Every finding on record at Maples Benzie County Medical Care

Based on observation, interview, and record review the facility failed to store, discard, and label medication in two of two medication rooms and one of two medication carts reviewed for medication storage.Findings include:On [DATE] at 9:45 AM, an observation was made of the medication cart on the 300-hall and was found to have one insulin pen with an opened date and without a discard date.On [DATE] at 9:50 AM, an observation made of the medication room on the 300 hall and found to have one opened tuberculin purified protein derivative (PPD) solution, 1 ml vial, lot #87891, and expiration date 2/2027 without an opened date. On [DATE] at 10:00 AM, an observation was made as this Surveyor exited the 300-hall medication room of Registered Nurse (RN) N who was administering medications to a resident in room [ROOM NUMBER] with her back turned to her medication cart. The medication cart was unsecured and unlocked until 10:05 AM. The 300-hall housed 20 residents in the unit, of which 18 had a diagnosis of dementia.An Interview with RN N on [DATE] at 10:05 AM revealed the following:When asked about the unlocked and unattended medication cart for 300 hall, RN N replied, I should not have left it unlocked. RN N was asked how long the PPD solution was ok to use after opening and replied, I am not sure how long they are good for or about dating them.On [DATE] at 9:30 AM, an observation made of the medication room on the 100-hall where multiple tuberculin PPD solutions were not labeled properly as follows:Lot # 87891, expiration date February 2027, opened without an opened date or an expiration date.Lot # 90878, expiration date [DATE], with an opened date of [DATE] and an expiration date marked as [DATE].Lot # 87891, expiration date February2027, with an opened date of [DATE] and an expiration date marked as [DATE].Lot # 87691, expiration date February 2027, with an opened date of [DATE] and an expiration date marked as 2/26.On [DATE] at 9:30 AM, an interview was conducted with Registered Nurse (RN) I who was asked how long the PPD solution was good for after opening and replied, I think it is 28 days, but I am not sure. RN I was asked if multi-use vials needed to be dated when opened and replied, Yes and with an expiration date. RN I was asked if she had a pharmacy recommendation formulary for how long medications were okay to use and provided a copy to this Surveyor.Review of pharmacy medication storage and stability pages with RN I who confirmed that the PPD solution is ok to use up to 30 days after opening.On [DATE] at 10:20 AM, an interview was conducted with the Director of Nursing (DON) who confirmed that [NAME]-use vials needed to be dated when opened and discarded per pharmacy recommendations. The DON also confirmed that medication carts are to be always locked unless attended by a nurse.On [DATE] at 11:15 AM, unit coordinator RN L was made aware of the medication storage noncompliance and replied, I just went through all the cart this past Friday.Review of policy titled, Medication Carts/Storage/Expired Medication, dated [DATE], read in part Objective.will maintain resident safety by routinely auditing for expired/discontinued/storing medications. Procedure.Open date and expiration date will be written on the labels provided in medication cart: a.) Expiration dates will follow the Storage and Stability guidelines on each unit.2. Removal of expired or discontinued medications.Expired medication will be returned to the pharmacy.or, in the case stock medications, wasted appropriately and restocked.Review of facility document titled, Medication Storage and Stability, dated [DATE], read in part .Injectables After Opened **date when opened** Description.Tubersol/Aplisol (PPD), Storage - Refrigerator, Expiration - 30 days.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include:On 01/12/2026 at 11:45 AM During a tour of the kitchen with Dietary Manager C, a fresh turkey still in the wrap was noted in a tray on the prep table. When asked what was happening with the turkey, Chef D stated it was thawed in advance and was getting ready to be cooked for a later meal. Chef D pulled out a probe thermometer and stabbed the turkey with the probe to get an internal temperature reading. After noting the temperature, he wiped the probe off with an alcohol wipe and put the cap back on the probe thermometer. When asked if since this probe was placed into an uncooked turkey, should it have been washed, rinsed and then sanitized prior to recapping and storage, Chef D pulled the thermometer out of the tray and went and washed, rinsed and then sanitized it before returning it to the storage container. 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; [NAME] 01/12/2026 at 12:00 PM, a slicer was observed on a prep table covered with a plastic covering. When asked why the plastic cover was on the slicer, DM C stated it was used for food prep, and the plastic cover was to keep it clean after being cleaned and sanitized. When the plastic cover was removed, some food debris was noted on the underside of the blade and casing of the slicer. DM C and kitchen staff demonstrated how after use, the slicer is dismantled with parts that can be removed, taken to the dish machine and non-removable items cleaned and sanitized in place. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch.On 01/12/2026 at 12:15 PM, during an observation with DM C, upon entering the walk-in freezer, Staff member E was observed picking up single serve plastic cups of ice cream that had fallen from a box onto the floor. Staff E was observed placing them back into the cardboard box and placing that cardboard box onto a shelf in the walk-in freezer. After the staff member walked out, DM C was asked what should happen to those single serve ice cream cups and he stated they should be thrown away. At that time, DM C removed them from the walk-in freezer and took them out to the kitchen and disposed of them in the garbage can. According to the 2022 FDA Food Code section 3-701.11 Discarding or Reconditioning Unsafe, Adulterated, or Contaminated Food.(D) FOOD that is contaminated by FOOD EMPLOYEES, CONSUMERS, or other PERSONS through contact with their hands, bodily discharges, such as nasal or oral discharges, or other means shall be discarded. [NAME] 01/12/2026 at 12:45 PM, during an observation of a satellite serving kitchen with DM C, Staff F was observed entering the prep area from the dining room and donning gloves without proper hand washing prior to putting the gloves on. According to the 2022 FDA Food Code section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12.immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (H) Before donning gloves to initiate a task that involves working with FOOD ; and (I) After engaging in other activities that contaminate the hands.

Based on observation, interview, and record review, the facility failed to provide a dignified dining experience based on the reasonable personal concept for two Residents (#47 and #33) of eighteen residents reviewed for resident rights.Findings include:Resident #47 (R47)Review of R47's Electronic Medical Record (EMR) revealed initial admission to the facility on 5/16/19 with diagnoses including dementia, diabetes, and long-term use of insulin. Review of, Section C: Cognitive Patterns in R47's most recent Minimum Data Set (MDS) assessment, dated 11/24/25, ranked R47's, Cognitive Skills for Daily Decision Making as, Severely impaired-never/rarely made decisions.On 1/12/2026 at approximately 12:20 PM, R47 was observed in the dining room with 16 other residents preparing to consume the midday meal. At approximately 12:31 PM, Registered Nurse (RN) J approached R47 in the dining room, lifted her shirt to expose her abdomen, and administered an injection in her stomach without providing privacy.Resident #33 (R33)Review of R33's EMR revealed initial admission to the facility on 1/19/24 with diagnoses including dementia, glaucoma (an eye condition that damages the optic nerve), and macular degeneration (a degenerative condition affecting the central part of the retina). Review of R33's most recent MDS assessment, dated 10/28/25, revealed a Brief Interview for Mental Status (BIMS) score of 5, indicative of severe cognitive impairment.On 1/14/2026 at 8:33 AM, R33 was observed eating breakfast in the dining room at a table with three other residents. RN N was observed interrupting R33 in the middle of the meal and administered eye drops. A total of 8 residents were in the dining room at the time of administration.On 1/14/2026 at 11:06 AM, an interview was conducted with the Director of Nursing (DON) regarding her expectations with medication administration in relation to dignity, privacy, and confidentiality. The DON stated residents are asked if they would like privacy if they are administered anything other than oral medications and may choose to have them administered in a common area. When asked about residents with cognitive impairments who are unable to make daily decisions, the DON stated, Typically, we try to do all our stuff [medication administration] in private. Review of the facility policy titled, Medication Administration, implemented 2/19/24, read, in part: .Policy Explanation and Compliance Guidelines: .provide privacy.

Based on interview and record review, the facility failed to provide written notifications of the reason for hospital transfers to residents/responsible parties and document information communicated to the receiving hospital for three Residents (R3, R13, and R49) of four residents reviewed for hospitalizations. Findings include:Resident #3 (R3) was transferred to the hospital emergency department (ED) on 10/20/25. There was no documentation in the electronic medical record (EMR) indicating a written notification of transfer was provided to R3 or R3's resident representative. The EMR of R3 did not include documentation of information communicated or provided to the receiving hospital when R3 was transferred on 10/20/25. The Director of Nursing (DON) and Clinical Coordinator Registered Nurse (RN) L were interviewed on 1/13/25 at 3:32 PM. The DON said information conveyed to the hospital when a resident was transferred to the hospital would be in a progress note in the EMR. The EMR of R3 was reviewed with the DON. No progress note was in the EMR regarding communication of information with the hospital for the transfer of R3 on 10/20/25. RN L was asked if a written notification of transfer was issued for R3's hospital transfer on 10/20/25. RN L confirmed no written notification of transfer was provided to R3 or R3's resident representative when R3 was transferred to the hospital. Resident #49 (R49) Review of the EMR census information for R49, dated 1/14/26, revealed a discharge on [DATE] and a return date to the facility on 1/12/26. A progress note for R49, dated 1/9/26, read in part .Observed (R49's name) lying on her right side in the bathroom with her feet towards the toilet and her head in her shower . Report called to (local hospital name) Transfer Coordinator.to anticipate arrival. The EMR of R49 did not include documentation of information communicated or provided to the receiving hospital when R49 was transferred on 1/9/26. Resident #13 (R13) Review of the EMR census information for R13, dated 1/14/25, revealed a discharge on [DATE] and a return date to the facility on 8/25/25. A progress note for R13, dated 8/18/25, read in part .She has been reluctant to go to the ER (emergency room).she agreed to go to the ER. EMS (emergency medical services) here to transport resident. Sent with paperwork and phone with charger. Called (local hospital name) Transfer department to notify of transfer per ambulance. The EMR of R13 did not include documentation of information communicated or provided to the receiving hospital when R13 was transferred on 8/18/25. On 1/14/26 at 10:31 AM, an interview was conducted with the Clinical Coordinator RN L, who confirmed that there is no written communication for reason for transfer for R13 or R49 and there is no specific communication for documentation to the receiving local hospital for continuation of care needs for residents being transferred out. Review of policy titled, Admission, Transfer, and Discharge Policy, dated 10/27/25, read in part Purpose: To ensure that all residents admissions, transfers, and discharges are completed in accordance with Centers for Medicare & Medicaid (CMS) regulations, the Michigan Public Health Code, and the home's philosophy of honoring each person's choices, dignity, and sense of belonging.Transfer Procedures.2. External Transfers (e.g., Hospital or Another Facility). The nurse must send the following with the resident: Current medication list and recent vitals. Transfer summary or hospital packet. Advance directives and contact information. Notify the resident's representative, attending physician, and responsible parties promptly. Document time, destination, mode of transport, and notification details. The policy Notification of Changes date 9/20/23 documented, in part: . The purpose of this policy is to ensure the facility promptly informs the resident . and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification . The facility must inform the resident . and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: .A transfer or discharge of the resident from the facility .

Based on interview and record review, the facility failed to monitor and document clinical assessment of changes of condition for two Residents (#3 & #15) of 18 residents reviewed for quality of care. Findings include:Resident #3 (R3) During an interview on 1/12/26 at 2:33 PM, R3 said he was sent to the hospital several times since being admitted to the facility. R3 was unable to recall the reasons for the hospitalizations but said he was admitted to the hospital for a week in October (2025) because of diabetes. The electronic medical record (EMR) of R3 disclosed admission to the facility on 4/26/18. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 indicating R3 had intact cognition. The MDS assessment indicated R3 had a diagnosis of diabetes, received daily injections of insulin, and was at risk for hyperglycemia (high blood sugar). Further review of the MDS revealed R3 received antibiotics for an active diagnosis of septicemia (a bloodstream infection). A nurse's progress note in the EMR dated 10/19/25 at 9:33 AM documented, in part: .staff reported to this RN [Registered Nurse] that resident has been off his baseline mental status with increased confusion/disorientation which has been worsening over the past 3 days. suspected [sic] worsening infection. upon [sic] assessment vital signs included HR [heart rate] 115 [beats per minute - bpm] . increased anxiety, confusion. There were no previous progress notes or assessments documenting a change in mental status for the three previous days as referenced in the progress note of 10/19/25 at 9:33 AM. A nurse's progress note in the EMR dated 10/20/25 at 10:08 AM read, Seen by [physician's name redacted]. Orders received to send to ER [emergency room] for AMS [altered mental status - general term for any significant change in a person's normal brain function, leading to confusion, disorientation, decreased alertness, unusual behavior, or changes in consciousness]. The progress note did not document an assessment or the condition of R3 upon transfer to the ER. There was no documentation in the EMR after the progress note on 10/19/25 at 9:33 AM documenting ongoing clinical assessment of the AMS of R3 prior to the nurse's progress note on 10/20/25 at 10:08 AM when the physician assessed R3 and ordered R3 transferred to the ER. A physician's visit note in the EMR dated 10/20/25 documented, in part: .Has demonstrated worsening mentition [sic: mentation] as of yesterday.staff reported ongoing altered mentition [sic] today. Patient is unable to converse and yells out incoherently. Staff reports heart rates have ranged from 115 [bpm] to 130's [bpm]. A hospital discharge form in the EMR dated 10/27/25 indicated R3 had been admitted to the hospital for diabetic ketoacidosis (a severe, life-threatening condition resulting from complications of diabetes that occurs when the body lacks sufficient insulin, leading to dangerously high blood sugar levels; common symptoms include weakness and confusion). The EMR of R3 did not include an assessment of R3's blood sugar levels while experiencing the AMS despite R3's history of insulin-dependent diabetes. There were no documented assessments monitoring temperature, pulse, or respirations of R3 while he was experiencing the AMS. The EMR did not contain documentation of assessment of R3's behaviors, orientation status, specific cognitive changes, changes in memory or judgment, speech, mood or other symptoms of AMS experienced by R3. A care plan dated as initiated on 8/8/23 read, in part: . [R3 name redacted] has impaired endocrine function r/t [related to] Diabetes Mellitus [group of diseases that affect how the body uses blood sugar] with hyperglycemia. An intervention dated as initiated 8/8/23 read: Monitor for signs/symptoms of hypoglycemia or hyperglycemia – confusion, lethargy, sweating, polyuria [excessive urination]. The Director of Nursing (DON) and Clinical Coordinator Registered Nurse (RN) L were interviewed on 1/13/26 at 3:29 PM. The DON said assessment information should be in the EMR of R3. The DON reviewed the progress notes and assessments of R3 and confirmed the absence of clinical documentation of change of condition. The DON said staff should monitor and assess residents with changes of condition at least each shift and document the assessment findings in the EMR. RN L said R3 had septicemia and they had suspected a worsening of the infection when R3 was identified with AMS. RN L was asked the reason there was no documentation indicating R3 was assessed and monitored for sepsis (a life-threatening condition caused by the body's response to an infection that can lead to organ failure and death) if they suspected the septicemia had worsened. RN L and the DON agreed there should have been documented assessments of R3 in the EMR. Resident #15 (R15) Review of R15's Electronic Medical Record (EMR) revealed initial admission to the facility on 4/26/21 with diagnoses including dementia and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred). Review of, Section C: Cognitive Patterns in R15's most recent Minimum Data Set (MDS) assessment, dated 1/5/26, ranked R15's, Cognitive Skills for Daily Decision Making as, Severely impaired-never/rarely made decisions. Review of a Nurses Note written 12/1/25 at 14:10 [2:10 PM] by Registered Nurse (RN) J read, in part: Increased drowsiness/weakness. Staff have been unable to get resident out of bed today as they have went into room multiple times per hour since 10 AM attempting to get her ready for the day, all attempts she refused.CNA [Certified Nursing Assistant P] reported to this RN that she heard coughing coming from the residents room and when she entered assisted [R15] with the coughing episode. She did have a productive cough, and expelled sputum (a mixture of saliva and mucus) which was reported to have scant red blood present . HR [heart rate] 74, SP02 [oxygen saturation] 91% on RA [room air], RR 24 [respiratory rate], temp [temperature] 98.5 . Lungs are slightly diminished in the bilateral lower lobes with faint coarse/crackles in the right lower lobe. She does have some tachypnea [abnormally rapid, shallow breathing] present at rest. Review of R15's EMR revealed no follow-up vitals or progress note to indicate R15's condition. Review of an Encounter note written by Physician Q on 12/1/25 at 11:19 AM read, in part: Patient [R15] is lying in bed at the time of the exam. Staff report no significant concerns today. no additional issues per nursing. No reported chest pain, shortness of breath, or fevers. On 1/14/2026 at 10:00 AM an interview was conducted with RN J regarding R15's change in condition on 12/1/25. RN J admitted R15's lungs didn't, sound great but her condition was monitored visually throughout the day. When asked if repeat vitals were taken, RN J stated they probably were just not entered in the EMR. When asked about further monitoring of R15's condition and communication between shifts, RN J stated, I probably should have put a follow-up note in [the EMR]. When asked why Physician Q's note did not reflect concerns were communicated from the nursing staff including shortness of breath or abnormal lung sounds as indicated in her earlier note, RN J stated Physician Q typically rounds at 9:00 AM and R15's change in condition happened around 10:00 AM. RN J verified she did not notify Physician Q of R15's change in condition after he initially rounded. On 1/14/2026 at 10:36 AM, an interview was conducted with Assistant Director of Nursing (ADON) R regarding clinical expectations when a resident change in condition occurs. ADON R indicated it is typically communicated either verbally or in an email to the unit ADON and then passed to the doctor if deemed appropriate. ADON R could not recall if R15's change in condition had been reported to her on 12/1/25. ADON R verified there should have been a follow-up note in R15's EMR indicating the outcome monitoring. On 1/14/2026 at 11:06 AM an interview was conducted with the Director of Nursing (DON) regarding change in condition clinical expectations. The DON stated information is typically passed off in report and residents will be added to the provider list in non-emergent situations. After reviewing R15's EMR, the DON stated she would expect to see a follow-up note indicating an update on the current condition. When asked if the physician should have been notified, the DON stated, Yes, I would have expected the physician to have been notified and followed up in the EMR.

