/13/22) (Resident #7) - review of fall on video showed resident stood and attempted to ambulate getting caught on his catheter. Resident was to have leg bag in place when out of bed. This was the intervention put in place from fall in 3/22. (RN #AA) did not change that in his plan of care. Attached is the warning she received. Education was provided that care plan is to (be) updated immediately . Review of Written Record of Verbal Warning for Registered Nurse (RN) AA dated 5/13/22, revealed, .You failed to change a resident's plan of care that was put in place as a fall intervention . Review of Provider Note dated 5/15/22, revealed, .(Resident #7) fell . He was sent to the hospital. He had a small left frontal cutaneous laceration and also, he has a small left frontal subdural hematoma measuring 8 mm .Impression: Closed head injury with a small abrasion and laceration of the left frontal scalp with a small, 8 mm, subdural hematoma . According to [MEDICATION(S)] Plus, a subdural hematoma is a collection of blood between the covering of the brain (dura) and the surface of the brain .most often the result of a severe head injury . https://medlineplus.gov/ency/article/ 3.html. Review of Progress Notes dated 5/17/22 at 3:16 PM revealed, .BIMS done with resident today. He could not recall the month or the day and had trouble with recall as well. While asking questions he asked what this had to do with the cows. Unable to hold a meaningful conversation and would revert back to the farming he had to get done . Review of Progress Notes dated 5/24/2022 at 10:52 PM, revealed, .Res sitting in w/c by fish tank when he leaned over and fell out of w/c onto left side. Writer heard fall with other staff. Res had a cut to left side of head that was bleeding. Staff applied pressure to wound and then assessed res. Res able to verbalize that he was trying to unhook a trailer when asked what he was doing. Res denied pain, PERRL (pupils are equal, round and react to light), ROM (range of motion) intact to all extremities, and no drooping noted to face. V.S. T:99.0, P:88, R:28, B/P:177/96, SpO2:96@RA. BG:274. House supervisor made aware . Review of Progress Notes dated 5/24/2022 at 6:46 PM, revealed, .(Physician) made aware of res fall, laceration to head, Neuros WNL per res . No new orders received . In an interview on 5/24/22 at 3:09 PM, Director of Nursing (DON) B reported (Resident #7) had a fall with a hematoma and the facility had sent him to the hospital and he received stitches to his head. DON B reported for all falls the IDT team reviews and talks about the falls every day, discuss care plans and interventions and if any changes were needed. Review of Orders dated 5/25/22, revealed, .Monitor laceration on L side of head apply CDD (clean dry dressing) if drainage noted q (every) 1 shift and PRN as