This citation pertains to Facility Reported Incident (FRI) 2611699.Based on observation, interview, and record review, the facility failed to identify and mitigate environmental hazards, ensure the appropriate use of assistive devices, and implement care planned interventions resulting in falls for three Residents (#24, #25, #26) of three residents reviewed for accident hazards and supervision. This deficient practice resulted in actual harm when Resident #24 sustained multiple lower leg fractures requiring surgical intervention. Findings include:Resident #24 (R24)Review of R24's Electronic Medical Record (EMR) revealed initial admission to the facility on 8/4/23 with diagnoses including vascular dementia, major depressive disorder, and personality disorder. Review of R24's most recent Minimum Data Set (MDS) assessment, dated 8/5/25, revealed a Brief Interview for Mental Status (BIMS) score of 10, indicative of moderate cognitive impairment. Further review of the MDS indicated R24 was independent in walking distances up to 150 feet and transferring from a bed to chair.Review of the facility incident summary submitted to the State Agency (SA) on 9/2/25 at 12:12 PM read, in part: [R24] was observed on the floor in the doorway of the bathroom today at 0835 [8:35 AM]. She was noted to have blood on her left ankle. It appeared that she has an open fracture of the left ankle. She was walking with CNA [certified nursing assistant] from the bathroom after having a shower . She was nude other than a towel around her. She lost her balance on the floor transition. She went backwards hitting her head on the door, she then went down to the floor. [R24] was not moved from the floor due to probable fracture. EMS [Emergency Medical Services] was called at approximately 0845 [8:45 AM] Fractures confirmed at 1127 [11:27 AM] per verbal report, acute comminuted displaced distal tibial diaphyseal fracture, acute comminuted displaced distal fibular fracture, acute proximal fibular fracture [three fractures of the lower two leg bones].Review of the Emergency Department (ED) Consultation Report on 9/2/25 read, in part: .patient seen in emergency department after having a slip and fall in the shower at her facility. she does have an open fracture with exposed tibia on exam. she will require surgical irrigation and debridement with surgical fixation of her tibia and possible fibula.On 9/17/25 at 9:28 AM, R24 was observed sitting at the edge of bed, eating breakfast in her room. Adhesive strips were noted over surgical wounds on both sides of R24's left ankle as well as under and inside R24's left knee. This surveyor entered R24's room and asked how she was feeling to which she replied, So-so. My ankle hurts. R24 was asked the reason for the surgical wounds, she replied, I fell. Three breaks [fractures]. When asked the location of the fall, R24 pointed at the private bathroom located near the foot of her bed and stated, I slipped. When asked if she was showering at the time of the fall, R4 replied, Yes. R24 asked if the floor was wet at the time of the fall to which she responded, Yes then indicated she no longer wished to pursue the conversation.On 9/17/25 a telephone interview was conducted with CNA A who verified she was assisting R24 in the shower at the time of R24's fall on 9/2/25. CNA A stated R24 was finished showering and was wrapped in a towel making her way toward the bedroom to get dressed. CNA A recalled as R24 stepped over the threshold separating the bathroom tile from the bedroom linoleum, her leg slipped out from behind her, and she proceeded to fall backward and hit her head on the doorframe. CNA A stated, At that point, I watched her bone pop out of her leg. When asked about her positioning at the time of the fall, CNA A stated she was walking backward into the bedroom as R24 was walking forward, just because I know the floor is so slippery. CNA A was asked if she attempted to use a shower chair, a gait belt, or non-skid footwear as ways to increase safety on the slippery floor. CNA A stated R24 is usually hard-headed and at times will not allow it. When asked if she attempted to utilize or offer a shower chair, gait belt, or footwear to R24, CNA A replied, No, I just assumed from prior experience that she would decline.Review of an Incident Note written by Registered Nurse (RN) G, dated 9/2/25 at 9:21 AM, read, in part: Called to room found [R24] lying on floor post shower. During shower CNA witnessed [R24] slip and fall, hit back of head on door, no grip socks in place was just getting out of shower feet floor still wet .Review of the Root Cause Review, signed by the Director of Nursing (DON) on 9/5/25 read, in part: Environmental/Equipment Factors: Floor wet from shower.Behavioral Factors (aggression, noncompliance, etc.): none.On 9/17/25 at 10:15 AM, an interview was conducted with RN G who verified she was the floor nurse on duty at the time of the fall on 9/2/25. RN G was called into R24's room and visualized her on the floor coming out of the bathroom with an open fracture to her left lower leg. RN G stated, The floor was wet. I was mad because she [R24] didn't have a gait belt on, and she can be really impulsive. or even use a shower chair. When I was a CNA, I always dried them [residents] off thoroughly on a shower chair or bench and put footwear on them and a towel on the floor. RN G recalled when she completed a head-to-toe assessment upon entering the room, R24's feet were damp.On 9/17/25 at 10:48 AM, an interview was conducted with CNA D regarding expectations for assisting residents to complete a safe shower. CNA D stated, .instead of trying to do a transfer in the bathroom to get to their room, I get them all dry, their feet dry, get them clothed, their socks on, their shoes on [in the shower room]. It doesn't take a rocket scientist to know you can't have an elderly person walking barefoot on a wet floor. Bare minimum for any resident, you shouldn't be walking anywhere, let alone on slippery floors, with bare feet.Review of a Nurses Note, dated 9/6/25 at 14:17 [2:17 PM] read, in part: .[R24 is now a 2-person full lift transfer. She ambulates with her wheelchair.Review of R24's Medication Administration Record (MAR) revealed the following order, initiated 9/4/25, upon re-admission to the facility: Oxycodone HCl Oral Tablet 5 MG (milligrams), give one table my mouth every 6 hours as needed for severe pain.R24 was administered oxycodone 26 times between 9/4/25 - 9/16/25 for pain management related to the left lower leg fractures and subsequent surgical intervention.Resident #25 (R25)Review of R25's EMR revealed initial admission to the facility 7/14/25 with diagnoses including bilateral primary osteoarthritis of the knees and abnormalities of gait and mobility. Review of R25's most recent MDS assessment, dated 7/22/25, revealed a BIMS score of 7, indicative of severe cognitive impairment.Review of R25's EMR revealed the following Incident Note written by RN G on 9/3/25 at 19:42 [7:42 PM]: Called to room by [CNA B] said that [R25] slipped and fell. When I arrived, resident was laying on the bathroom floor supine no footwear or gait belt or towel on floor. Shower chair in SE [southeast] corner of shower.Lower back and pelvic girdle and hip discomfort upon palpation. Called [physician] for V.O. [verbal order] to send to ER [emergency room].On 9/17/25 at 10:49 AM, an interview was conducted with CNA B who stated she overhead R25 had fallen in the shower while she was being assisted by CNA C. CNA B stated when she arrived at the scene of the fall, the water was running and only one wheel [out of four] was locked on the shower chair.On 9/17/25 at 2:46 PM, an interview was conducted with CNA C who confirmed she was assisting R25 at the time of her fall. CNA C explained she positioned R25's wheelchair near the shower chair to help her transfer. CNA C recalled, I tried to lock the shower chair, but I must have unlocked the wheels by mistake. I also forgot to put a towel on the ground. she didn't have any shoes on at the time. When CNA C was asked if the water was running at the time of the fall, she stated, Yes, it was pretty slippery. CNA C stated when R25 attempted to transfer, the shower chair slipped out for underneath her, causing her fall backward on the shower tile. CNA C confirmed R25 was not wearing a gait belt at the time of the fall.Review of R25's plan of care revealed the following intervention, initiated 8/21/25: Transferring: CGA [contact guard assist] with gait belt and a 2ww [2 wheeled walker] for stand-pivot transfers.Review of a Witness Statement written by CNA D on 9/3/25 at 6:30 PM read, in part: [CNA C] came out of her [R25's] room and told me she slid to the floor. I ran in the room and found [R25] sitting in pain on the floor, she told me the shower chair slid away. The wheels were NOT locked, the floor was wet, and shower running. She [R25] was naked with bare feet on a wet floor!On 9/17/25 at 2:01 PM, an interview was conducted with CNA D who verified she was the first one on the scene after CNA C notified her of the fall. CNA D recalled, When I got there, the water was running, her wheelchair was pushed out behind her, she [R25] was on the floor, the shower chair was in front of her with only one wheel locked. I was mortified.Review of the Root Cause Review, signed by the DON on 9/5/25 read, in part: Environmental/Equipment Factors: No gb [gait belt], no footwear, no locked wheels.Resident #26 (R26)Review of R26's EMR revealed initial admission to the facility 8/1/24 with diagnoses including Alzheimer's disease and repeated falls.Review of an Incident Summary submitted to the SA on 8/5/25 at 2:19 PM read, in part: [R26] was observed on the floor in her room at 0745 [7:45 AM] this am [morning]. [R26] was observed to have a moderate amount of dried blood around her head. [R26] was assisted into full lift sling and lifted to her bed. During the transfer to the bed [R26] began to complain of right hip pain. [R26] was taken to [acute care hospital] for evaluation. [R26] was noted to have a right femur fracture and L2 [lumbar] compression fracture at that time.Review of the Root Cause Review, signed by the Assistant Director of Nursing (ADON) on 8/5/25 read, in part: Interventions/Corrections Implemented: bed alarm to alert staff when [R26] is getting out of bed.Review of R26's plan of care revealed the following intervention, initiated 8/5/25: [R26] uses a bed alarm. Please ensure proper place of alarm pad while [R26] is in bed or in her recliner.Review of an Incident Note written on 9/9/25 at 14:56 [2:56 PM] by RN I read, in part: RN responded to call light pulled out of wall in resident room. Upon entry into room resident was noted to be sitting on the floor with legs straight out in front of her, back against bed frame, left hand on floor supporting her upper body. She was sitting on her floor mat with grippy socks on, CNA was with her. Appears to have slid out of bed. Bed alarm was in place, however, was not on at time of fall.On 9/17/25 at 12:11 PM, an interview was conducted with CNA E who verified she first responded to R26's fall on 9/9/25. CNA E stated she was assisting with feeding in the dining room was she noticed R26's call light was going off. When she went to investigate, she found R26 on the floor with the pancake alarm at the foot of the bed. CNA E stated, When I got in there, I noticed that her [R26] bed alarm wasn't on. I think she coincidentally pulled the pancake alarm out of the wall on her way down. CNA E explained the bed alarms have a switch located on the side that allows them to be turned on or off. CNA E stated the CNA on the night shift who helped R26 to bed most likely forgot to turn it on. On 9/17/25 at 3:23 PM, an interview was conducted with the DON regarding recent falls at the facility. The DON stated it is expected all care planned interventions are in place. On 9/17/24 at 3:34 PM, an interview was conducted with the Nursing Home Administrator (NHA) and DON who understood the concerns related to the falls. Review of the facility policy, titled, Accidents and Supervision, reviewed 8/14/23, read, in part: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s).

This deficient practice pertains to Facility Reported Incident (FRI) 2573015.Based on observation, interview, and record review, the facility failed to follow the care plan to prevent falls for one Resident (#3) of three residents reviewed for accident hazards and supervision.Findings include:Resident #3 (R3):Review of R3's electronic medical record (EMR) revealed initial admission to the facility on 1/31/25 with diagnoses including dementia, difficulty walking, unsteadiness on feet, and repeated falls. Review of R3's most recent Brief Interview for Mental Status (BIMS) evaluation, dated 8/5/25, revealed a score of 3, indicative of severe cognitive impairment. Review of the FRI documentation submitted to the State Agency (SA) revealed the following: [R3] had a fall on 7/25/25 at 1952 [7:52 PM]. Noted to have a hematoma [bruise] above right eye. upon review it is noted that no one saw the incident occur. He [R3] was observed on the floor after the event. he [R3] has poor impulse control and severe cognitive impairment. Noted prior intervention to not leave resident on toilet without assistance and for resident to have gripper socks or shoes on at all times when not in bed.Review of R3's previous incident reports revealed a prior fall which occurred on 5/13/25, resulting in a right hip fracture. Review of a progress note, dated 5/13/25 at 4:08 AM, written by Registered Nurse (RN) I read, in part: Called to [facility unit] for resident [R3] on the floor. reports increased pain at right hip. Regular socks on feet. observed fist size protrusion at right hip. Call to 911 at 2:25 [AM] for EMS [Emergency Medical Services] and possible transport to hospital. EMS arrived, assessed, loaded resident on gurney d/t [due to] resident unable to raise right leg. [R3] left with EMS at 2:42 [AM], to [local hospital] for evaluation and treatment. Intervention: Ensure that [R3] has non-skid socks/footwear on while in bed.Review of R3's plan of care revealed the following focus: SAFETY: [R3] has a risk for injury r/t [related to] risk for burn from spill, high risk for falls.The following interventions were listed on R3's plan of care: Ensure that [R3] is wearing nonskid shoes or gripper socks when ambulating or mobilizing in w/c [wheelchair], initiated 2/20/25.Ensure that [R3] has non-skid socks/footwear on while in bed, initiated 5/13/25.Review of the most recent Fall Risk Assessment on 7/31/25 revealed at score of 65.0, indicating R3 was identified as a high fall risk.On 8/12/25 at 1:25 PM, R3 was observed on a recumbent stepper bike in the rehabilitation room. R3 was asked how his right hip felt to which he replied, It's still sore. Review of a Witness Statement written by Certified Nursing Assistant (CNA) B on 7/25/25 revealed the following questions and answers: When did you last see the resident and what were they doing? 7:15ish PM assisted him [R3] from w/c to bed. What did you see concerning the alleged incident? N/A [not applicable] aside from our unit did not have a single pair of grippy socks - so I could not put grippy socks on him [R3] when I assisted him at 7:15ish.On 8/12/25 at 12:30 PM, a telephone interview was conducted with CNA B regarding her interaction with R3 on 7/25/25. CNA B confirmed she transferred R3 to bed and assisted in changing R3's clothes to sleepwear while he was sitting on the edge of the bed. CNA B stated she removed R3's shoes and noticed he was wearing normal (non-gripper) socks. CNA B stated she left to go retrieve a pair of gripper socks from the linen storage room but realized there were no socks stocked. When asked the usual protocol if the unit were to run out of supplies, CNA B stated staff was supposed to restock the supplies from either laundry or borrow from a different unit. CNA B admitted she was too busy at the time and did not locate a pair of gripper socks for R3 to wear prior to leaving him in bed. When asked if R3 was care planned to wear gripper socks while in bed, CNA stated, He is now. I'm unsure if he was at the time [of the fall].Review of a Witness Statement written by CNA C on 7/25/25 revealed the following questions and answers: What were you doing prior to the incident? Getting slip socks [grip socks] for him and there was none on the unit. What did you see concerning the alleged incident? [R3] did not have any slip socks [grip socks] on or in his room so I went to get some and there was none on the unit.On 8/12/25 at 12:30 PM, a telephone interview was conducted with CNA C regarding R3's fall on 7/25/25. CNA C recollected she responded to R3's sounding bed alarm and located R3 in the bathroom upon entrance into the room. CNA C stated, I noticed he didn't have any gripper socks on. so I told him I was going to grab a pair from the storage room. He's usually fine in the bathroom alone. CNA C reported when she was unable to find gripper socks in the storage closet, she left the unit to locate a pair. Upon return to the unit, CNA C saw Licensed Practical Nurse (LPN) D assessing R3 who was on the floor after an apparent fall. CNA C stated, I don't understand why anybody would put him in regular socks.he shouldn't have had those socks in his room to begin with.Review of an Unwitnessed Fall Report written by LPN D on 7/28/25, read, in part: Heard a loud bang noise. went to resident room, He [R3] was laying on the floor on his right side facing towards bathroom. Head was propped against wall. quarter size hematoma visible to forehead above right eye. Intervention to not leave [R3] unattended while in bathroom and wear non-skid socks of shoes at all times when out of bed.On 8/12/25 at 12:43 PM, a telephone interview was conducted with LPN D regarding R3's fall on 7/25/25. LPN D recalled R3 was left unattended in the bathroom and fell after attempting to self-transfer. LPN D admitted , He's [R3] pretty impulsive. When asked if R3 was wearing gripper socks at the time of the fall, LPN D stated, No, just normal socks. When asked if R3 was care planned to wear gripper socks, LPN D replied, I would assume he's care planned for gripper socks.On 8/13/25 at 10:37 AM, an interview was conducted with Assistant Director of Nursing (ADON) G regarding any injuries R3 sustained because of the fall on 7/25/25. ADON G stated R3 was transferred to an acute care hospital for further testing due to reports of increased right hip pain and eventually readmitted to the facility.On 8/13/25 at 10:54 AM, an interview was conducted with the Director of Nursing (DON) regarding care plan implementation expectations. The DON confirmed R3 should have been wearing gripper socks per his plan of care. The DON stated if gripper socks were not available on the unit, it is expected for personnel to locate additional pairs within the facility.Review of the facility policy titled, Fall Risk Protocol: High Risk, dated 5/18/22, read, in part: .Protocol: implement interventions.that address unique risk factors: medications, psychological, cognitive status, recent change in function status, or root causes of recent fall(s).Review of the facility policy titled, Adding Interventions to the Plan of Care for Events, dated 5/15/17, read, in part:Purpose: the purpose of the intervention is to assure that we are doing everything possible to prevent a similar event from occurring again and to keep our residents safe .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 77 residents of the facility. Findings include: On 12/2/24 at approximately 11:49 AM, observations in the Oak dining room were conducted. A stainless steel pan was observed sitting on an ice base, filled with a green liquid like substance. The temperature of the food was measured and found to be 48 F. An interview with Food Service Worker (FSW) I was conducted at this time, who stated the product was pureed salad. FSW I was requested to measure the temperature of the food with a facility thermometer. FSW I removed a thermometer from an adjacent drawer, and without any attempt to sanitize the probe of the thermometer, placed it in the food. FSW I was observed to push the thermometer stem to the bottom of the steel pan and reported a temperature of 39 F. FSW I was then asked to retract the thermometer somewhat so the temperature of the center of the product could be measured accurately. FSW I then reported a temperature of 48 F. When asked if the temperature of the product had been measured before service had begun, FSW I stated Yes. FSW I then stated the temperature was 37 F about 20 minutes prior. FSW I stated he was not aware the temperature of the foods was to be measured in the middle of the product and to protect against the tip of the thermometer from coming into contact with the bottom of the pan which was in contact with the underlying ice. When asked why the probe of the thermometer had not been sanitized prior to placing it into the food, FSW I stated the thermometer had been sanitized prior to placing it in the drawer, but then acknowledge that the probe of the thermometer was not protected from any contamination in the drawer. FSW I failed to implement any corrective action related to the food's temperature. On 12/2/24 at approximately 12:15 PM, an interview was conducted with the Dietary Manager (DM) H. The observations above were discussed and explained that no corrective action had been implemented related to the food being above the maximum holding temperature of 41 F. DM H stated that the food should be placed in the refrigerator to cool it down. No documentation of temperature demonstrating the food was in compliance with temperature below 41 F was provided. The FDA Food Code states: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 C (130 F) or above;P or (2) At 5 C (41 F) or less On 12/3/24 at approximately 8:41 AM observations were made of the morning meal in the Pine unit. Wiping cloths were observed to be stored in a red bucket, adjacent to the food preparation/service area. FSW J was requested to demonstrate the process of ensuring adequate sanitizing chemicals were present in the solution with the wiping cloths. FSW J removed a short length of QT 40 test strips, used to measure the concentration of quaternary ammonium (quat) in solution. FSW J swished the strip in the solution for approximately two seconds, removed it and read the concentration at more than 400 PPM (parts per million). FSW J was then requested to review the test strip package for directions for proper of the use of the strips. FSW J stated he had not be instructed to hold the strip still, in the solution for ten seconds before comparing the color of the strip to the package to determine the concentration. FSW J stated the only part he had been instructed on was the temperature of the water. The FDA Food Code states: 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A)EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (5) At any time during the operation when contamination may have occurred.

Based on observation, interview, and record review, the facility failed to provide adaptive dining equipment for one Resident (#27) of one resident reviewed for nutrition. This deficient practice resulted in increased difficulty with independent eating. Findings include: Resident #27 (R27) Review of R27's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including dementia, muscle weakness, and limitations of activity due to disability. Review of R27's most recent Minimum Data Set (MDS) assessment, dated 9/10/24, revealed a Brief Interview for Mental Status (BIMS) score of 10/15, indicative of a moderate cognitive impairment. On 12/2/24 at 11:53 AM, R27 was observed eating their lunch meal in bed. R27 was utilizing a stainless-steel fork and demonstrated difficulties with independent feeding due to a noticeable tremor of his right hand. Noodles were observed spilling onto R27's chest due to the tremor. On 12/2/24 at 3:22 PM, a phone interview was conducted with R27's Durable Power of Attorney (DPOA) O regarding self-feeding. DPOA O verified R27 had a progressive tremor in his right hand. DPOA O stated R27's ability to self-feed had improved since receiving special silverware from the facility. Review of R27's Plan of Care read, [R27] receives built-up/curved utensils for his meals. Review of R27's Tray Card read, Equipment: Built-up Utensils (1 each), curved spoon. On 12/4/24 at 8:15 AM, R27 was observed eating the breakfast meal in bed which consisted of eggs, waffles, and oatmeal. R27 was observed with standard stainless-steel cutlery and demonstrated an uncoordinated trajectory to his mouth. R27 was observed appearing to become frustrated and eventually resorted to eating the waffle with his hand. On 12/4/24 at 8:17 AM, an interview with conducted with Certified Nursing Assistant (CNA) L regarding R27's adaptive equipment needs. CNA L verified R27 was supposed to receive adaptive utensils with every meal. CNA L was unsure if R27 received the prescribed adaptive utensils with his breakfast meal. On 12/4/24 at 8:22 AM, an interview was conducted with [NAME] N regarding resident adaptive equipment needs. [NAME] N indicated equipment needs are located on the respective resident's tray card. When asked if R27 received the built-up utensils and curved utensils noted on his tray card, [NAME] N was observed retrieving them from a kitchen drawer. [NAME] N verified the cutlery was never placed on R27's meal tray. On 12/4/24 at approximately 10:55 AM, an interview was conducted with the Director of Nursing (DON) regarding adaptive equipment expectations. The DON verified residents should receive adaptive equipment per their plan of care. Review of facility policy titled, Adaptive Eating Devices, undated, read, in part: .Adaptive devices are available for those needing them . Adaptive devices in use are . provided for each meal. Adaptive devices are noted on each resident's diet card .

Based on observation, interview, and record review, the facility failed to implement revised care plan interventions for falls sustained by one Resident (#67) of three residents reviewed for falls. This deficient practice resulted in the potential for potential for additional falls and potential for subsequent injury. Findings include: On 12/2/24 at 12:30 PM, Resident #67 (R67) was observed on the 400 unit sitting in a recliner in the living room area. R67 had a tab alarm device placed on them (Device used to alert caregivers, should R67 attempt to rise from the recliner without assistance). Review of R67's medical record revealed admission to the facility on [DATE] with diagnoses including cerebral infarction (stroke-occurs when blood flow to the brain is blocked, or otherwise disrupted, causing brain tissue to die), aphasia (affects a person's ability to understand and/or express themselves), and dementia. Review of R67's Minimum Data Set (MDS) quarterly assessment, dated 8/6/24, revealed R67 scored a 2/15 on the Brief Interview of Mental Status (BIMS) assessment indicating severe cognitive impairment. Review of R67's progress note, dated 6/22/24 at 1:00 PM, read in part, .upon entering room [R67] was observed laying on the floor perpendicular to the side of his bed with his head resting on the bottom of his bedside table .Resident does have 2 bruises to the top of right hand, right elbow is red, abdomen is reddened to the right middle side. Left knee is red, left crease of arm is red. Right side of right eye/head slightly red where resident was laying his head down on the end of his bedside table . Review of R67's progress note, dated 9/3/24 at 7:20 PM, read in part, Resident unwitnessed fall out of wheelchair found face down, facial trauma . Review of R67's progress note, dated 10/26/24 at 11:36 PM, read in part, .Fall was witnessed .TV room. Resident was reaching for item(s) at time of the fall .Fall Risk Score: 9 .Wheelchair was involved in fall. Wheelchair was not unlocked at time of fall .New. Location: Right knee. Pain score: 3 .Skin note: Right knee scab post fall Review of progress note, dated 12/02/24 at 1:49 PM, read in part, Had a fall on 10/26/24 and has a tab alarm for his chair and is to have staff keep eyes on him at all times. Uses a wheelchair for ambulation dependent on staff and has foot pedals . Review of R67's care plan, dated 5/1/24, read in part, .Focus: Safety: [R67's] is High risk for injury related to fall risk, Gait/balance problems, Poor communication/comprehension. [created on date 5/2/24] Goal: The resident will be free of falls through the review date [created on date 8/13/24]. Interventions/Tasks: Wheelchair and other assistive devices are in good repair. Remove malfunctioning equipment from use [created on 5/2/24]. [R67's] needs either non skid socks or shoes while up in .wheelchair [created on 5/17/24] . Further review of R67's care plan, dated 5/1/24, lacked additional interventions after R67 fell on [DATE], 9/3/24, and 10/26/24. On 12/4/24 at 8:35 AM, a review of R67's electronic medical record was conducted and revealed, a lack of post fall evaluation and fall risk evaluation on 6/22/24 and 9/3/24, and no documentation on the Kardex or care plan to routinely check for placement and operation of R67's tab alarm. On 12/4/24 at 9:10 AM, an interview was conducted with Certified Nursing Assistant (CNA) G who was asked if they knew when R67's tab alarm was added as a fall intervention and replied, I think it was about a month ago, maybe a little more, but I am not sure. On 12/04/24 at 12:15 PM, an interview was conducted with the Director of Nursing (DON) who was asked about R67 and their frequent falls and replied, After each fall a new intervention should be added. Nursing is also required to complete a post fall and a new fall risk evaluation. The DON was then asked when R67's tab alarm was added and replied, I am not sure I would have to look. The DON reviewed R67's care plan and stated, The tab alarm should have been documented in the medical record and the guardian should have been made aware at the time it was implemented. The DON stated, There is a post fall checklist that nursing fills out. I will get you a copy. Review of policy titled, Fall Risk Assessment, dated 5/18/22, read in part, Policy: It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents. Policy Explanation and Compliance Guidelines: 1. The risk assessment will be completed by the nurse or designee upon, admission, quarterly, or when a significant change is identified .3. An At Risk for Falls care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly. 4. The At Risk for Falls care plan will include interventions, including adequate supervision, consistent with a resident's needs, goals, and current standards of practice in order to reduce the risk of an accident. 5. Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary, in accordance with current standards of practice. Review of policy titled, Post Fall Assessment and Intervention, dated 7/10/17, read in part, Purpose: To provide an analysis of each resident fall in an attempt to prevent future falls or decrease injuries related to falls. Policy Interpretation and Implementation: 1. The DON or designee will conduct the fall report and all witness statements, develop an initial summary report, and ensure an intervention was placed on the care plan . Review of document titled, Falls Checklist, dated 5/15/24, revealed the following: Resident assessment . All falls must have an intervention put in the care plan . Complete a Fall risk assessment . Review of policy titled, Alarms, dated 5/20/22, read in part, Policy Statement: To provide staff with guidelines on proper usage and application of alarms for use with residents. Policy Interpretation and Implementation .2. Place on CNA Kardex and on nursing Care plans and state 'Check for placement and operation every shift.' .

Based on observation, interview, and record review, the facility failed to ensure sanitary storage of respiratory equipment for two Residents (#19 and #20) of two residents reviewed for respiratory services. Findings include: Resident #20 (R20) Review of R20's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) and Parkinson's Disease. Review of R20's most recent Minimum Data Set (MDS) assessment, dated 9/3/24, revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. Review of R20's EMR revealed the following pharmacy order: Ipatropium-Albuterol Solution 0.5-2.5 mg/mL (milligrams/milliliter): inhale orally two times a day (between 8:00 AM - 9:00 AM and again between 5:00 PM - 6:00 PM) for wheezing. On 12/2/24 at 11:36 AM, R20 was observed sleeping in a wheelchair in her private room. A nebulizer (a medical device which turns liquid medication into a very fine mist that can be inhaled through a face mask or mouthpiece) was observed assembled and stored on top of a dresser. Additional observations of the assembled nebulizer stored on top of the dresser were made on: 12/3/24 at 8:19 AM, 12/3/24 at 12:12 PM, and 12/3/24 at 3:36 PM. Condensation was again observed in the nebulizer cup on 12/3/24 at 3:36 PM. Resident #19 (R19) Review of R19's EMR revealed initial admission to the facility on [DATE] with diagnoses including hypoxemia (low levels of oxygen in the blood) and congestive heart failure (CHF). Review of R19's most recent MDS assessment, dated 9/24/24, revealed R19's cognitive skills for daily decision making as, severely impaired. Review of 19's EMR revealed the following order: 1-3 L [liters] of Oxygen as needed to maintain SpO2 [oxygen saturation] above 90%. On 12/2/24 at 12:35 PM, R19 was observed sitting in a wheelchair in a common area, receiving supplemental oxygen via nasal cannula from an oxygen concentrator. A portable oxygen tank was observed affixed to R19's wheelchair with additional oxygen tubing, not in use, hanging on the back of the wheelchair. A protective storage bag was not observed. On 12/03/24 at 9:13 AM, oxygen tubing was again observed hanging on the back of R19's wheelchair, not in use. A protective storage bag was not observed. Oxygen tubing resting on top R19's bed, not in use, was observed on the following dates: 12/3/24 at 10:33 AM, 12/3/24 at 11:59 AM, and 12/4/24 at 10:15 AM. On 12/4/24 at 10:17 AM, an interview was conducted with Licensed Practical Nurse (LPN) M regarding expectations with respiratory equipment storage. LPN M stated following each nebulizer treatment, the equipment should be rinsed and laid out to dry. LPN M stated after drying, the nebulizer equipment should be stored in its designated case or bag for infection control purposes. LPN M stated oxygen tubing and nasal cannulas should be stored in a bag when not in used. LPN M observed R19's oxygen tubing stored on top the bed with this Surveyor and stated, There should be a storage bag. On 12/4/24 at 10:48 AM, an interview was conducted with Clinical Care Coordinator (CCC) B regarding respiratory equipment storage expectations. CCC B indicated oxygen tubing should be dated and stored in a bag when not in use and nebulizer equipment should be cleaned after each medication administration. CCC B confirmed the floor staff required additional education to meet these expectations. Review of facility policy titled, Oxygen Use, revised 3/1/17, read, in part: .when the nasal cannula/tubing are not in use, place them in a Ziploc bag attached to the oxygen concentrator . Review of facility policy titled, Administering Medication through a Small Volume (Handheld) Nebulizer, reviewed 10/12, read, in part: .rinse the nebulizer equipment according to facility protocol, or; rinse with hot water, allow to drive on a paper towel .when equipment is completely dry, store in a plastic bag with the resident's name and date on it .

Based on observation, interview and record review, the facility failed to maintain infection control practice during dressing changes for one Resident (#46) of three residents reviewed for wound care. Findings Include: Resident #46 (R46) On 12/2/24 at 12:42 PM, during an interview, Registered Nurse (RN) R stated R46 stage II pressure injury which was in-house acquired. RN R stated she believed it to be from R46 having periods of prolonged sitting. On 12/3/24 at 2:30 PM wound care was observed performed by Licensed Practical Nurse (LPN) S for the pressure injury located on the coccyx of R46. During this observation LPN S failed to perform any hand hygiene after taking off her gloves following removal of the old dressing. LPN S applied new gloves on her hands and failed to perform any hand hygiene before cleansing and applying the new dressing. Immediately following the observation of wound care, an interview was completed with LPN S who acknowledged the concerns and indicated she was not aware hand hygiene needed to be performed between removal of old dressings and application of new dressings. On 12/4/24 at 1:51 PM, during an interview, the concern was reviewed with Clinical Care Coordinator (CCC) RN B regarding hand hygiene between old dressing and new dressing being applied. RN B acknowledged lack of hand hygiene concern at which time the facility policy addressing the concern was requested. On 12/4/24 at 2:00 PM the Hand Hygiene policy provided, dated 2/15/24 was reviewed in the presence of the Nursing Home Administrator (NHA) and read as follows: . All staff will perform hand hygiene procedures to prevent the spread of infection . . 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. . 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. . After handling contaminated objects . Before applying and after removing personal protective equipment (PPE), including gloves . Before and after handling clean or soiled dressings, linens, etc. After handling items potentially contaminated with blood, bodily fluids, secretions, or excretions . When during resident care, moving from a contaminated body site, to a clean body site . After review of the policy, NHA acknowledged the hand hygiene concern.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure adequate and proper hand washing fixtures in two of four satellite kitchens. 2. Failing to ensure proper cooling procedures were followed for cooked food, cooled and stored in the walk in freezer. 3. Failing to maintain hot food at the proper temperature during holding on the steam table. 4. Failing to provide back flow protection on a hose connection in the kitchen. 5. Failing to provide proper back flow protection on two waste lines serving food preparation sinks in the kitchen. These deficient practices have the potential to result in food borne illness among any and all 78 residents of the facility. Findings include: 1. On 1/29/24 between 1:15 PM and 2:30 PM, initial observations were made of the main kitchen and four satellite kitchens. The hand sinks in the Pine and Elm units' kitchens were activated to wash hands. The installed faucets were electronically activated by motion of the hands near/under the goose neck spout. The water temperature was found to be cold and the time the faucet remained on was less than ten seconds at each faucet. On 1/30/24 between 7:15 AM and 8:30 AM, observations were made during the morning meal. All four satellite kitchens were observed and each of the hand sinks were used to wash this surveyor's hands. All four sinks were observed to be motion activated with the temperature of the water controlled by mixing valves under the sink. No manual controls were available. In both the Pine and Elm units, the water provided by the faucet continued to shut off during the washing process, at times failing to return water flow for more than ten seconds. The water being discharged for hand washing was measured with a probe thermometer to reach a maximum of 66 F and 59 F respectively during the hand washing process. On 1/30/24 at 7:55 AM an interview with cook C was conducted related to the hand wash sink. Cook C stated that hot water was rarely available at the sink used by the cooks in the kitchen. At 8:10 AM an interview with Cook D was conducted related to the sink used for hand washing. Cook D stated the same, that hot water rarely was produced from the hand sink faucet. On 1/30/24 at approximately 10:20 AM, an interview with Environmental Services Director (ESD) H was conducted related to the satellite kitchen hand sinks. ESD H stated the facility has had continuing problems with the sinks and the mixing valves controlling the water temperatures. ESD H also stated the electronic motion activated faucets were problematic and was of the understanding that type of faucet was required by law. ESD H stated the facility would begin replacing the faucets with manual controls to ensure proper flow and tempered water was provided for food service staff. The FDA Food Code 2017 states: 5-202.12 Handwashing Sink, Installation. (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 38 C (100 F) through a mixing valve or combination faucet. Pf (B) A steam mixing valve may not be used at a HANDWASHING SINK. (C) A self-closing, slow-closing, or metering faucet shall provide a flow of water for at least 15 seconds without the need to reactivate the faucet. 2. On 1/29/24 at approximately 2:15 PM, during the initial observations, the walk in freezer in the main kitchen was observed to have many two gallon Lexan containers with left over foods. An interview with Chef B was conducted at this time and asked about cooling procedures and documentation of the same. Chef B pointed to a clip board and stated the documentation for cooling was on the cooling log sheet. Three full containers, one labeled Taco Meat dated 1/24; one labeled beef Burgundy dated 1/29; and one labeled sausage peps dated 1/8 were inventoried on the shelf in the freezer. A review of the cooling log sheet indicated there was not any evidence these three foods were cooled and documented as meeting cooling criteria. On 1/30/24 at 8:55 AM the same observation was made of the freezer, with the three above mentioned containers of food remaining on the shelf. At 9:00 AM, an interview was conducted with Chef B who verified that all cooled foods in the freezer, should follow the defined cooling procedure and be documented on the cooling log. 3. On 1/30/24 at approximately 8:45 AM, observations were made of the morning meal service. A container of food being held on the steam table in Oak unit was identified as pureed Sausage by Cook D. The temperature of the sausage was measured using a metal stem probe thermometer and found to be 117 -124 F. Cook D was requested to measure the temperature of the food, using a facility thermometer, and reported a temperature of 122 F. The FDA Food Code 2017 states: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11 4. On 1/29/24 at approximately 1:45 PM, observations were conducted of the main kitchen. At this time a green garden type hose, with a hand sprayer affixed to the end, was observed connected to a dual water line, with a Y connection, combining the two into one for the green hose and terminating with a hand held sprayer. the sprayer was lying in one of the sinks of the three compartment sink which was directly adjacent. The two water lines were identified as 1/2 copper pipes providing a hot and cold water source and located on the wall behind the cooking stove. No back flow prevention device was connected to the water lines. At this time, an interview was conducted with Chef B who acknowledged the presence and use of the hose. Chef B stated the hose was used for filling the steamer equipment located in close proximity to the hose. Chef B was unaware of the need for backflow protection on the hose and stated it had been that way since he had begun working, which was about a year. 5. On 1/30/24 at approximately 2:45 PM, observations were made in the main kitchen with Dietary Manager ((DM) A. Two stainless steel sinks were identified by DM A as sinks used to wash and process foods, including produce. The drain lines from both of these sinks were observed to be connected directly to the sanitary sewer line without the benefit of an air break. This exposes the food preparation sinks to potential back flow or back siphonage of contaminated waste water from the sanitary sewer lines. DM A stated, related to this issue, I was told this was grandfathered in because of the age of the building. The FDA Food Code 2017 states: 5-202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). 5-202.14 Backflow Prevention Device, Design Standard. A backflow or backsiphonage prevention device installed on a water supply system shall meet American Society of Sanitary Engineering (A.S.S.E.) standards for construction, installation, maintenance, inspection, and testing for that specific application and type of device. 5-203.14 Backflow Prevention Device, When Required. A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap as specified under S 5-202.13 P; or (B) Installing an APPROVED backflow prevention device as specified under S 5-202.14. P 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. P

Based on interview and record review, the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. This deficient practice resulted in the potential for ineffective coordination of medical care and delayed resolution of facility issues, placing all 75 residents in the facility at risk for quality care concerns. Findings include: During an interview on 1/31/24 at 2:40 PM, the QAPI process was discussed with the Nursing Home Administrator (NHA). The NHA stated the QAPI team met at least quarterly and as needed to coordinate and evaluate quality assessment program activities. The attendance documents were reviewed for the 1/20/23, 7/20/23, 9/8/23, 9/22/23, 12/17/23, and 1/25/24 meetings. No attendance documentation was found between February and June. The NHA has assumed her role recently and could not speak to the attendance during that time frame. Review of facility policy titled, QAPI Plan, dated 11/8/23, read in part, .QAA Committee: .Committee meetings are held on a quarterly basis at a minimum. The committee shall maintain written meeting agendas, minutes, attendance records, and QAPI program progress reports .