needed. Cleanse with NS (normal saline) an apply CDD is draining . Review of Orders dated 5/25/22, revealed, .Monitor abrasions to L knee every day and evening shift . During an observation on 5/26/22 at 9:26 AM, CNA D assisted by CNA JJ assisted resident from his wheelchair to his bed in his room. CNA D reported she felt more comfortable with another staff to assist with resident, he was normally a one assist, as he hasn't been standing very good. CNA D reported he had an incident yesterday and was going this afternoon for an x-ray. Resident #56: Review of an Admission Record revealed Resident #56 was a male with pertinent diagnoses which included anxiety, urgency of urination, dizziness and giddiness, stroke, ulcer of [NAME] of left foot, chronic pain syndrome, and history of falling. Review of a Minimum Data Set (MDS) assessment for Resident #56, with a reference date of 4/21/22 revealed a Brief Interview for Mental Status (BIMS) score of 00 out of a total possible score of 15, which indicated Resident #56 was severely cognitively impaired. Review of current Care Plan for Resident #56, revised on 10/27/2020, revealed the focus, .I need assistance with my ADL's. AEB: Needs assistance with bed mobility, transfer, walking .toilet use . with the intervention .My toileting ability is: Assist x 1-2 based on level of arousal. Go slowly when I stand as I become dizzy easily . Review of Progress Notes dated 5/17/2022 at 8:49 PM, revealed, .At approx. 1900 writer called to resident bathroom. Resident was lowered to floor in bathroom after knees buckled during peri care. Resident did not hit head, Neuros WNL (within normal limits) PEERL (pupils are equal, round and react to light) WNL. 2 abrasions to L knee measuring 1.5cm x 0.5cm and 0.4cm x 0.3cm, areas cleansed with NS, patted dry and left OTA (open to air) due to no drainage. No c/o pain or discomfort at that time. BP-107/72, P-61, R-16, T-98.2, SpO2-97% and BG 128. House supervisor made aware . Review of Fall Huddle dated 5/17/22, revealed, .Exact Location of Incident: Room - Bathroom .Describe exactly what you saw: When staff standing resident to provide care after toileting res. knees gave out and staff lowered res on to knees .List causes or potential causes: Gait belt use was not performed by staff .Any other information or specific factors that may have contributed to this fall? No gait belt use .Describe Injuries: Abrasions to L (left) knee . 