Based on observation, interview, and record review, the facility failed to honor resident's rights and provide a dignified dining experience for four Residents (R45, R6, R68, and R22) of four residents reviewed for dignity while dining. This deficient practice resulted in the disrespectful treatment of residents and the potential for avoidable weight loss, decreased socialization, and feelings of frustration and helplessness. On 1/30/24 at 12:59 p.m., Resident #45 (R45) was observed to be sleeping at one of the dining room tables during the noon meal on the 200-unit. R45's head was tilted fully-forward with his chin on his chest and a long string of saliva flowing from R45's mouth. An untouched plate of food was in front of R45. Registered Nurse K (RN K) was eating yogurt while sitting directly across the table from R45. RN K was not socializing, engaging, or interacting with the residents sitting at the table. Certified Nursing Assistant J (CNA J) was observed sitting at a table with other residents while eating a plate of food on a facility-issued tray. CNA J was intermittently taking a bite of food from the plate in front of her using her fingers, then giving Resident #22 (R22) a bite of food from a plate in front of R22. CNA J was not interacting or speaking with R22. CNA J was eating from her own plate while assisting R22 to eat without washing or sanitizing her hands. At another dining table, Residents #6 and #68 (R6 and R68) were sleeping with untouched plates of food in front of them. Certified Nursing Assistant I (CNA I) was at the table adjacent to R6 and R68 eating a plate of food on a facility-issued tray. Staff were not supervising, encouraging, or assisting residents to eat. When staff noticed the surveyor observing the dining room, CNA I picked up the plate of food she had been eating from and disposed of the remainder of the food on the plate. CNA I awakened R45 and began feeding the resident while standing over him. CNA I did not interact or converse with R45. RN K disposed of the yogurt container and exited the dining area without supervising or assisting any of the residents. CNA J stopped consuming food from the plate in front of her and focused on feeding R22 but continued without speaking or interacting with R22. The Nursing Home Administrator (NHA) was interviewed on 1/31/24 at 11:06 a.m. regarding Residents Rights. The NHA said the Michigan Department of Community Health's (MDCH) booklet Know Your Rights is reviewed with each resident and/or responsible party (RP) as part of the admission packet when residents are admitted to the facility. An admission packet was examined and contained the booklet referenced by the NHA. The booklet read in part: You have the right to receive necessary nursing, medical and social services to reach and maintain the highest practicable physical, mental, and social well-being.You have the right to adequate and proper care. An undated policy titled 'Meal Service and Distribution' was reviewed and read in part: 4. Positioning and assistance at mealtimes must be appropriate for residents' needs. 5. Residents' meals are distributed promptly with supervision as needed by Nursing staff. A policy dated 12/27/2022 titled 'Promoting/Maintaining Resident Dignity' was reviewed and read in part: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life. 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. The Director of Nursing (DON) was interviewed on 1/31/24 at 2:22 p.m. When questioned regarding the expectations of staff duties in the dining room during resident meals, the DON said staff is expected to assist and supervise residents during mealtimes. When asked if staff is expected to eat their personal meals at the table with residents during resident meals, the DON said staff had a break room to consume their meals and stated, We don't allow them to take a break during mealtimes because resident's need assistance - It's the expectation they don't take a break during resident mealtimes.

Based on observation, interview, and record review, the facility failed to ensure weights were obtained accurately, monitored weekly, and nutritional assessments were completed monthly for one Resident (#31) of two Residents reviewed for weight loss. This deficient practice resulted in the potential for further significant weight loss. Findings include: On 1/30/24 at 8:00 AM, Resident #31 (R31) was observed in the dining room of the 300 unit sitting at a table with one other resident. R31 had a cup of coffee in front of her. R31 did not have any food in front of her and she held her cup of coffee sipping it for approximately 15 minutes. After R31 was finished with her coffee she had a small bowl of oatmeal and a spoon. R31 ate very slowly while the other residents at the table were receiving assistance with their meal. R31 was not observed to eat any additional food at this time just her coffee and oatmeal. Review of R31's medical record revealed she was admitted to the facility on [DATE] with diagnoses including dementia and depression. A review of the 11/28/23 Quarterly Minimum Data Set (MDS) assessment revealed she had scored 4/15 on the Brief Interview of Mental Status (BIMS) assessment indicating impaired cognition and was set up and clean up assistance and independent with eating. Review of R31's care plan, date printed 1/30/24, read in part, Nutrition: [R31] has not been eating consistently well, and she has lost a large amount of weight recently. She had difficulty chewing/swallowing .She had a history of self-feeding difficulty .She is at risk for weight/appetite changes .needs supervision and assistance at times . Review of R31's weight log revealed the following: 1/1/24 - 133.0 pounds (%-17.19 / -27.6 pounds x 1 month -significant weight loss) 12/2/23 - 160.6 pounds (likely inaccurate weight not rechecked) 11/24/23 - 133.0 pounds (%-9.77 / - 14.4 pounds x 6 months - insidious weight loss) 5/16/23 - 139.0 pounds (%-5.7 / -8.4 pounds x 2 days - significant weight loss) 5/14/23 - 147.4 pounds - R31's weigh log revealed she was not receiving weekly weights as indicated in her nutritional assessments. Review of R31's nutritional assessment, dated 10/26/23, revealed an average food intake of 51-75%, frequently accepts snacks, and level of intake likely suboptimal (not meeting) to meet estimated needs and would benefit from resuming oral nutritional supplement. Summary revealed weekly weights. Review of R31's nutritional assessment, dated 11/27/23, revealed an average food intake of 26-50%, snack acceptance none since readmit, and level of intake likely suboptimal to meet estimated needs and would benefit from resuming oral nutritional supplement. Summary revealed weekly weights. Review of R31's order, start date 11/28/23, read in part, Magic cup, two times a day, give at 1400 [2:00 PM] and 2000 [8:00 PM] . Review of the last nutritional note titled weight gain/loss for R31, dated 11/28/23, revealed the following: . 131-159 lb IBW [ideal body weight] range 11/25/23 CBW [current body weight] 133.2 lb 10/26/23 30 days 149.8 lb (-16.6 lb / 11.08%) 09/01/23 85 days 147.0 lb (-13.8 lb / 9.39%) 05/31/23 178 days 145.6 lb (-12.4 lb / 8.52%) sig wt [significant weight] loss unplanned & unavoidable .& diet downgrade - There were no nutritional notes titled weight gain/loss or further assessments since the 11/27 and 11/28/23 nutritional notes related to her significant weight loss. On 1/31/24 at 12:00 PM, and interview was conducted with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). The DON was asked if the dietitian should have a follow up nutritional assessment regarding the significant weight loss note on 11/27/23 and replied, Yes. He should have put one in for the month of December as a follow up to the significant weight loss. The DON was asked about weekly weights and deferred the question to the dietitian. The DON was asked about R31's approximately 28-pound weight gain value (weight taken on 12/2/23) and replied, The weight should have been retaken the same day. I do not know why she was not. The NHA also agreed that the dietitian should be making monthly notes on residents with weight loss. On 1/31/24 at 12:15 PM, an interview was conducted with Registered Dietitian (RD) A. RD A was asked why he did not make a follow up nutritional assessment for R31 and her continued weight loss and replied, I guess I have not been doing that. RD A agreed that there should have been a follow up note. RD A was asked about the frequency of weights for R31 and replied, Everyone is weighed the first day of each month. RD A was asked about the weekly weights indicated in R31's nutritional assessments and replied, I guess I should have put an order in for weekly weights. On 1/31/24 at 2:20 PM, an interview was conducted with Certified Nursing Assistant (CNA) M who was asked what he does if he gets a resident weight that is five or more/less than the prior weight obtained and replied, I would reweight the resident right away. On 1/31/24 at 2:25 PM, an interview was conducted with Licensed Practical Nurse (LPN) O who was asked what she does if she gets a resident weight that is five or more/less than the prior weight obtained and replied, Well you would reweight the resident on that same day. Review of facility policy titled, Weight Assessment and Intervention, dated 5/29/18, revealed, . 3. Any weight change of 5# (3# if under 100 lbs.) or more since the last weight assessment will be retaken the same day for confirmation. If the weight is verified, nursing will immediately notify the CDM [certified dietary manager]. The CDM will communicate wt. (weight) changes monthly to the dietician. 4. The CDM will review the unit Weight Records to follow individual weight trends over time . Review of facility policy titled, Significant Weight Loss, undated, read in part, e. Place the resident/client on weekly weights for one month and review these weights weekly .

Based on observation, interview, and record review, the facility failed to investigate injuries of unknown source for one Resident (R68) of one resident reviewed for abuse. This deficient practice resulted in the potential for unidentified abuse. Findings include: Resident #68 (R68) was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, adjustment disorder with mixed disturbance of emotions and conduct, depression, and others. R68 had a left below knee amputation and required assistance from staff for Activities of Daily Living (ADL). A quarterly Minimum Data Set (MDS) assessment was completed on 11/21/23. R68 scored '00' on the Brief Interview for Mental Status (BIMS) examination, indicating severe cognitive impairment. The MDS documented R68 experienced delusions and wandering behavior. Care plans for R68 included plans of care for impaired cognitive function, impaired decision making and depression, and actual psychosocial well-being problem. On 1/30/24 at 8:57 a.m., R68 was observed sleeping in a recliner in the lounge. R68's upper extremities were visible. An area on the left forearm appeared to be scar tissue formation that presented as a stretched, pink-white colored area with puckered edges. A review of R68's progress notes from 11/1/23 through 1/30/24 revealed entries regarding areas of skin impairment. On 1/4/24 at 10:44 p.m., the documentation noted Right toe - big toe two pinpoint open areas. On 12/23/23 at 10:44 a.m., a note was entered for skin tear on LUE (left upper extremity) anterior forearm noted, wound bed red skin flap in c-shape and 50% intact. Cleansed with saline and applied bandaid to cover . An entry was made on 11/6/23 at 9:44 p.m. that documented: .left knee (front) - small scabbed area on knee . A progress note of 11/2/23 at 9:23 p.m. read .skin is not intact. The following have been noted: right knee (front) has scabbed area .the skin issue is not new . On 1/30/24 at 9:39 a.m., the Administrator (NHA) and Director of Nursing (DON) were asked to provide all incident reports for R68. The incident reports provided were for R68's falls that occurred In July, September, and November of 2023. No incident reports were provided for the areas of skin impairment documented in R68's medical record. The DON was interviewed on 1/30/24 at 11:25 a.m. about incident/accidents, investigation, and reporting. The DON confirmed there were no further incident reports for R68. When queried regarding the expectation for incident report completion, the DON said the policy was for incident report completion for all incidents or accidents and provided examples that included falls, burns, and any skin impairment. The DON stated the procedure would be for incident report completion by the nurse on the floor, then interdisciplinary team (IDT) review at the next morning meeting. When asked about incident reports for R68's skin impairments, including the skin tear identified on 12/23/23, the DON replied, I didn't even know she had a skin tear. The DON reviewed R68's progress notes. The DON agreed R68 was cognitively impaired and unable to reliably verbalize the source of the injuries. The DON defined injury of unknown source as Injuries like bruises or skin tears that are not witnessed. The DON said the facility conducted investigations into injuries of unknown source even if it doesn't need to be reported to the State. The DON confirmed she did not have any investigations, witness statements, or incident reports for the skin tear, open area, or scabbed areas for R68. The DON agreed that the root-cause of the skin impairments had not been determined and there were no care plans regarding R68's risk for skin impairments other than pressure injuries. An undated policy titled 'Skin Injuries (name of facility)' read in part It is the policy of this facility to complete timely incident reporting of all resident skin injuries. Thorough investigations will occur for any suspicious skin injuries or injuries of unknown cause . The Director of Nursing or designee will be responsible to review the report and investigate. Additional actions will be required if the injury is deemed to be suspicious in nature .Witness statements will be required by staff involved if a skin injury is of unknown nature or is suspicious .The residents care plan shall be updated with appropriate interventions for treatment or for avoidance of future injuries.

Based on interview and record review, the facility failed to ensure the licensed pharmacist reported recommendations and medication regimen irregularities to the attending physician, Medical Director, and the Director of Nursing for Two Residents (R68 and R8) of five residents reviewed for medication regimen reviews and recommendations by the licensed pharmacist. This deficient practice resulted in the potential for clinically significant adverse medication consequences affecting all 75 residents in the facility. Findings include: Resident #68 (R68) was admitted to the facility on [DATE]. The licensed pharmacist conducted a review of R68's medication regimen on 12/28/23. The pharmacist documented in R68's medical record in part, Potential irregularity found. See report . There was no pharmacist report found in the medical record. Resident #8 (R8) was admitted to the facility on [DATE]. The pharmacist conducted a review of R68's medication regimen on 10/25/23. The pharmacist documented in R8's medical record in part, Potential irregularity found. See report . There was no pharmacist report found in the medical record. The Director of Nursing (DON) was interviewed on 1/31/24 at 2:22 p.m. The DON was asked where the pharmacist's medication regimen review reports were located. The DON said the facility received the pharmacist's recommendations for the last quarter of 2023 on 1/29/24. The DON confirmed the pharmacist completed the recommendations each month, but the pharmacy failed to deliver the recommendations to the attending physician, Medical Director, and Director of Nursing for the months of October, November, and December 2023. A policy titled 'The [NAME] Drug Regimen Review (DRR) Process' dated 12/14/16 read in part Pharmacy will perform a DRR on each resident no less than monthly . The consultant pharmacist will deliver the recommendations .