1.5 x 0.5 and 0.4 x 0.3 .Intervention: Staff education: Education provided to (CNA #II) about gait belt use . Review of Progress Notes dated 5/18/2022 at 10:43 PM, revealed, .Fall on 5/17/2022 reviewed at Fall Committee. All Safety Interventions in place per plan of care and continues to be appropriate at this time. Staff education provided . Review of Progress Notes for Resident #56 revealed no documented refusals by resident to wear a gait belt during ambulation. During an observation on 5/24/22 at 10:36 AM, observed a paper on the door to Resident #56's room, upon further review, the document was a form for 15-minute checks for Resident #56. In an interview on 5/24/22 at 10:37 PM, CNA D reported the form hanging on the outside of the door were for 15-minute checks for Resident #56. CNA D reported she was to make note of what the resident was doing every 15 minutes and she would sign it. Once it is completed, it would go in the chart. CNA D reported the form for 15-minute checks was replaced every day. During an observation on 5/25/22 at 3:15 PM, review of the 15-minute form on the door for Resident #56 revealed missing documentation for a 15-minute check for 2:30 PM and 2:45 PM. Also, no initials were in the time slots for 1:25 PM, 1:30 M, and 1:45 PM for this date.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IDENTIFY THE ROOT CAUSE OF A FALL AND IMPLEMENT RESIDENT-DIRECTED INTERVENTIONS FOR 1 OF 5 RESIDENTS (#12) REVIEWED FOR FALLS, FAILED TO STORE 1 OF 1 TREATMENT CARTS BETWEEN 500 AND 600 HALL THAT CONTAINED TOXIC CHEMICALS IN A SECURED MANNER AND FAILED TO MAINTAIN AN OXYGEN TANK FROM BEING DEPLETED FOR 1 OF 3 RESIDENTS (#1) REVIEWED FOR OXYGEN THERAPY FROM A TOTAL SAMPLE OF 23 RESIDENTS, RESULTING IN A RIGHT HIP FRACTURE FOR RESIDENT #12, POTENTIAL FOR INGESTION OF HAZARDOUS CHEMICALS BY COGNITIVELY IMPAIRED RESIDENTS AND POTENTIAL FOR DEVELOPING LIFE THREATENING RESPIRATORY DISTRESS FOR RESIDENT #1. FINDINGS INCLUDE: ACCORDING TO THE FACE SHEET RESIDENT #12 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE]. THE [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] REFLECTED THE RESIDENT'S BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) SCORED 15 OUT OF 15 POSSIBLE POINTS. HOWEVER, THE CARE PLAN RELATED TO MOOD AND PSYCHOSOCIAL WELLBEING DATED 9/16/11 AND UPDATED 12/7/11 REFLECTED THE RESIDENT COULD BECAME ANXIOUS AND WORRISOME, AND REFLECTED THE RESIDENT RECEIVED AN ANTI-DEPRESSANT. THE CARE PLAN RELATED TO COMMUNICATION DATED 6/28/11 REFLECTED THE RESIDENT HAD IMPAIRED HEARING AND DID NOT USE HEARING AIDS. ON 1/4/12 AT 10:00 A.M., THE RESIDENT WAS GREETED WHILE SHE WAS OBSERVED SITTING IN HER WHEELCHAIR NEXT TO HER BED IN HER ROOM. THE RESIDENT IMMEDIATELY STATED SHE COULD NOT HEAR WELL, BECAME ANXIOUS, SAID SHE WAS GETTING READY TO GO TO A THERAPY SESSION AND DID NOT WISH TO TALK. THE FALL CARE PLAN INITIATED 6/28/11 (admitted ) REFLECTED RESIDENT #12 WAS AT RISK OF INJURY/FALLS RELATED TO AN IMPAIRED MOBILITY, WEAKNESS, HISTORY OF FALLS, [DIAGNOSES REDACTED]. THE CARE PLAN ALSO INCLUDED OTHER RISK FACTORS SUCH AS THE USE OF MEDICATIONS SUCH AS CARDIAC, DIURETIC, ANTIDEPRESSANT, ANTICOAGULANT, STEROID AND NARCOTIC. THE FALL assessment dated [DATE] HAD A TOTAL