Based on observation, interview, and record review, the facility failed to ensure hand hygiene was performed in accordance with accepted standards of practice and facility policy during the provision of wound care and medication administration for two Residents (R8 and R376) of three residents reviewed for infection prevention and control. This deficient practice resulted in the potential for the development and transmission of communicable diseases and infections. Findings include: Resident #8 Resident #8 (R8) was admitted to the facility 5/9/16 with diagnoses of cardiomyopathy (a disease of the heart), amputation of the right lower extremity, peripheral vascular disease, and others. R8 developed vascular wounds on his left lateral calf and left lateral ankle. The treatment order contained the directive to cleanse both wounds with Dakin's solution, a hypochlorite (bleach) solution used to treat skin and tissue infections. A review of R8's medical record revealed the resident had received two courses of antibiotic therapy in January due to bacterial infections in the wounds. On 1/30/24 at 3:04 p.m., Licensed Practical Nurse L (LPN L) was observed completing dressing changes to R8's wounds. LPN L washed her hands and put on gloves before beginning the dressing changes. The top wound was uncovered to expose a large vascular wound on the left lateral calf with evident vascular discoloration extending from below the knee to the ankle circumferentially around the entire leg. LPN L changed gloves twice while treating the wound but did not perform hand hygiene between glove changes. LPN L did not remove the soiled gloves or perform hand hygiene before moving to the other wound. LPN L revealed the wound on R8's left lateral ankle using the same gloves used on the calf wound. When finished with the wound care tasks, LPN L gathered the refuse bag that was utilized for the soiled dressings and placed it on the floor. LPN L completed the treatments and dressing changes to both of R8's wounds without performing hand hygiene until after the treatments were completed and both wounds were dressed. The Director of Nursing (DON) was interviewed on 1/31/24 at 2:22 p.m. The DON said the facility expectations for completing dressing changes were contained in the policy for pressure injury and produced an undated policy titled 'Pressure Ulcer Treatment.' The policy contained a dressing change procedure and read in part: 5. Wash hands and apply gloves. 6. Remove old dressing, remove gloves, and wash hands. 7. Apply clean gloves. 9. Apply dressing/treatment . 10. Discard gloves and wash hands. 11. Place treatment bag in the biohazard waste container if indicated. Resident #376 Resident #376 (R376) was admitted to the facility on [DATE] with diagnoses that included cellulitis (a bacterial infection of the skin) of the left lower extremity, Bacteremia (bacteria in the blood), gangrene (death of tissue), and others. R376 was receiving prescribed intravenous antibiotic due to the infections. During a medication administration observation on 1/31/24 at 9:10 a.m., Registered Nurse N (RN N) was observed to be eating potato chips from a bag of potato chips on top of the medication cart. RN N disposed of the empty bag when she had finished consuming the potato chips but did not wash or sanitize her hands. RN N commenced emptying unit-dose packets of medications for R376 into a plastic medication dispensing cup. When the medications were in the cup RN N placed her ungloved and uncleansed finger in the medication cup and touched the medications. RN N said pharmacy dispensed additional medication tablets in the packet to meet the dose prescribed by the physician. RN N donned gloves and began rummaging through the garbage to obtain the empty medication packet to verify the dosage and number of tablets that had been dispensed. After searching through the refuse, RN N removed the gloves and picked up the medication dispensing cup from the med cart without performing hand hygiene after glove removal. RN N administered the medications to R376 without washing or sanitizing her hands. A policy titled 'Medication Administration Guidelines' dated 4/30/2020 did not contain hand hygiene expectations during medication administration. During the interview with the DON on 1/31/24 at 2:22 p.m., the DON confirmed concerns with breaches of infection control practices with dressing changes and medication administration. When asked why the nurses did not adhere to standards of practice for hand hygiene during medication administration and dressing changes, the DON shook her head and stated, We have a lot of work to do. An undated policy titled 'The [NAME] Isolation - Categories of Transmission Based Precautions Policy' was reviewed and read in part: Standard Precautions shall always be used when caring for residents regardless of their suspected or confirmed infection status. The Centers for Disease Control (CDC) recommendations for Standard Precautions and Hand Hygiene documents in part: Healthcare facilities should require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations. Hand hygiene is an essential element of Standard Precautions. Standard Precautions are intended to be applied to the care of all patients in all healthcare settings, regardless of the suspected or confirmed presence of an infectious agent. Implementation of Standard Precautions constitutes the primary strategy for the prevention of healthcare-associated transmission of infectious agents among patients and healthcare personnel. Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. These include: hand hygiene . Standard Precautions are also intended to protect patients by ensuring that healthcare personnel do not carry infectious agents to patients on their hands .Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: immediately before touching a patient, after touching a patient or the patient's immediate environment . after contact with environmental contaminants . before and after eating food . after contact with blood, body fluids, or contaminated surfaces . immediately after glove removal . ( CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings | Infection Control | CDC; Hand Hygiene Guidance | Hand Hygiene | CDC; Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) (cdc.gov).

Based on interview and record review the facility failed to communicate a change of condition notifications per facility policy and standards of practice for one Resident (R3) of three residents reviewed for condition change. This deficient practice resulted in the inability for family to provide timely medical direction and anxiety, and the inability for the physician to provide medical care direction based on goals set between the physician and the resident. Findings include: This citation pertains to intake #MI00138437 Resident #3 (R3) Review of R3's electronic medical record (EMR), revealed an original admission to the facility on [DATE] with medical diagnoses of chronic obstructive pulmonary disease, anxiety, depression, hypertension, insomnia, and diabetes mellitus. R3's census tab revealed she was discharged on [DATE] to a local hospital. Review of R3's three-day functional assessment, dated 3/3/23, revealed dependence for activities of daily living involving oral hygiene, toileting hygiene, showering, upper and lower body dressing, sit to stand position, chair/bed transfer, and toilet transfer. R3 also required partial/moderate assistance for activities of daily living involving eating, rolling left to right, sit to lying position, and lying to sitting position. Review of R3's incident and accident report, dated 3/4/23 and timed 12:53 AM, read in part, .12:30 AM Responding to calls for help Nurse and CNA (Certified Nurse Aide) found resident on floor horizontal to bed. Resident Description: Unable to articulate the situation .Immediate action taken: Description: .bump to right forehead with bruising .incontinent of stool .Injuries Observed at Time of Incident: Injury Type: Bruise. Injury Location: 1.) Top of Scalp .Mental Status: Unable to assess at this time . Review of R3's hospital summary, dated 3/3/23, revealed a medication list including aspirin (a blood thinner) 81 mg (milligrams) one tab every day at noon. Review of R3's progress notes, dated 3/4/23 at 1:32 AM, read in part, .[physician N] notified per text [family member O] notified per text. On 8/31/23 at 10:09 AM, an interview was conducted with Registered Nurse (RN) J. RN J was asked if he recalled R3 and her fall and replied, Yes. I do recall her. RN J confirmed that R3 had fallen out of bed just after midnight on 3/4/23. RN J also confirmed that he texted R3's family member O and was unable to leave a message as the line he tried to text was a landline and that the family member was not called after R3 had fallen out of bed. RN J confirmed that a text is not normally how a family is notified of an event and that a telephone call is proper procedure. RN J stated that R3 had hit her head during the fall, and she sustained a bump and bruise on her right forehead. Review of R3's neuro check assessment form, dated 3/4/23 at 12:30 AM, revealed, at 6:15 AM a low and or decrease blood pressure of 89/49. At 7:15 AM a line was drawn through assessments of; level of consciousness, movement, hand grasp, speech, pupil reaction, nurses notes and initials. Neuro assessment at that time indicated an abnormal assessment with decrease level of consciousness, weakness in right- and left-hand grasp, pupil reaction sluggish, and no movement. At 11:15 AM similar abnormal assessment from 7:15 AM was documented. Review of R3's progress note, dated 3/4/23 at 11:56 AM, read in part, On earlier neuro check some abnormal result .Large bruise area noted right forehead and one by her left knee. (R3) unable to communicate and problems she is having. Called DR (doctor) .(on call) and gave her up date. Order received to send (R3) to .(local hospital) for (evaluation) . On 8/31/23 at 9:06 AM, an interview was conducted with family member O. Family member O was asked about R3's fall and if he was notified and replied, No. I did not find out she fell at the facility until after she was at the local hospital when I went to see her there. I met her after she was placed at the facility on 3/3/23 around two or three in the afternoon, came to see her around six, and left her that evening around nine in the evening. The facility never called me when she initially fell . There was a female nurse (RN K) who called me to tell me they were sending her to the hospital on 3/4/23 just before noon. They told me she was not feeling well the night before. Family member O was very upset and stated, Couldn't they tell she needed to go get checked out at the hospital. They just picked her up and put her back to bed and left her. On 8/31/23 at 12:10 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked if the doctor should have been spoken to about R3's fall and condition and replied, Yes. The doctor should have been spoken to verbally, not texted and made aware of the incident and R3's findings. The DON was asked to provide proof of the text message from RN J to the doctor and was unable to produce at the time of the abbreviated survey. The DON confirmed that R3 should have been sent to the local hospital for evaluation sooner and the family should have been contacted immediately after the fall as should the doctor. The DON also confirmed that R3's decrease in blood pressure on 3/4/23 at 6:15 should have been communicated to the doctor and the neuro check assessment form should have been fully completed by nursing staff. Review of facility policy, Condition Change, dated 3/16/16, read in part, Whenever a resident's condition deteriorates, the resident's family, responsible party (or guardian) and the physician must be notified. 1. A condition change may be defined as: a. A vast difference in his/her vital signs .d. Any time a resident falls, sustains an injury .

This citation pertains to intake MI00135277. Based on interview and record review, the facility failed to provide appropriate behavioral health services for the expression of suicidal ideation for one Resident (#202) of three Residents reviewed for behavioral health. This deficient practice resulted in actual harm when Resident #202 intentionally overdosed on ibuprofen, resulting in the Resident's hospitalization with subsequent unresponsiveness requiring fluid resuscitation. Findings include: Resident #202 was admitted to the facility on [DATE]. A review of Resident #202's most recent, complete Minimum Data Set (MDS) assessment, dated [DATE] revealed diagnoses including dementia, anxiety disorder and bipolar disorder (disorder characterized by extreme alterations in mood from manic to severe depression). Further review of the MDS assessment revealed Resident #202 was independent for walking and transfers and required set up help only for dressing, eating and toilet use. Resident #202 scored 15 out of 15 on the Brief Interview for Mental Status, indicating she was cognitively intact. A review of Section D - Resident Mood Interview (PHQ-9), revealed Resident #202 reported feeling down, depressed or hopeless 7 to 11 days and reported having a poor appetite or overeating ,d+[DATE] days of the 14-day look back period. A review of Resident #202's hospital Emergency Department Report, dated [DATE] at 4:35 p.m., revealed the following: EMS [emergency medical services] apparently was called due to profound slurred speech and acute onset of altered mentation at 10 AM [10:00 a.m.] . patient is minimally following commands and per EMS is [sic] stopped responding with verbal stimuli in route . Assessment/Plan: Acute encephalopathy [altered brain function] . Further review of Resident #202's hospital documentation revealed the Resident's condition continued to worsen after hospitalization . A hospitalist note, dated [DATE] at 5:44 a.m., revealed the following: Contacted by nurse for patient being hypotensive and more lethargic. Normal saline 1L [one liter] bolus ordered followed with maintenance IV [intravenous] fluids at 125 cc/h, repeated labs showed worsening kidney function . by the end of my shift patient was waking up and becoming more alert, stated that she took 2 bottles of ibuprofen, intentional suicidal attempt, patient placed on suicide precautions . Focus Notes - Last 24 hrs [hours]: [DATE] 04:45 [4:45 a.m.] Patient unresponsive to sternal rub at shift change, day shift reports patient mentation waxes and wanes. Blood pressure soft. Provider paged to room to assess. 1 liter bolus given . [DATE] 05:53 [5:53 a.m.] Patient awake and verbalizing desire to end her life. Patient acknowledges taking two bottles of ibuprofen with the intent of ending her life prior to hospital admission . A review of Resident #202's Hospitalist Progress Note, dated [DATE] at 4:00 p.m., revealed the following: Assessment/Plan . 1. Acute encephalopathy suspect primarily [secondary to] NSAID [non-steroidal anti-inflammatory drug] overdose . 2. Intentional overdose of nonsteroidal anti-inflammatory drug (NSAID) as suicide attempt - after being admitted and mentation started to improve, pt [patient] woke and stated she took 2 bottles of ibuprofen as a suicide attempt. [Facility] confirmed with a receipt in her room of 2 ibuprofen bottles 200mg [milligram] tablets #100. They only found one empty bottle, however [patient] reported taking two. So she would have consumed 20,000 - 40,000mg of ibuprofen on ,d+[DATE] [[DATE]] at some point. [discussed with] poison control, reviewed current lab trends and clinical status . They noted that severe effects often occurs when doses of >400mg/kg [more than 400 milligrams per kilogram of body weight] are ingested, which was her case, and effects of acute encephalopathy would likely begin ,d+[DATE]hr [six to eight hours] after ingestions, which seems consistent with the acuity of her encephalopathy onset . Drug screen reviewed: positive for ibuprofen . Psychiatric Issues depression, bipolar disorder no longer suspected, suspected personality disorder, PTSD [post-traumatic stress disorder] .3. Acute kidney injury suspect in setting of NSAID overdose, baseline Cr [creatinine: chemical indicative of how well the kidneys are filtering waste from the blood] 0.9 [mg/dL], peak at 1.8, now down to 1.3 . It was noted the hospital reference for normal creatinine levels were 0.6 mg/dL (milligrams per deciliter) - 1.1 mg/dL. A review of a hospital Suicide Severity Screening, dated [DATE] at 5:49 a.m., revealed Resident #22 was assessed to be a high risk for suicide. Further review revealed when asked In the past month have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?, Resident #202 responded, yes. A review of Resident #202's Psychiatric Progress Note, dated [DATE] at 4:37 p.m., revealed the following: . When asked why she wanted to kill herself, she stated, hell. When asked if she means that life feels like hell, she says, yes. When asked if she feels like living or dying today, she says, if [Resident #300] would just love me again . A review of Resident #202's facility electronic medical record (EMR) revealed the Resident was transferred to the emergency department for evaluation on [DATE]. Further review of the EMR revealed the following: [DATE] at 9:43 p.m. - Nurses Notes. 2000 [8:00 p.m.] nauseated with multiple episodes of vomiting. Weak, extensive assistance required transferring from toilet to bed. LOC [level of consciousness] altered, responds to verbal stimuli but very slowly . [DATE] at 10:15 a.m. - Behavior Note. Before breakfast this AM [morning] resident was quite lethargic. After removing blankets discovered she was incontinent of both bladder and bowel. This is unusual for her . [physician] came on unit and decided it would be best to send her out [to emergency department] for evaluation. Changes are too dramatic. [DATE] at 11:31 a.m. - . called [hospital, name redacted] and spoke with nurse caring for [Resident #202] to let them know we did find an empty 2 pack of ibuprofen., 100 caplets of 200 mg each, in her room hidden in a drawer. The bottles themselves have not been located. A review of Resident #202's physician progress note for the date of service [DATE], signed on [DATE] at 6:00 p.m., revealed the following: Chief Complaint/Nature of Presenting Problem: Emesis. History of Present Illness: . seen today for reports of multiple bouts of emesis . She has had significant change in level of consciousness. She is only oriented to person, not to place, time or situation . She does report being saddened by having separated rooms from her previous roommate . Assessment: . Decreased level of consciousness . escalation of care due to acute change . Major depressive disorder with single episode . feels her moods have slightly worsened. Recently had somewhat aggressive behavior . A review of an undated facility investigation report revealed Resident #202 and Resident #300 were married in a civil ceremony while residing at the facility. After the ceremony, the Residents resided in a double room together, until Resident #300's condition deteriorated, and family requested he be moved to a private room for comfort. According to a facility Witness Statement, signed by Social Services Designee (Staff) S and Registered Nurse (RN) T, dated [DATE], Resident #300 was moved to a private room on [DATE]. Further review of the Witness Statement, revealed the following: . went to speak to [Resident #300] about the room change. [Resident #202] was in room sleeping during the conversation but awoke when she heard us speaking. Please see attached progress note for more details . A review of the attached progress note, signed by Certified Nurse Aide (CNA) U and dated [DATE] at 2:50 a.m., revealed the following: Behavior Note. Late Entry. Resident was very upset about [Resident #300] getting moved to his own room. I was trying to comfort the resident and she made the statements she was going to kill herself [and] she wishes she could just die [and Resident #300] promised that they would die together. Resident was also asked if she knew what happened to [Resident #300's] necklace that he always wears, she responded with I know exactly where it is but I'm not telling. Resident did end up telling where it was. She stated that if she saw if on [Resident #300] she would rip it off him. During an interview on [DATE] at 12:05 p.m., CNA U confirmed the statements she recorded in the Behavior Note, on [DATE] at 2:50 a.m., to be true and accurate. CNA U reported she immediately notified Staff S and the nurse on duty at that time, of Resident #202's suicidal ideation and expressions of self-harm. CNA U stated she could not remember the exact time Resident #202 expressed the desire to die or the name of the nurse on duty whom she alerted to Resident #202's behavior. CNA U reported Resident #202 was upset about the CNA looking for Resident #300's necklace with his previous, deceased spouse's wedding band threaded on it. CNA U stated no room check for harmful objects or substances was conducted during her shift on [DATE]. CNA U stated after alerting nursing and Staff S of Resident #202's comments, she went about caring for other residents. Further review of Resident #202's EMR for [DATE], including all progress notes, assessments, physician notes and Behavioral Care Solutions (BCS) documentation revealed no follow-up to Resident #202's comments regarding the expression of suicidal ideation on [DATE]. A review of physician orders and point of care documentation revealed no initiation of suicide precautions, including a search of the Resident's room, prior to [DATE]. On [DATE] at 12:12 p.m., the Director of Nursing (DON) reported RN V cared for Resident #202 during the 7:00 a.m. through 7:00 p.m. shift on [DATE]. An attempt to reached RN V by telephone was made on [DATE] at 12:15 p.m. No return call was received prior to the end of the survey on [DATE]. During an interview on [DATE] at 11:20 a.m., Resident #202 confirmed she had intentionally taken two full bottles of ibuprofen prior to her transfer to the emergency department on [DATE]. Resident #202 could not recall how many pills but stated both bottles were full and she threw the empty bottles in her bathroom trash. Resident #202 stated she had counseling while hospitalized and now feels better. She stated Resident #300 passed away while she was hospitalized , and she never had the chance to say goodbye. Resident #202 reported she took the ibuprofen because she was in need of attention and was lonely. During an interview on [DATE] at 12:23 p.m., Staff S reported being unaware of Resident #202's verbal expression of suicidal ideation on [DATE]. Staff S stated she was not notified of Resident #202 commenting she wishes she could just die or that she was going to kill herself. Staff S confirmed no referral for evaluation of suicidal ideation by Behavioral Health or the physician was initiated prior to the Resident presenting with decreased level of consciousness on [DATE]. Further review of Resident #202's EMR revealed the following: [DATE] at 3:52 p.m. - Late Entry: RN [V'] and [Staff S] social services went to speak with [Resident #300]. [Resident #202] was in the room sleeping in the bed next to [Resident #300] . agreed with being in his own room, as he feels it will help him feel better. [Resident #202] was very upset . RN and [Staff S] assisted [Resident #202] out of the room to speak with her. [Resident #202] continued to state you are taking everything from me. tried to explain that the move was about [Resident #300] and his care and not about her. [Resident #202] continued to state that is was about her. [Staff S] and this RN [V] made multiple attempts to explain to [Resident #202] but she was not understanding. [Resident #300's] necklace [with deceased spouse's ring] was placed on his neck. Orders placed to check this every 2 hrs [hours] as [Resident #202] stated she would take it off him. [DATE] at 2:54 p.m. - [Resident #202] ambulated to inside of nurses' station to confront a staff member while she was giving report. [Resident #202] stated that she thought you were my friend. Staff member stated she was unaware of why resident was upset. Staff stated that she was just attempting to give report. [Resident #202] began to cry and became agitated and requested to speak to [Nursing Home Administrator, NHA]. [DATE] at 10:54 a.m. - Care plan and CNA tasks updated to reflect q 15 minute [every 15 minute] checks for her location. [Resident #202] is disruptive with care with her significant other [Resident #300] and must be accompanied when she visits with him. During an interview on [DATE] at approximately 11:15 a.m., the DON confirmed Resident #202 was not assessed for suicidal ideation or risk after the Resident made suicidal comments to CNA U on [DATE] or prior to her hospitalization on [DATE]. The DON stated it appeared the focus was on the care and comfort of Resident #300 and Resident #202's mental status was not sufficiently taken into account. The DON reported when a Resident expresses thought of self-harm, a complete assessment should be conducted by nursing staff, the physician notified and increased safety monitoring immediately implemented. A review of the facility policy titled Suicide Threats, dated [DATE], revealed the following: Resident suicide threats shall be taken seriously and addressed appropriately. Staff shall report any resident threats of suicide immediately to the Charge Nurse. The Charge Nurse shall immediately assess the situation and shall notify the Director of Nursing or Administrator of such threats. A staff member shall remain with the resident until the Charge Nurse arrives to evaluate the resident. After assessing the resident in more detail, the Charge Nurse shall notify the resident's attending physician and responsible party and shall seek further direction from the physician. Appropriate nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in the resident's behavior. The resident surround should be searched for any objects that could be using in harming self. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. If the resident remains in the facility staff will monitor the resident's mood and behavior and update care plans accordingly until a physician has determined that a risk of suicide does not appear to be present.