SCORE OF 11 POINTS. THE NOTE AT THE BOTTOM OF ASSESSMENT INSTRUCTED UTILIZATION OF FALL ALARM IF THE SCORE WAS 5 OR MORE. HOWEVER, THE RESIDENT WAS PROVIDED A FALL ALARM AT NIGHT ONLY. ON 1/5/12 AT 2:20 P.M., THE UNIT NURSE, (STAFF "C") STATED SHE WAS VERY FAMILIAR WITH RESIDENT #12. STAFF "C" STATED," THE RESIDENT AMBULATED EITHER WITH A WALKER OR WHEELCHAIR BY HERSELF, BUT THE STAFF WANTED TO MAKE SURE THE RESIDENT WAS SAFE AT GETTING HERSELF OUT OF BED AT NIGHT BECAUSE PEOPLE GET DISORIENTED OR UNSTEADY WHEN THEY FIRST WOKE UP, THUS THE RESIDENT WAS PLACED AN ALARM BEFORE SHE WENT TO SLEEP." PERSONAL ALARMS CAN HELP TO MONITOR A RESIDENT'S ACTIVITIES, BUT DO NOT ELIMINATE THE NEED FOR ADEQUATE SUPERVISION. THE NURSING NOTE DATED 8/6/11 REFLECTED RESIDENT #12 AS HAVING INFECTION ON HER LEFT LOWER LEG AND WAS BEING TREATED WITH INTRAVENOUS ANTIBIOTIC. AT 4: P.M. ON THE SAME DAY THE NURSING NOTE STATED THE RESIDENT WAS OBSERVED SITTING ON THE FLOOR IN HER ROOM. THE INCIDENT REPORT DATED 8/6/11 REFLECTED THE RESIDENT HAD STATED, " I WAS TRYING TO EMPTY THE BROWN WATER PITCHER AND SLIDE (SIC) TO THE FLOOR." DURING THE WEEK OF SURVEY AT VARIOUS TIMES OF WATER PASSING THE PLASTIC WATER PITCHERS WERE OBSERVED TO BE VERY LARGE AND COULD HOLD APPROXIMATELY 1 LITER OF WATER. THE CAUSE OF FALL ON THE 8/6/11 REPORT WAS LISTED AS "SELF TRANSFERRING. " THE INTERVENTIONS INCLUDED ASKING RESIDENT TO TURN ON HER LIGHT FOR ASSISTANCE AND THE FALL ALARM HAD BEEN ADDED AT ALL TIMES. HOWEVER, THE NURSING NOTE DATED 8/8/11 REFLECTED THE FALL ALARM RETURNED TO BEING ON AT BED TIME ONLY DUE TO THE RESIDENT'S AGITATION. THE NURSING NOTE DATED 10/16/11 REFLECTED RESIDENT #12 REFUSED TO HAVE HER FALL ALARM, SHE WAS UPSET, YELLING AND STATING, " I DON'T KNOW WHY I NEED THIS." RESIDENT WAS REPROACHED AND THE NEED FOR ALARM WAS EXPLAINED. RESIDENT #12 AGREED TO HAVE IT ATTACHED. THE NEXT NURSING NOTE ENTRY DATED 10/17/11 AT 3:25 P.M., (LESS THAN 24 HOURS LATER) REFLECTED, "DUE TO NO ATTEMPTS TO SELF TRANSFER AT NIGHT, FALL ALARM DISCONTINUED AT THIS TIME." ON 1/4/12 AT 12 NOON, BOTH UNIT NURSES, (STAFF "B" AND "E") STATED," WE ALL THOUGHT THAT SHE WAS SAFE WITHOUT ALARMS BECAUSE SHE WAS INDEPENDENT IN HER ROOM." WHEN STAFF "B" AND "E" WERE ASKED WHAT ASSURANCE OR MONITORING TOOL THEY COULD PRESENT AS A PROOF THAT THE RESIDENT WAS INDEED SAFE PRIOR TO DISCONTINUING ALARM, THEY STATED THOSE REPORTS WERE ALL DISCARDED. THE NURSING NOTE DATED 10/27/11 AT 5:55 A.M., 10 DAYS AFTER THE REMOVAL OF FALL ALARM, REFLECTED, "RESIDENT OBSERVED ON FLOOR WITH HEAD AGAINST THE RECLINER. RESIDENT YELLING 'HELP ME.' COMPLAINED OF PAIN IN RIGHT. RIGHT FOOT ROTATED OUTWARD." THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL AND THE DIAGNOSTIC IMAGING REPORT DATED 10/27/11 REFLECTED THE RESIDENT AS HAVING THE RIGHT HIP FRACTURE. THE HOSPITAL CONSULTATION REPORT DATED 10/28/11 CONFIRMED THAT THE RESIDENT HAD INTERTROCHANTERIC/SUBTROCHANTERIC FRACTURE WITH DISPLACEMENT AND ANGULATION. IT WAS RECOMMENDED THE RESIDENT TO HAVE HIP SURGERY. THE REVIEW OF THE INCIDENT REPORT DATED 10/27/11 REFLECTED RESIDENT #12 HAD STATED, "I WAS GETTING MY STUFF OUT FOR MY BATH AND I SLIPPED." THE CAUSE OF THE FALL WAS LISTED AS "NOT USING CALL LIGHT." THE INTERVENTIONS INCLUDED PLACING A FALL ALARM AGAIN. HOWEVER, FURTHER ANALYSIS OF 2 INCIDENTS (8/6/11 AND 10/27/11) REVEALED THAT BOTH RESIDENT'S STATEMENTS HAD SIMILARITIES. ON BOTH INCIDENTS THE RESIDENT WAS ATTEMPTING TO GRAB OR GATHER SOME OBJECTS AND FAILED. THE ROOT CAUSE MIGHT HAVE BEEN HER PHYSICAL CONDITION SUCH AS POOR GRIP STRENGTH OR BALANCE PROBLEM RATHER THAN "SELF TRANSFER" OR "NOT USING CALL LIGHT" AS STATED IN THE INCIDENT REPORTS. ON 1/5/12 AT 2:00 P.M., RESIDENT #12 WAS OBSERVED HAVING A DRESSING CHANGE IN HER ROOM ON HER RIGHT LOWER LEG WOUND WHICH HAD BECOME INFECTED AND WAS BEING TREATED WITH TWO INTRAVENOUS ANTIBIOTICS. THE RESIDENT HAD A LEG INFECTION DURING A FIRST FALL(8/6/11) ALSO. THE RESIDENT HAD SIGNIFICANT SWELLING OF BOTH LEGS AND SCATTERED SKIN WOUNDS THAT COULD ADDITIONALLY CAUSE PAIN AND DISCOMFORT. AGAIN, RESIDENT #12 HAD MEDICAL CONDITIONS THAT PUT HER AT INCREASED RISK FOR FALLS. ON 1/5/12 AT 3:30 P.M., THE FALL COMMITTEE CHARGE NURSE, (STAFF "A") STATED THE FACILITY WAS TRYING TO HONOR THE RESIDENT'S WISH NOT TO WEAR AN ALARM AND HAD ASKED FOR REHABILITATION SERVICES SCREENING FOR ADVICE. THE REHABILITATION SERVICES REPORT DATED 8/10/11 REFLECTED RESIDENT #12 HAD FALL ALARM USE AT ALL TIMES AFTER A FALL 8/6/11, THEN IT WAS REMOVED DURING DAY TIME ONLY ON 8/8/11 DUE TO RESIDENT'S AGITATION. THE REPORT DID NOT ADDRESS IF THE RESIDENT WAS SAFE NOT HAVE AN ALARM. THE REHABILITATIVE SCREENING REPORT DATED 8/26/11 REFLECTED RESIDENT #12 ATTENDED RESTORATIVE NURSING UNIT INCONSISTENTLY, AND HAD MANY EXCUSES TO REFUSE. RESIDENT #12 WAS ENCOURAGED TO PARTICIPATE WITH RESTORATIVE NURSING UNIT AND ENCOURAGED TO AMBULATE WITH "STAFF" IN HALLWAYS. THE REPORT CONTINUED TO STATE, " NURSING NOTIFIED VERBALLY AND IN WRITING TO ASSIST RESIDENT WITH AMBULATION IN HALLWAYS. HOWEVER, THE CARE PLAN DATED 6/28/11 AND UPDATED 10/27/11 DID NOT HAVE THIS INFORMATION AS A FALL RISK INTERVENTION. ON 1/6/12 AT 1:00 P.M., STAFF "A" WAS ASKED WHETHER THE FACILITY HAD ANY EVIDENCE TO SHOW THAT THE RESIDENT HAD MORE FREQUENT AND DIRECT SUPERVISION TO ENSURE THE RESIDENT WAS SAFE WITHOUT AN ALARM OR NOT. STAFF "A" WAS ALSO ASKED WHETHER THE FACILITY HAD CONDUCTED ANOTHER FALL ASSESSMENT PRIOR TO DISCONTINUING THE ALARM TO ENSURE THE INTERVENTION WAS NOT NECESSARY OR NOT. THE FACILITY INCLUDING STAFF "A" WAS NOT ABLE TO PRODUCE EITHER DOCUMENT. ( ) ACCORDING TO PHYSICIAN ORDERS [REDACTED]. THE FOLLOWING WAS OBSERVED DURING THE INITIAL FACILITY TOUR ON 1/3/12 BETWEEN THE HOURS OF 7:20 P.M.