This citation pertains to intake MI00133945. Based on interview and record review, the facility failed to protect Resident (#100's) right to be free from neglect when the facility failed to ensure staff competency in following resident care plans and in the use of a mechanical lift during transfers. This deficient practice resulted in actual harm when Resident #100 sustained a fractured right femur, subsequent surgical repair and hospitalization . Findings include: A review of Resident #100's Minimum Data Set (MDS) assessment, dated [DATE], revealed she was admitted to the facility on [DATE] and had diagnoses including dementia, stroke, hearing loss and reduced mobility. A review of the MDS assessment Section C- Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) was not completed due to Resident #100 being rarely/never understood. The Staff Assessment for Mental Status revealed Resident #100 had impaired long and short-term memory and moderately impaired decision making. Further review of the MDS assessment revealed Resident #100 was assessed as having Functional Limitation in Range of Motion, in both lower extremities and required two-person, physical assistance for toilet use (how resident uses the toilet room . transfers on/off toilet, cleanses self after elimination . and adjust clothes .). A review of Resident #100's Electronic Medical Record (EMR), accessed on [DATE] at 10:39 a.m., revealed the following: [DATE] 01:06 (1:06 a.m.) Nurses Notes . Notified by CNA (Certified Nurse Aide H) at approximately 2145 (9:45 p.m.) this nurse was needed in rm (room), entered rm and found (Resident #100) laying on her bed and her CNA (CNA F) standing nearby, (CNA F) explained that (Resident #100) was slipping out of the standing (sit to stand lift used to assist resident to rise to a standing position on the lift base for transfer to another surface) lift sling and she was hanging there, so (CNA F) went outside the rm and yelled for help, (CNA G) came into the rm to help. (CNA G) lifted her (Resident #100's) upper half and (CNA F) took her (Resident #100's) legs and they put her into bed. During the transfer or while in the sling, (Resident #100) sustained a small skin tear to her right forearm. Once in bed (Resident #100) c/o (complained of) right leg pain. It hurt when her leg was moved. Per both (CNA F) and (CNA G) (Resident #100) did not fall or hit her leg during the transfer. Leg was examined and found to have a scratch down her right inner thigh. There was also a bruise behind her right calf. The age of the bruise is unknown to nurse . [DATE] 12:50 (12:50 p.m.) Nurses Notes . As the day went on (Resident #100) began to complain of increased pain . [DATE] 13:59 (1:59 p.m.) Nurses Notes . Assessment of right lower extremity revealed swollen right thigh . Palpation of the right thigh (Resident #100) complains of pain. Any movement of the thigh causes discomfort. Right inner thigh is larger than the other. Call to on call (physician) at 1500 (3:00 p.m.) . gave approval to send (Resident #100) for assessment . Director of Nursing (DON) informed via phone call at 1504 (3:04 p.m.) instructs to send via EMS (Emergency Medical Services) . A review of Resident #100's hospital History and Physical, dated [DATE] at 20:33 (8:33 p.m.), revealed the following, in part: Pt (patient) arrives via EMS from (facility) post fall last night. EMS (states) (facility) staff (state) it was a bad transfer . Assessment/Plan . 2. Femur fracture, right: Xray: Obliquely oriented fracture (angled fracture going completely through the bone, most often cause by fall or trauma) or spiral fracture (fracture winds around length of bone, twisting injury) through the distal diaphysis (bone shaft) of the right femur (thigh bone) . A review of Resident #100's Radiology Report, dated [DATE] at 5:55 p.m., revealed the following, in part: Findings . Obliquely oriented displaced (pieces of bone moved to the point a gap formed around the fracture) fracture of the distal right femoral diaphysis with rotational component. Medial displacement and rotation of the distal fracture fragment noted mild overlap of fracture fragments . A review of Resident #100's Orthopedic Consultation, dated [DATE] at 7:42 a.m., revealed the following, in part: Patient has been placed on the OR (Operating Room) schedule with the offer for surgical stabilization to assist with pain management and stabilization for transfers. This would be in the form of open reduction internal fixation of the femoral shaft . Diagnostic Results: Impression . There is oblique right mid to distal femur fracture . there is over 10 cm (centimeters) of shortening/overriding bone in these images. A review of an incident report dated [DATE] at 9:45 p.m., revealed the following: Witnessed Fall . (Resident #100) . Level of Consciousness: Alert. Mobility: Wheelchair bound. Mental Status: Oriented to Person. Predisposing Situation Factors: During transfer. It was noted there were no Predisposing Environmental Factors, or Predisposing Physiological Factors, marked regarding Resident #100's fall. A review of the investigation documents for (Resident #100) fall with fracture on [DATE], provided by the DON, revealed the following: As reported by (RN I) in her incident note and in personal interview . At approximately 2145 (9:45 p.m.) on [DATE] (CNA F) was providing (bedtime) care for (Resident #100). She (CNA F) had taken her to the bathroom in the sit to stand lift. Upon finishing she raised (Resident #100) up into a standing position with the sit to stand lift. Per an interview with (CNA F) the belt was snug, and the leg straps were on per instructions. (CNA F) stated that as she wheeled (Resident #100) out of the bathroom (Resident #100) let her legs go slack which caused her to almost slip out of the sling but due to the sling belt (Resident #100) was held up and did not fall to the floor . In both a personal interview and written statement by (CNA G) . it was learned (CNA G) was in the process of taking soiled linen to the hopper room when she heard (CNA F) call out for help. (CNA G) went in and saw (Resident #100) slipping out of the sling and that it was around her armpits. (CNA G) yelled for (CNA H) in case they needed another hand. Together, with (CNA G) controlling the lift, (CNA G) holding the sling/upper torso and (CNA F) taking (Resident #100's) legs they lifted her into bed. (CNA G) reports that (Resident #100) yelled out in pain and that (CNA G) thought the leg was turned. Further review of the facility investigation documents revealed the following: (Registered Nurse (RN) K)was the nurse on duty the next morning . mid-afternoon (RN K) noted through (Resident #100's) slacks that her right leg was swollen . (Resident #100) was having pain and the leg was shortened at that time . (RN K) notified the physician and sent (Resident #100) to the emergency room for evaluation. X-ray report revealed an obliquely oriented fracture or spiral fracture through the distal diaphysis of the right femur . (Resident #100) did undergo surgery at (acute care hospital) . (Resident #100) has been wheelchair bound for several years and has severe dementia . Her transfer status was to be done with 2 assists and sit to stand lift, however, (CNA F) stated she was unaware of this . The root cause of the fracture is undetermined. Theories are that it may have been a pathological fracture when she slid downward and that the leg straps held her calves in place putting pressure on the femur. There is also a thought that at the time it occurred it was not displaced but after sitting in a reclining position in the wheelchair the next morning . it became displaced and began to swell. A review of the interview statements included with the facility investigation documents revealed the following: Interview with (RN I) on [DATE]: (RN I) admits that (Resident #100) was having some pain but because (CNA F and CNA G) stated there was no fall and that (Resident #100) did not bump her leg on the lift she (RN I) did not do anything more. (RN I) did state that she observed a skin tear to the right inner thigh which she cleansed and dressed but did not see anything unusual about the appearance of (Resident #100's) leg . Interview with (CNA G) on [DATE]: When asked if the leg straps were intact, she could not recall . Interview with (CNA H) on [DATE]: When asked what she observed she stated that she saw (Resident #100) sitting on the floor beside the bed with the sling around her armpits. She did not know if the leg straps were on or not. She stated that (CNA G) picked her up by the upper torso and (CNA F) took her legs and lifted her up and into the bed. (CNA H) followed with the sit to stand lift which (Resident #100) was still attached to. (CNA H) said (Resident #100) complained of pain to the right leg and it appeared to her that it was turned inward. Interview with (CNA F) on [DATE]: (CNA F) stated that she had put the leg straps on the lift which was unreported and is policy. There is a handle on the back of the new slings for the sit to stand. (CNA G) lifted (Resident #100) with the handle and (CNA F) lifted by (Resident #100's) legs . we are a no lift facility . this was an improper transfer and (Resident #100) should have been lowered to the floor and a full lift used to put her into bed . It was also pointed out that the Kardex/care plan stated that two staff should be with (Resident #100) when any type of lift is used . Further review of the facility investigation documents revealed the following: . some thoughts on what happened. The (right femur) fracture may have occurred when she began to slide out of the sling as her calves were still in the leg straps (fracture was mid-femur). Or did it happen when they picked her up by her legs and torso . A review of CNA F's undated, signed statement included we transferred (Resident #100) back to bed, (CNA H) noticed her right lower leg was turned toward her left leg . at this point I was concerned . (Resident #100) was in extreme pain. I was very concerned and returned to (Resident #100's) room approximately 15 (minutes) later, she was still in pain . (RN I) reassessed her and said she believed she was ok. A review of all accident and incident reports from [DATE] through [DATE] revealed on [DATE], Resident #100 fell when CNA F attempted to transfer the Resident, without assistance, using the sit to stand lift. Further review of the incident report titled Witnessed Fall, dated [DATE] at 10:05 p.m., revealed the following: The emergency call light went off in (Resident #100's room), followed (CNA M) . Entered room and found (Resident #100) sitting on her bottom on the floor with (CNA F), standing in back of (Resident #100) supporting her back and head. (Resident #100's) legs were still strapped to the new standing lift. (CNA F) stated I had to lower her to the floor because she was slipping out of the sling . Predisposing Environmental Factors: None. Predisposing Physiological Factors: Incontinent. Predisposing Situation Factors: Improper footwear. During transfer. Other Info: (CNA F) was transferring (Resident #100) in the new sit to stand lift and was getting her ready for bed. (Resident #100) was incontinent and barefoot. Further review revealed Immediate Action Taken: (CNA M) unfastened (Resident #100's) legs from the lift straps and lowered her legs to the floor . The signed investigation document attached to the fall reported included An intervention on the care plan was to have 2 staff present with the sit to stand . It was noted in review, Resident #100's legs were still strapped to the sit to stand lift upon staff entering the room and finding Resident #100 on the floor with CNA F. A review of Resident #100's care plan revealed the following plans were initiated, and active, prior to the Resident's fall on [DATE]: Focus: (Resident #100) is high risk for falls (related to) confusion, deconditioning, gait/balance problems. Date Initiated [DATE]. Goal: (Resident #100) will be free of minor injury through the review date. (Resident #100) will not sustain serious injury through review date. Date Initiated: [DATE]. Interventions: (Resident #100) to be sit to stand lift for transfers, downgrade PRN (as needed) to full lift when not actively assisting with BLE (bilateral lower extremities). Date Initiated: [DATE]. Two staff members to operate new lifts until everyone is comfortable. Date Initiated: [DATE]. Focus: (Resident #100 has an ADL (Activities of Daily Living) self-care performance deficit (related to) dementia. Date Initiated: [DATE]. Goal: (Resident #100) will maintain current level of function in all ADLs through the review date. Date Initiated: [DATE]. Interventions: Transfer - (Resident #100) requires extensive assistance by 2 staff to move between surfaces as necessary. Date Initiated: [DATE]. Focus: (Resident #100) Transfers. Date Initiated: [DATE]. Goal: (Resident #100 will maintain level of function through review date. Date Initiated: [DATE]. Interventions: (Resident #100) is a sit to stand lift with a medium sling for transfers. May downgrade to full lift when needed. Date Initiated: [DATE]. Two staff when sit to stand used. Date Initiated: [DATE]. During an interview on [DATE] at 1:00 p.m., the facility Training Coordinator, Licensed Practical Nurse (LPN) B reported after Resident #100's fall on [DATE], CNA F reported she did not feel comfortable using the sit to stand lifts. LPN B was asked what the procedure was for assessing staff competencies following accidents, including resident injuries during transfers. LPN B stated after a fall with injury the Interdisciplinary Team (IDT) review the incident reports and determine what they believe to be the cause of the fall and review the care plan for appropriateness. LPN B add that if failure to follow facility policies and care plans were believed to have contributed to the fall, staff would be re-educated, and competency assessed. LPN B stated CNA F was not retrained on lift use or competency assessed after the fall from the lift on [DATE] and before Resident #100 fell from the lift on [DATE]. LPN B reported after Resident #100's fall on [DATE], CNA F was scheduled to be re-trained and have competency assessed on using the sit to stand lifts but left employment with the facility prior to completion. LPN B stated all staff were trained in [DATE], when the facility received new sit to stand lifts, were instructed to use two-person assistance until comfortable using the lift and were to report if more training was needed. LPN B reported all staff are trained on the facility's no lift policy and should not physically lift a fallen resident from the floor, but instead get assistance and use a total, mechanical lift to transfer the resident for safety. On [DATE] at 2:00 p.m., LPN B was asked how someone could fall out of the sling on the sit to stand lift. LPN B stated she is unsure how Resident #100 could have slipped out of the sling, if the sling was appropriately secured to the Resident and the lift. She added that some residents may become weak during transfers, that is why Resident #100 was care planned for two-person assistance using the lift. LPN B reported after Resident #100's fall on [DATE], CNA F was instructed not to perform any lift transfers until she could be retrained and reassessed for competency. During an interview on [DATE] at 3:34 p.m., the DON reported she was aware Resident #100 had a previous fall on [DATE], while being transferred by CNA F using the sit to stand lift. The DON acknowledged CNA F did not follow Resident #100's care plan and transferred the Resident with the sit to stand lift without the presence or assistance of another staff member. When asked if CNA F was reassessed for competency using the new sit to stand lifts after the Resident's fall on [DATE], the DON stated she would expect the CNA to be assessed using the lift to determine teaching needs and safety using the lift. The DON reported she could not provide documentation of CNA F being reassessed for safety and competency in transferring residents using the sit to stand lift following the fall on [DATE]. The DON stated on [DATE], a nurse spoke with CNA F regarding the necessity of following Resident #100's care plan and not transferring the Resident alone. The DON confirmed CNA F transferred Resident #100 using the sit to stand lift on [DATE], without assistance and the Resident fell during the transfer. The DON also confirmed Resident #100 sustained a fracture during the transfer which required surgical repair and hospitalization . When asked if CNA F was aware of the possibility of the Resident falling if transferred with the sit to stand, without two-person assistance, the DON acknowledged CNA F should have been aware of the risk due to Resident #100's prior fall on [DATE]. The DON confirmed CNA F was no longer employed by the facility. A review of CNA F's Employee Disciplinary Notification, dated [DATE], revealed the following, in part: Major Infractions: Violation of Safety Rules. Failure to Follow Instructions/Policy/Procedures. Supervisor Remarks: You did not check the Kardex (care plan) for the residents transfer status and inappropriately transferred the resident. The notification was signed by CNA F on [DATE]. On [DATE] at 11:26 a.m., an attempt was made to reach CNA F by telephone to confirm the CNA's written statement. No return call was received. On [DATE] at 11:36 a.m., an attempt was made to reach CNA G by telephone to confirm the CNA's written statements. No return call was received. CNA G was no longer employed by the facility at the time of the survey. On [DATE] at 11:42 a.m., an attempt was made to reach CNA H by telephone to confirm the CNA's written statement. No return call was received. CNA H was no longer employed by the facility at the time of the survey. Resident #100 returned to the facility on [DATE] at 4:45 p.m., following hospitalization for surgical repair of her right femur fracture. Further review of the EMR revealed Resident #100 expired at the facility on [DATE] at 9:16 p.m. A review of the facility policy titled Abuse, Neglect and Exploitation, dated [DATE], revealed the following, in part: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation . Definitions: Neglect means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . Prevention of Abuse, Neglect and Exploitation: B. Identifying, correcting and intervening in situations in which abuse, neglect . is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift . and to assure that the staff assigned have knowledge of the individual resident's care needs .