-7:30 P.M., IN RESIDENT (#1'S) ROOM : 1. RESIDENT (#1) WAS OBSERVED AS HELP WAS REQUESTED TO RETURN TO BED. 2. RESIDENT (#1) WAS OBSERVED AS SHE STATED, "I'M LIGHT HEADED AND DIZZY." 3. RESIDENT (#1) WAS OBSERVED AS SHE STATED, " I'M FEELING FUNNY." 4. CHARGE NURSE "G" WAS OBSERVED AS SHE UNSUCCESSFULLY ATTEMPTED TO RETURN RESIDENT (#1) TO BED. 5. CHARGE NURSE "G" WAS OBSERVED AS SHE ATTACHED THE OXYGEN TUBING FROM THE PORTABLE TANK ON RESIDENT (#1'S) WHEELCHAIR TO THE OXYGEN CONCENTRATOR IN THE ROOM. 6. CHARGE NURSE "G" WAS OBSERVED AS SHE LEFT THE ROOM, RETURNED WITH AN AIDE AND TOGETHER THEY WERE UNABLE TO TRANSFER RESIDENT (#1) TO BED. 7. RESIDENT (#1) WAS OBSERVED AS SHE STATED," I CANNOT STAND TO TRANSFER BECAUSE I FEEL LIGHT HEADED AND FUNNY." 8. THE AIDE WAS OBSERVED TO LEAVE THE ROOM, RETURN WITH ANOTHER AIDE AND FACILITATED A TRANSFER TO BED WITH UTILIZATION OF A PORTABLE LIFT. 9. THE NEEDLE OF THE GAUGE OF THE PORTABLE OXYGEN TANK ON THE WHEELCHAIR WAS OBSERVED TO LOCATED IN THE MID SECTION OF THE RED AREA. CHARGE NURSE "G" WAS INTERVIEWED ON 1/06/12 AT 7:30 P.M. SHE STATED WHEN RESIDENTS ARE RETURNED TO THEIR ROOMS, IT IS THE EXPECTATION, THE OXYGEN TUBING IS IMMEDIATELY RE- ATTACHED TO A MAIN OXYGEN CONCENTRATOR LOCATED IN THEIR ROOMS. SHE VERIFIED WHEN THE NEEDLE IS LOCATED IN THE RED OF THE GAUGE OF A PORTABLE TANK, IT IS THE RESPONSIBILITY OF THE AIDE TO OBTAIN A NEW ONE ON THE AFTERNOON SHIFT. CHARGE NURSE "G" WAS UNABLE TO VERIFY THE TIME RESIDENT (#1) HAD ACTUALLY BEEN IN THE WHEELCHAIR WITH OXYGEN TUBING ATTACHED TO THE PORTABLE OXYGEN TANK. CHARGE NURSE "G" STATED RESIDENT (#1) NORMALLY WAS ABLE TO ASSIST WITH A TRANSFER WITH THE ABILITY TO BEAR WEIGHT TO HER LEGS. RECORD REVIEW OF NURSES NOTES DATED 1/03/12, 7:30 P.M., WHICH HAD BEEN 10 MINUTES AFTER RESIDENT (#1'S) INITIAL STATEMENT, REFLECTED THE OXYGEN LEVEL RECORDED FOR RESIDENT (#1) WAS 85% WITH OXYGEN AT 3 LITERS ORDERED. THE RECORD REFLECTED THE OXYGEN WAS THEN INCREASED TO 4 LITERS AND THE OXYGEN LEVEL QUICKLY RAISED TO THE DESIRED 90% . RECORD REVIEW OF THE FACILITY "OXYGEN ADMINISTRATION POLICY" DATED 8/2009 REFLECTED NO NOTATION OR DIRECTION TO WHO WAS RESPONSIBLE FOR MONITORING THE PORTABLE OXYGEN TANKS TO ENSURE ADEQUATE CONCENTRATIONS WERE MAINTAINED. AIDE "H" WAS INTERVIEWED ON 1/06/12 AT 2:15 P.M. SHE STATED THE MAINTENANCE DEPARTMENT DELIVERED THE PORTABLE OXYGEN TANKS 3 TIMES A DAY. SHE STATED IT DEPENDS ON THE AMOUNT OF OXYGEN UTILIZED FOR A RESIDENT AS TO HOW FAST THE TANKS EMPTY. NURSE "I" WAS INTERVIEWED ON 1/06/12 AT 2:20 P.M. SHE STATED AIDES RE-ATTACH OXYGEN TUBING TO A RESIDENT'S MAIN CONCENTRATOR IN THEIR ROOMS WHEN THEY RETURN THEM TO THE ROOM. SHE STATED THE TANKS ARE ROUTINELY CHECKED