This citation pertains to intake MI00133945. Based on interview and record review, the facility failed to ensure appropriate assistance with bed mobility according to the resident care plan for one Resident (#102) of three residents reviewed for accidents. This deficient practice resulted in actual harm when Resident #102 fell from bed and sustained a head laceration requiring emergent transfer to the emergency department and sutures. Findings include: A review of Resident #102's Minimum Data Set (MDS) assessment, dated 12/08/2022, revealed the Resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety, muscle weakness and chronic pain. Resident #102 had severe, cognitive impairment. A review of a facility incident report, dated 12/9/2022 at 6:30 a.m., revealed the following, in part: (Resident #102). Incident Location: Resident's room. Incident Description: This nurse called to the resident's room stating the resident had rolled out of bed to the floor while the CNA (Certified Nurse Aide) was cleaning and changing the resident. The resident was observed on the floor next to her bed with an approximate 5 cm (centimeter) laceration on her left forehead. The laceration was bleeding. Pressure with a 4 x 4 gauze was given to the lacerated area until bleeding stopped. Ambulance was called and resident was transferred to (acute care hospital) for evaluation . Other Info: Resident was being cared for by her assigned CNA, being changed and cleaned after incontinence of bowel when resident rolled out of bed. A review of Resident #102's Emergency Department Report, dated 12/09/2022 at 7:33 a.m., revealed the following, in part: Physical Exam: Skin: Small superficial skin tear on left elbow region 1 cm in size . Similar 1 cm superficial laceration on left lateral hip. There is also a 3 cm laceration to the left eyebrow region gaping 1.6 cm . There are some exposed nerves that appear to be fully intact . Medical Decision Making: Patient is a full assist and as she was being transferred this morning apparently fell hitting her head causing a laceration to the left eyebrow region. This was witnessed by staff . she also sustained small skin tears to the left elbow and left hip region . Patient's forehead laceration is anesthetized and repaired (sutured) . A review of Resident #102's Electronic Medical Record (EMR) revealed the following: 12/9/2022 11:38 (a.m.). Nurses Notes: (Resident @102) returned at 0946 (9:46 a.m.) form (acute care hospital) . 9 sutures above left eyebrow . A review of a (Facility) Witness Statement, signed and dated by CNA C on 12/09/2022, revealed the following: I (CNA C) was changing (Resident #102) in her bed. I started off on the side away from the wall getting her cleaned and dressed . I moved her bed and got on the side next to the wall. While cleaning her . and holding her, (Resident #102) rolled off her bed. (Resident #102) hit her head, forehead, blood started coming out going everywhere . During a telephone interview on 2/10/2023 at 2:48 p.m., CNA C confirmed her written statement, dated 12/9/2022, to be true and accurate. CNA C added Resident #100 was hard to roll in bed. CNA C stated she unlocked the bed and moved the bed away from the wall to roll the Resident on the Resident's right side. When she rolled the Resident over, CNA C reported the Resident just kept rolling, and fell off the opposite side of the bed from where the CNA was standing. When asked if the Resident's care plan called for a two-person assistance with bed mobility, CNA C stated she did not look at the care plan, adding it did not occur to me. CNA C reported she had worked at the facility for five years and this incident never occurred before. A review of Resident #102's care plan revealed the following, in part: ADLs: (Resident #102) has an ADL (Activities of Daily Living) self-care deficit performance deficit (related to) dementia . Bed Mobility: [NAME] required extensive assistance by 2 staff to turn and reposition in bed as necessary. A review of the care plan revision timeline revealed the following: Bed Mobility: (Resident #102) requires extensive assistance by 1 staff to turn and reposition in bed (every) 2 hours and as necessary, Revision Date: 6/21/2022. Bed Mobility: (Resident #102) requires extensive assistance by 2 staff to turn and reposition in bed as necessary, Revision Date: 9/20/2022. Bed Mobility: (Resident #102) requires extensive assistance by 2 staff to turn and reposition in bed as necessary, Revision Date: 11/21/2022. During an interview on 2/10/2022 at 3:34 p.m., the Director of Nursing (DON) stated care plans should be checked by staff at the beginning of each shift, prior to caring for the residents, to determine if any changes have been made. The DON reported she was aware of the incident involving Resident #102 rolling off the bed while being repositioned by CNA C. When asked if the CNA C should have used another staff to assist in turning Resident #102, the DON stated she was unsure what level of assistance the Resident was care planned for at that time. The DON confirmed, staff should be following resident care plans to ensure safe care. A review of the facility policy titled Accident and Supervision, revealed the following, in part: Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 3. Implementing interventions to reduce hazard(s) and risk(s) . Definitions: Accident refers to any unexpected or unintentional incident, which results in injury or illness to a resident . Implementation of Interventions - using specific interventions to try to reduce a resident's risks form hazards in the environment. The process includes: . Documenting interventions (e.g., plans of action developed by the Quality Assurance Committee or care plans for the individual resident) . Resident specific approaches may include . Implementing specific interventions as par of the plan of care.

This citation has 2 deficient practice statements (DPS) and pertains to intakes # MI00130986, #MI00132283 and #MI00125389. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to ensure thorough fall investigations were completed, interventions were in place, and new interventions were initiated to prevent falls for three Residents (#56,#62, and #66) out of six Residents reviewed for falls. This deficient practice resulted in repeated falls and a fall with fracture for Resident #62. Findings include: Resident #62 On 11/28/22 at 11:33 p.m., Resident #62 (R62) was observed up in her wheelchair near the door of her room in the hallway. R62 was attempting to self propel herself into her room. She was noted with a wheelchair alarm and a seat belt in place. R62 was asked how she was doing but did not respond. At this time, RN K and CNA G were both at the nurses station, out of view of R62 going into her room alone. CNA G was noted to be using his cell phone under the desk. On 11/29/22 at 12:27 p.m., R62 was observed self propelling in her wheelchair with her seat belt on back into her room. On 11/30/22 at 12:45 p.m., R62 was observed up in her wheelchair with her seat belt on. Certified Nurse Aide (CNA L) was observed putting the footpedals on R62's wheelchair. R62 was wearing slip on slippers with no back to the slipper. On 11/30/22 at approximately 4:21 p.m., R62 was observed in her wheelchair alone self propelling toward her bed and taking her slippers off leaving just her white socks on. On 12/1/22 at 11:08 a.m., R62 was observed up in her wheelchair in the common area outside of her room self propelling. R62's seat belt as not in place and the right food pedal was still on the wheel chair. A review of R62's medical record revealed she admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, diabetes, and repeated falls. A review of her 9/6/22 Minimum Data Set (MDS) assessment revealed she scored 0/15 on the Brief Interview for Mental Status (BIMS) assessment, indicating severely impaired cognition. This review showed she did not walk during the review period, required the extensive assistance of two plus staff for transfers, and used a wheelchair. A review of her previous MDS dated [DATE] revealed she scored 10/15 on the BIMS assessment, indicating moderately impaired cognition, walked and transferred with the extensive assistance of one staff member, and used just a walker. A review of a Physical Restraint/Alarm Evaluation/ Re-Evaluation for R62 dated 9/27/22 revealed the following: . Gets out of bed, stands from chair, recent hip fx (fracture) . Recommended three day trial of least restrictive physical restraint/alarm: Date : (blank) X Seat belt . There were no reminders checked off regarding the consent, order or care plan, and the final recommendation section was blank. There was no staff signature or signature date. A review of R62's fall Investigation and Investigation forms revealed the following: On 6/6/22 at 6:50 p.m., This nurse was in the nursing station getting report from (name of LPN R). We heard an alarm going off in the distance. I entered (R62's) room and observed (R62) sitting on the floor. (CNA J) was first in the room and saw the fall from the doorway. (R62) had stood up from her w/c and fell on her bottom . The Incident review form included the Intervention/Corrections implemented as Don't leave R62 unattended in her room (she does wheel herself in there so staff will need to be observant). On 6/11/22 at 1:45 p.m. was a fall in the Residents bathroom. LPN R had a gait belt around R62 but was unable to stop the resident from falling. On 7/1/22 at 4:40 a.m., (R62) was found by (CNAV) during bed checks. Resident was face down on floor . A review of CNA V's statement for this event revealed, .She (R62) was laying on her stomach next to bed . her pad alarm was in bed under her and did not activate (it was on). We did not hear anything and 2 of the 3 CNA's on unit were sitting in that side of living room close to room . and noted she last checked on the resident two hours prior. The Incident Review form noted, Her alarm was on but not in the proper place- she had moved them . Ensure alarms are in place during rounds. Review of the care plan revealed that the intervention to ensure alarms were out of R62's reach was already initiated on the care plan as of 1/27/21, and was revised on 5/3/22, and therefore should have been in place. On 7/5/22 at 2:00 a.m.(R62) observed on the floor on her right side . head under head of bed . red area at right hip, slight pain on palpation . shrinkage noted at the time of EMS exam . on call physician called, okay to send out for right hip evaluation . A review of the Incident Review form revealed, (CNA N) had just done a purposeful round and the alarm was on. When (R62) fell it was turned off. It was functional. The first thought was to place the alarm out of her reach but the cords are not log enough . the final decision was to put hip protectors on her. A review of CNA Ns statement revealed, Was in nurses station opening (name of EMR) to chart and check residents heart a loud crash noise ran to residents room and found her on the floor . On 7/9/22 at 6:40 p.m., .(CNA P), she states '(R62) is on the floor' this nurse entered the room and (R62) was observed on the floor on her left side . the alarm pad was observed between (R62's) legs and a towel around it. The alarm was 'on' but was not sounding due to the towel . The Incident Review form intervention was, Do not put a towel around the safety alarm. This was already a care planned intervention initiated in May 2022, that was not implemented prior to this fall. On 7/22/22 at 8:15 p.m., Nursing description: Walked by (R62's) room and witnessed her on floor of her room . (R62) has an indwelling foley catheter and the drainage bag was attached to the bed when she got up. She recently had an increased (sic) in her Sinemet d/t (due to) frequent falls . An email statement was attached to the report written by LPN U which revealed, This writer found (R62) on the floor she was sitting on her R (right) side with both hands on the floor . Her foley catheter bag was still attached to the bed . At the time of the fall she was lying in bed with slipper socks on but the alarm was not turned back on by the CNA when (R62) was last repositioned . There was no documentation of who the CNA was that failed to turn the alarm on and no indication if they were disciplined or educated. The intervention per the Incident Review form revealed, If (R62) is restless at night bring her out of her room for better observation and to lower her risk of falls. On 8/21/22 at 9:25 p.m., Heard (CNA J) calling out, 'Fall' . (R62) lying beside her bed with her right hand hanging onto the side rail. Her upper body and head were elevated off the floor. Blood was dripping from her right elbow . checked over again once back in bed. (R62) started to c/o (complain of) pain in her right upper leg. Pain was 10/10 when leg was palpated or moved slightly . EMS called @ (at) 2240 (10:40 p.m.) and here by 2250 (10:50 p.m.) . EMT's examined and questioned (R62) . pain was now 1/10 . she denied significant pain . Decision made not to send her to (Name of Hospital) . Foley tubing pulled taut when she got up. Hip protectors checked and on @ all times. They were not on . A statement from CNA J revealed, I heard bed alarm and saw call light flashing. Ran to (R62's) room and she was on the floor . I pull(sic) the alarm and call light out of the way and yelled for the nurse . A summary of the incident revealed, .The following Monday morning .she was still having pain of 10 out of 10 and ordered a 3-view X-ray of her right hip and a 2-view x-ray of her right femur. The results came back as a displaced fracture of the right femoral neck. She was then transported to (name of Hospital) for repair . The interventions for this fall are to place the foley bag in a basin on the floor. This is so when she gets up it is not hooked to the bed . She does have hip protectors ordered. At the time of the fall they had been taken to laundry and were drying . On 9/22/22 at 4:35 p.m., (LPN R) called to (R62's) room by (CNA P), (R62's) electric recliner was in the standing position. (R62) was lying on her left side on the floor in front of her chair, eye glasses lying on the floor lens missing . noted 3 cm wide bump on her forehead left of center . redness to left patella (knee) . A review of a witness statement with no name or date of writing revealed, At nurses station: Last saw (R62) at 4:20 pm - place ice pack on R (right) hip for c/0 pain. A review of a written summary for this event revealed, . It was apparent that (R62) had taken the control and lifted the chair into an upright position and then slid out onto her left knee and forehead. The lift control was removed and will be kept out of her reach . A review of the care plan revealed no intervention was initiated to keep the recliner control out of reach. On 9/26/22 at 5:15 p.m., (R62) was in the west living room. Sitting after an activity with a group of others. (LPN R) was in and out of the living room, passing medications. (R62's) alarm went off (LPN R) went to the alarm and saw (R62) holding herself off the floor by holding the wheel chair handle of the wheel chair in front of her . (R62's) feet and lower legs were caught in the foot pedals of her wheel chair . A review of the incident summary for this fall revealed, . Her feet were under her wheelchair foot pedals . There was (sic) 4 staff present on the floor at the time. The intervention was to have (R62) in line of sight anytime she is in the wheelchair . No new interventions regarding not leaving R62 with her foot pedals on the wheelchair unattended or when not being pushed. There was also no indication in the report if R62 had removed her own seat belt, or if it had not been placed back on by staff. On 11/25/22 at 7:25 a.m., (Nurses summary left blank) . other info: (R62) was attempting to get out of bed by herself. Alarm was sound but staff was unable to get to her before her knees were on the mat beside her bed. She was barefoot . Review of a witness statement by CNA M revealed, I was in the nurses station talking about Tksgvng (Thanksgiving) w/ (RN K) . Her (R62's) light went off, our convo (conversation) came to a stop as we made our way to (R62's) room. Her bed was all the (sic - way) to the floor her mat was in place, but her knees touch the mat. That was her fall. Under the section of when the resident was last checked, CNA M wrote, Last rounds. On 12/1/22 at 11:11 a.m., an interview was conducted with the Director of Nursing (DON) regarding R62's falls. When asked about the 7/1/22 fall where it indicated CNA's were sitting in the common area when it occurred, the DON made no comment. The DON was asked about the multiple falls (7/1/22 and 7/5/22 for example) where R62 was accused of turning her alarms off despite the care planned intervention from 2021 to keep the bed alarm out of reach. The DON stated, I don't remember if we got a longer cord? I don't remember to be honest. When asked about the 7/9/22 fall (alarm was wrapped in a towel), the DON stated, I don't know why they wrap it in a towel. Anyway's I talked to them and said don't do that . The DON was asked if since it was a previous fall intervention not to do that, if the CNA who had done it was disciplined or educated one on one for not following the care plan. The DON stated, It does (happen) if we can identify who it was (that did it), but I can't write everybody up if you don't know. When asked about the 7/22/22 fall (CNA did not turn alarm back on) the DON reported she didn't recall that fall and may not have been at the facility during that time. When asked about the 8/21/22 fall (hip protectors were not put on), the DON stated, That was (CNA J) . they (hip protectors) were both in the laundry room, one was drying and the other in a basket. After that we put two more pairs in the treatment room. When asked about there not being a discipline or education in CNA J's record for neglecting to follow the care plan and the fall resulting in a fracture, the DON just stated, She got educated. When asked if R62 was wearing appropriate footwear during the 9/22/22 fall, the DON reported, If you didn't see it (documentation) it probably wasn't there We generally make people take those (nonskid slippers) home. The ones you put your foot in and it just slides in, those are dangerous too. When asked if R62 had her alarming seat belt in place during the 9/26/22 fall as it was not noted in the report, the DON reported initially the belt was just a normal seat belt that didn't alarm. When asked about the foot pedals being left on if staff weren't around, the DON reported that she didn't know, but that staff have to have them on to push her. When asked about the 11/25/22 fall the DON indicated she was still investigating it. When asked about the concern of staff sitting at the nurses station and residents being found on the floor because the alarms are not answered in time, the DON reported the facility had already recognized that as an issue and were going to be fixing that. When asked about the intervention of R62 not having access to the recliner control, the DON provided no comment. A review of R62's fall care plan initiated on 6/6/21 revealed the following: .a seat belt will be placed on (R62's) wheelchair (9/28/22) .be sure (R62's) call light is within reach and encourage the (sic) her to used it . (6/6/21) . Bed alarm while in bed in addition continue to activate chair alarm when up. Place bed alarm control box out of (R62's) reach @ (at) all times. (initiated 1/27/21, revised 5/3/22). Do not leave (R62) in her room unattended in her w/c (wheelchair). She tends to self transfer to her recliner or bed. (6/7/22). Do not wrap alarm pad in a towel or place anything around it, the pressure/weight will prevent the alarm from sounding (7/9/22) . If she is awake at that time she should be assisted with morning care and brought out to the dining room (11/25/22) . Ensure seatbelt alarm is turned on when in w/c (9/29/22). Ensure that (R62) is wearing appropriate footwear-tennis shoes, when ambulating with her walker (initiated 6/6/21, revised 11/21/22). Ensure the alarms are in place during rounds (7/7/22) . Frequent purposeful rounds when (R62) is in her room (Initiated 5/20/22, revised 11/21/22). Gripper socks when in bed (8/22/22) . Hip protectors at all times (7/6/22) . If (R62) is restless bring her out of her room at night to better observe her and lower her risk of falling (initiated 7/22/22, revised 8/1/22). (R62) has 2 pair of hip protectors - if both are in laundry there are 2 spare pair in the household and a new pair in storage (9/19/22) . (R62) has been placed on high risk fall list. Her light is a priority (initiated 5/7/22, revised on 11/21/22) .(R62) uses a bed alarm on the back of her recliner and a chair alarm on the seat of her recliner. Make sure both are on when (R62) is in her recliner (6/21/22). (R62) uses pancake alarm. Ensure the device is in place and working properly (6/6/21). Make sure chair alarm is on and in working order (12/21/21). Make sure that (R62) has two cough drops on her bedside table (initiated 10/5/21, revised 11/21/22). Mat to be placed beside (R62's) bed while in it (8/22/22) . Safety alarm is not to be placed under cushions. blankets, or other items, as the additional weight/pressure prolongs the alarming (initiated 3/23/22, revised 9/27/22) . Between 7/1/22 and 12/1/22, R62 had eight falls. During three of the falls (7/22/22, 8/21/22, and 11/25/22), care planned interventions were not implemented and the 8/21/22 fall resulted in a fall with fracture and a decline in physical status. Two other falls documented R62 as turning her own fall alarm off, despite previous interventions to place the bed alarm box out of reach. Resident #66 On 11/28/22 at 11:36 a.m., Resident #66 (R66) was observed in her wheelchair near the staff bathroom. R66 was wearing a seatbelt and there was an alarm on her wheelchair as well. R66 was asking about the staff bathroom and when asked if she needed to go to the bathroom she stated she did. On 11/29/22 at 12:27 p.m., R66 was observed up in her wheelchair with the seatbelt on in the common area and hallway of her unit. Resident was being guided to the dining area for lunch. On 11/30/22 at 12:45 p.m., R66 was observed seated at the dining room table. She started to push her wheelchair backward and undid her seatbelt which started to alarm, and exclaimed Its loud! CNA M went over to R66 and stated, You keep unplugging it that's why it's being loud. Put it back together. R66 buckled the seatbelt and pushed R66 back toward the table. R66 started, to say I don't which CNA M interrupted with Do you need to do something? R66 quietly stated, Well no. CNA M informed R66 that she had not finished her lunch. On 11/30/22 at 4:20 p.m., R66 was in the common area of the unit and was observed unplugging her seat belt. Licensed Practical Nurse (LPN) R encouraged R66 to re-buckle her seat belt. LPN R stated to R66, Can you hook that up? Do you know why its on? to which R66 stated, Because they don't want me getting out. Approximately two minutes later R66 unplugged her seat belt again, and CNA O asked her to keep her seat belt on. R66 then asked this CNA O who was carrying a load of laundry to a room if she could help her and the CNA O responded No. On 11/30/22 at approximately 4:24 p.m., R66 was asked was observed aimlessly self propelling in the common area. When asked if there were any activities or things for her to do, R66 stated, Not really. A review of R66's medical record revealed she admitted to the facility on [DATE] with diagnoses including dementia, adjustment disorder, adult failure to thrive, and history of falling. A review of the most recent 11/1/22 Significant Change MDS Assessment revealed she scored 3/15 on the BIMS assessment, indicating severely impaired cognition and had no falls since readmission or the previous assessment. R66 was assessed as needing extensive assistance of two staff for toileting and bed mobility, and extensive assistance of one staff for ambulation. A review of her MDS assessment dated [DATE] revealed she required only supervision of one staff for toileting and bed mobility, no supervision or assistance for transfers, and just supervision of one staff for ambulation requiring no mobility devices. A review of a Facility Reported Incident (FRI) investigation for R66 for a Fracture of Unknown Source on 10/25/22 revealed the following: .At around 2130 (9:30 p.m.) (RN W) heard (CNA J) call out for help. (RN W) and (CNA P) responded to her call and observed (CNA J) supporting (R66) in the doorway to her room. (CNA J) stated that (R66) had cried out and said she could not walk. When (CNA J) heard her she was standing in the doorway. (R66) had been able to walk from her bed to the doorway without calling out. (R66) was very unsteady and complained of right knee pain. (R66) denied that anything happened and said she did not fall . once in bed (RN W) stated that (R66) again pointed to her kneed but then ran her hand up her thigh indicating that area hurt as well . The following morning (CNA M) called for (LPN R) to come to (R66's) room as she was having pain and she could not sit up or move her right leg without crying out . She (R66) had facial grimacing and was reluctant to move . There was no bruising or redness or any visible indication that she may have fallen . EMS transported (R66) to (name of Hospital) . an x-ray was done which revealed a mildly displaced fracture of the femoral neck without dislocation . (R66) had surgical repair of her hip at (Name of Hospital) on 10/25/22 and tolerated it well . This investigation did not have a conclusion section to discuss the investigation of the possible cause of the injury. A review of the witness statement written by RN S on the morning R66 was found unable to walk revealed, .(LPN R) stated (R66) has not been able to get out of bed this morning - and she (is) screaming in pain when R (right) thigh/hip is palpated . This RN attempted to palpate area - (R66) screamed in pain . no markings to show of any type of fall. Staff state no fall - (R66) stated 'I fell ' but unable to say how or when. (R66) is confused at baseline . A witness statement written by CNA J written 10/25/22 revealed, In living room with another resident when I heard (R66) yelling she needed help because she can't walk. Ran to her she at doorway was standing and tipping side ways. I put my arms around her and steady her and yelled for help. Waited for other staff to help assist/walk her to her bed . when asked what happened or if she fell she said No I don't know what happen (sic). This statement revealed R66 was last checked at 8:30 p.m. (an hour prior) and was noted to be sleeping at the time. A review of R66's incident and accident reports revealed the following: 11/6/22 4:50 p.m. (R66) had been sleeping in the recliner in the west lounge. This nurse (LPN R) and (CNA H) heard (R66's) chair alarm sounding, (LPN R) and (CNA H) were in the nurse's station and went running to the west lounge, before reaching the lounge there was a loud noise, found (R66) on her knees facing the recliner, with her arms resting on top of the footrest. (R66) was attempting to get up on her feet . A summary of this event revealed the new intervention for this fall was, . have a staff member sit with (R66) any time she chooses to sit in the recliner whether the footrest is elevated or not to prevent self-transferring . 11/9/22 5:18 p.m., Observed (R66) laying on the floor on her back next to her w/c in the living room. (R66) stated she was trying to get to the recliner and didn't make it . when asked (R66) if she was in pain, (R66) stated 'No, just a little bit on my right hip' . A summary of the incident revealed, (CNA Q) heard (R66's) alarm go off in the living room; she had been in her wheelchair. He ran toward her and before he reached her she stood and grabbed the arm of the recliner before she lost her balance. She fell before he reached her . an intervention was put in the plan of care to give her diversional activities such as shredding paper, folding towels, etc . A review of R66's fall care plan initiated 4/7/22 revealed in part, (R66) is at high risk for falls a belt alarm in my wheelchair may help me remember to only get up with assistance (10/28/22) . Encourage (R66) to participate in activities that promote exercise .(4/7/22) . I have had a hip fracture and may forget I need assistance. Please place hip protectors on me at all times until healed (10/27/22). If (R66) is in a crowded area redirect her to a safe location (5/10/22, revised on 10/27/22) . Staff will sit with (R66) when she chooses to sit in the recliner, whether feet are elevated or not. to prevent self-transferring (11/6/22). The resident needs activities to minimize the potential for falls while providing diversion and distraction. While (R66) is in wheelchair, please provide activity that (R66) enjoys doing like folding laundry or cleaning tables. She typically is at fall risk because she is trying to do these things while standing up from her wheelchair . (initiated 11/9/22, revised 11/21/22) . Observations between 11/28/22 through 11/30/22 revealed R66 not being provided diversional activities of her preference, such as paper shredding or folding clothes. On 12/1/22 at approximately 11:33 a.m., the DON was asked about the intervention of providing diversional activities for R66 and stated, They'll (staff) usually get towels out of linen room. Used baskets before. When informed no diversional activities were observed being provided for R66 during observations between 11/28/22 and 11/30/22, the DON provided no comment. 38328 Resident #56 A review of the Progress Notes section of the Electronic Medical Record (EMR) revealed the following: 10/31/2022 (8:15 a.m.) Incident Note . Heard yelling out- entered room and observed resident lying on the floor alongside her bed, head @ foot of bed and feet @ head of bed, on her right side . She was very incontinent of urine, in her PJ's, w/o (without) footwear on, alarm in place, not sounding . During an interview on 11/29/22 at 3:24 p.m., Family Member (FM) X stated Resident #56 had falls a few days after her admission to the facility and ended up with two black eyes and bruised ribs with one out of place on August 19th, 2022. FM X stated she felt there were not enough staff to watch everybody. FM X stated she was ready to move Resident #56 out of the facility, but felt the staffing and care was much better now. A review of the incidents for Resident #56 revealed the following: A review of the incident report dated 6/10/22 at 6:30 p.m., revealed Resident #56 was heard yelling and was found lying on her back with blood coming from her right eyebrow. Non-skid shoes/socks were implemented after this fall. A review of the incident report dated 8/21/22 at 8:50 p.m., revealed Resident #56 was observed on the floor in front of the clean linen room for the unit. Resident # 56 was unable to say what she was trying to do. There was no new intervention identified in this incident following the fall. A review of the incident report dated 8/31/22 at 9:35 a.m., revealed Resident #56 was observed lying on her back, calling for help in the doorway of her room, and had fallen and hit her head. The incident report went on to discuss Resident #56 was persistently complaining of needing to go to the bathroom. Resident #56 was toileted after the fall and had a bowel movement. A review of the incident report dated 10/31/22 at 7:13 a.m., revealed Resident #56 was heard yelling out and upon entering the room was found lying on the floor next to her bed on her right side. On 11/29/22 at approximately 4:05 p.m., during an interview, the Director of Nursing (DON) was asked if non-skid shoes and socks would be a baseline care planning intervention for fall risk reduction. The DON stated yes, but Resident #56 would be one to take them off. The DON went on to stated Resident #56 was very ambulatory and often took herself to the bathroom. When asked if the other two interventions on her fall care plan should be baseline interventions, the DON agreed they would be considered baseline. On 11/29/22 at 4:15 p.m., during a follow-up interview, the DON acknowledged the care plans were not where they needed to be and were in the process of being cleaned up. When asked if she felt a toileting program would be appropriate, the DON agreed a toileting program would be appropriate for Resident #56. The DON also acknowledged encouragement of a resident who lacks cognitive ability to use a call light should not be encouraged to use the call light as an intervention and would not be appropriate. A review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #56, revealed short term and long term memory issues and Resident #56 was severely cognitively impaired. A review of the care plan High risk for falls, with an initiation date of 6/17/22, had interventions which included the following: Anticipate and meet (Resident #56)'s needs. Initiated on 6/17/22. Be sure (Resident #56)'s call light is within reach and encourage (Resident #56) to use it for assistance as needed. Initiated on 6/17/22 and revised on 11/18/22. Non-skid socks or shoes with non slip soles. Initiated on 6/10/22. Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound. Initiated on 6/10/22. There were no other care planning interventions to address the falls sustained by Resident #56 on 8/21/22, 8/31/22 or 10/31/22. Deficient Practice #2 Based on observation, interview, and record review, the facility failed to prevent an elopement from the facility for One Resident (#67) of two residents reviewed for elopement. This deficient practice resulted in the potential for further elopements. Findings include: Resident #67 During an observation and interview on 11/28/22 at 2:01 p.m., Resident #67 was perseverating on going out to look at a fallen tree across the street. Resident #67 was upset that he was told he could not go and look at this tree that fell down. Resident #67 did not present as cognitively intact and demonstrated word salad communication at times during the interview. A review of an Elopement incident dated 10/14/22, revealed Front Desk Staff FF had let Resident #67 out of the facility. Staff FF thought Resident #67 was a visitor and let him out when Resident #67 identified himself as a visitor and stated he needed to go outside and get the keys out of his car. Five staff were on the unit at the time of the incident and the incident occurred while staff were getting residents ready for dinner per witness statements. A review of a Behavior Note dated 10/14/22 at 8:58 p.m., revealed the following: During dinner today, (Resident #67) was actively exit seeking. With redirection he sat down to eat his soup. This nurse was at the med cart prepping medication when I heard CNA ([Certified Nurse Aide] HH) yellout(sic) hey that's (Resident #67)! to which this nurse looked up and saw (Resident #67) walking outside in the parking lot with his walker .I talked to the front desk asking how hegot(sic) out without the alarm going off to which he stated (Resident #67) knocked on the door and told the front desk he was a visitor and needed to go out to his car and grab his keys, to which the front desk let him out and entered the code to the door, so the alarm did not go off .The front desk was unaware of who (Resident #67) was and did in fact believe he was a visitor . Author Licensed Practical Nurse (LPN) GG During an interview on 11/30/22 at 8:06 a.m., the DON was asked why there was nothing in the body of the policy to address elopement prevention, only what to do when an elopement occurs. The DON acknowledged the policy should include education to staff on how to prevent elopements from happening in the first place, and to make sure they are not letting out residents without supervision. During this interview, Receptionist II proceeded to show this surveyor a binder kept at the receptionist desk which contained pictures of all the residents at the facility. Receptionist II stated the facility has always had this binder at the desk as far as she knew. The DON stated she was not aware of this binder being located at the reception desk. Both the DON and Receptionist II agreed staff who sat at the desk should be aware of the binder and check it before letting anyone off the units and out of the building. During an interview on 11/30/22 at 3:49 p.m., LPN GG confirmed Staff FF had let Resident #67 off the unit and out of the facility under the premise he was a visitor and not an employee. LPN GG also confirmed Resident #67 was .very skillful in his exit seeking . and that she had educated Staff FF to please make sure to ask the nurse for the unit before letting anyone off the unit. A review of the care plan Elopement risk, for Resident #67, with an initiation date of 8/12/12 had the following interventions: 1:1 staff as necessary when agitated and exit seeking Initiated on 8/15/22. A name tag will be made up for (Resident #67) to be clipped to the back of his shirt to alert people that he is a resident of (facility). Initiated on 10/18/22. A picture of (Resident #67) is posted throughout the facility. He will also wear a picture/resident ID tag(to be provided). Initiated on 8/12/22. Call administrators cell phone number when agitated and unable to redirect so he can speak with him. Initiated on 8/12/22. Distract