BY AIDES WHEN RESIDENTS RETURNED FROM ACTIVITIES, THERAPY, MEALS OR THE BEAUTY SHOP. NURSE "J" WAS INTERVIEWED ON 1/06/12 AT 2:25 P.M. SHE STATED IF A PORTABLE TANK EVER NEEDS TO BE REFILLED, ALL THE AIDE OR NURSE NEEDS TO DO IS CONTACT MAINTENANCE OR ANOTHER NURSE. MAINTENANCE WORKER "K" WAS INTERVIEWED ON 1/06/12 AT 2:30 P.M. HE WAS OBSERVED WITH A CART WHICH CONTAINED PORTABLE OXYGEN TANKS IN THE HALLWAY. HE STATED HE WAS TO COMPLETE THE FINAL CHECK OF ALL OF THE PORTABLE TANKS UTILIZED IN THE FACILITY. HE STATED THIS WAS COMPLETED 3 TIMES A DAY BY MAINTENANCE, WITH THE LAST CHECK COMPLETED BY MAINTENANCE AT 3 PM. WHEN ASKED WHO COMPLETED THIS FOR THE AFTERNOON SHIFT, HE STATED," I BELIEVE THE JANITOR DOES, BUT THE AIDES WILL OBTAIN AND CHANGE OUT TANKS FREQUENTLY." MAINTENANCE DIRECTOR "L" WAS INTERVIEWED ON 1/06/12 AT 2:40 P.M. HE STATED IT WAS NOT THE RESPONSIBILITY OF THE JANITOR ON THE AFTERNOON SHIFT TO CHECK AND CHANGE PORTABLE OXYGEN TANKS. HE STATED THE AIDES COMPLETED THIS. HE STATED THERE WAS NO RECORD OR MONITORING AS TO HOW LONG A PORTABLE OXYGEN TANK LASTED. HE STATED THEY DID THIS BY MEMORY AND KNEW THE LOCATIONS OF THE VARIOUS REQUIRED TANKS. HE STATED IF A RESIDENT REQUIRED OXYGEN AT 2 LITERS, THE TANK SHOULD LAST FOR 2-2.5 HOURS. HE STATED IF A RESIDENT REQUIRED OXYGEN AT 3-4 LITERS, THE PORTABLE TANK SHOULD LAST ABOUT 1-1.5 HOURS. HE AGAIN STATED HE AND THE DAY SHIFT MAINTENANCE STAFF JUST KNEW BY MEMORY WHERE THE PORTABLE OXYGEN TANKS WERE LOCATED IN THE FACILITY AND THERE WAS NO LIST WHICH INDICATED IF A RESIDENT REQUIRED MORE OXYGEN TO BE DELIVERED. HE STATED THIS IS WHEN THEY WOULD HAVE TO DEPEND ON THE NURSING STAFF TO MONITOR. HE STATED WE DEPEND ON MEMORY AND NO LITERATURE IS AVAILABLE FOR ACTUAL LITERS UTILIZED WITH TIME FRAMES. HE STATED THE MAINTENANCE STAFF COULD NOT PRODUCE AN ACTUAL RECORD TO TELL FACILITY STAFF: WHICH RESIDENTS OXYGEN TANKS WERE BEING MONITORED OR WHEN EACH TANK WAS LAST CHECKED OR CHANGED OR THE ACTUAL AMOUNTS UTILIZED BY THE RESIDENTS WHO UTILIZED THE PORTABLE TANKS. ( ) DURING THE ENTRANCE TOUR OF THE FACILITY ON 1/03/12 AT 7:30 P.M., THE CLEAN UTILITY ROOM LOCATED AT THE ENTRANCE OF THE 500 HALL WAS OBSERVED. THE DOOR TO THE ROOM WAS NOT LOCKED AND A TREATMENT CART WAS PARKED INSIDE. THE TREATMENT CART WAS NOT LOCKED. WHEN THE DRAWERS WERE OPENED, THE CONTENTS INCLUDED TUBES OF CLOTRIMAZOLE CREAM EACH WITH A PRESCRIPTION LABEL FOR A SPECIFIC RESIDENT. A BOTTLE OF HYDROGEN PEROXIDE, WHICH CAN BE HAZARDOUS IF SWALLOWED, WAS LOCATED IN A LOWER DRAWER. THE CLEAN UTILITY ROOM, DINING ROOM, AND NURSING STATION ALL SURROUNDED A CENTRAL SEATING AREA. THERE WAS NO NURSE OBSERVED IN ANY OF THOSE AREAS, NOR IN THE HALLWAYS OF THE 400 OR 500 UNITS AT THE TIME THE CART WAS DISCOVERED UNSECURED. 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