Based on observation, interview, and record review, the facility failed to prevent accidents and injuries related to fall prevention for four Residents ( #102, #103, #104, and #106) of five residents reviewed for accidents. This deficient practice resulted in actual harm for Resident #102 and Resident #103 (hip fractures), and the potential for major injury to residents. Findings include: A review of Resident #106's face sheet revealed an admitted [DATE]. Resident #106 had a history of medical diagnoses which included [CONDITION(S)], altered mental status, and failure to thrive. On 1/11/21 at 2:40 p.m., Certified Nurse Aide (CNA) D and CNA ''E'' were observed transferring Resident #106 from the wheelchair into the bed with the full lift (a mechanical lift used to transfer people who are unable to stand). The brakes on the lift were not locked when Resident #106 was lifted out of the wheelchair and lowered into bed. In a follow up interview with CNA D on 1/11/21 at 2:46 p.m., CNA D reported the brakes should have been locked on the full lift when Resident #106 was raised out of the wheelchair and lowered into the bed. CNA D said they forgot to lock the brakes. A review of Resident #102's face sheet revealed an admitted [DATE]. Resident #102 had a history of medical diagnoses which included bilateral below the knee amputations, anxiety, and depression, During an interview on 01/12/21 at 12:42 p.m., CNA B reported they had just finished giving Resident # 102 a shower. The sling for the lift had been placed on the lift's hooks. The hooks should have had rubber stoppers on the ends to prevent the sling from slipping off the hook, but they were not there. As Resident #102 was raised out of the shower chair, the sling slipped from the hook. When this happened, Resident #102 fell from approximately four feet onto the floor. CNA B clarified they had been performing the transfer without any other staff being present to assist. CNA B reported the accident could have been prevented if the stoppers would have been in place and another staff member had been present. During an interview on 1/14/21 at 8:00 a.m., the Director of Nursing (DON), verified rubber stoppers should have been in place and there should have been two staff members assisting with Resident #102's transfer with the lift. The DON reported these were significant contributing factors. A review of the incident investigation information dated 12/13/20 revealed the following information, Called to [Resident #102]'s room by CNA, [Resident #102] being transferred via full-lift from shower chair to bed when strap came loose from lift and [Resident #102] fell from around 4' [feet] onto her left side and striking [Resident#102] face/head . A progress note written on 12/13/21 at 11:25 a.m. by Registered Nurse (RN) C revealed the following information, Patient sent to ER [Emergency Department] following fall at 10:45 a.m. from full lift. fell to left side of the body causing bruising and hematoma to left side of forehead. Major complaints left hip pain. Fall happened following shower . An additional progress note written on 12/13/21 at 11:25 a.m. by RN C revealed the following information, This nurse update D.O.N in regard to patients hip Xray. Progress note states left hip fracture, still waiting for head CT, and Pelvis CT . A review of the Full Lift policy with the most recent revision date of 5/8/20 revealed the following information, 1. Two certified and/or licensed staff will be required to use a full lift . d. Ensure strap stoppers are in place .6. Perform check to ensure all four straps are securely in place . A review of Resident #103's face sheet revealed an admitted [DATE]. Resident #103 had a history of medical diagnoses which included falls, dementia, difficulty walking, and muscle weakness. A review of the incident investigation information regarding an unwitnessed fall on 12/30/20 revealed the following information, [Resident #103] called out Help me from [Resident #10]'s room. This nurse observed [Resident #103] laying on the floor. There was a smear of blood on the floor noted under right elbow. Head to toe assessment completed, abrasions to right ring and index finger and skin tear at the right elbow [Resident #103] complained of pain in right leg . [Resident #103] stood with the assist of two .but was unable to stand erect .This nurse and another nurse re-evaluated [Resident #103]'s leg, shortening noted . The Fall Investigation dated 12/30/20 revealed the following information, . [Resident #103] did have a bed alarm in place however it did not alarm. Investigation showed that it was switched off .A femur x-ray showed a comminuted angulated proximal femoral fracture. X-ray of the pelvis showed the same .Root cause analysis: [Resident #103] had dementia with poor safety awareness. [Resident #103] had been put to bed at 1915 [7:15 p.m.] and had been toileted at that time. It was concluded that [Resident #103] woke up, had to urinate again, and attempted to ambulate without assistance which led to [Resident #103]'s fall. Care plan updated to the following: Upon return from the hospital staff were to check the alarm for placement and proper operation when put in [Resident #103]'s bed . On 1/12/21 at 2:53 p.m., RN A reported Resident #103 had fallen in their room when they tried to ambulate to the bathroom. RN A said Resident #103 had a history of impulsiveness and would often try to get to get to the bathroom without assistance. Resident #103 had a pressure alarm and a pancake alarm (a large round device that is sensitive to movement and will alert staff when a resident is moving). When Resident #103 had gotten out of bed and fell , neither of the alarms had sounded. RN A reported they had no knowledge of Resident #103 getting out of bed until Resident #103 was heard calling for help. RN A reported Resident #103 would often sit on the side of the bed when the alarms sounded, and wait for staff assistance. The alarms served as a reminder for Resident #103 to wait for assistance to get to the bathroom. RN A said staff knew to listen for the alarm because that would alert them Resident #103 was getting out of bed and required assistance. RN A reported the failure of the alarms to sound were the main contributing factors to Resident #103's fall. RN A said upon inspection at the time of Resident#103's fall, the pressure alarm was found to be turned off. On 1/14/21 at 8:00 a.m., the DON confirmed Resident #103's bed alarm had been turned off. The DON said this was a contributing factor to Resident #103's fall. Resident #103's radiology report dated 12/30/20 revealed the following information, Trauma Unwitnessed fall at 21:45 (9:45 p.m.). Right leg pain .Impression: Comminuted angulated proximal femoral fracture [broken upper leg bone] . Resident #104's face sheet revealed an admitted [DATE]. Resident #104 had a history of medical diagnoses which included dementia, falls, dizziness, weakness, difficulty walking. A review of the Fall Investigation [Resident #104] January 4, 2021 @1430 [2:30 p.m.] revealed the following information, [Resident #104] had non-skid socks on. The alarms were on [Resident #104]'s bed .The pad alarm had a tear in it and has been replaced. During an interview on 1/14/21 at 8:00 am., the DON reported the torn bed alarm was a contributing factor to Resident#104's fall.

THIS CITATION HAS TWO DEFICIENT PRACTICE STATEMENTS (A AND B). A. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO RECOGNIZE ELOPEMENT RISK FACTORS, FAILED TO DEVELOP AND IMPLEMENT CARE PLAN INTERVENTIONS TO PREVENT AN ELOPEMENT, FAILED TO EFFECTIVELY MONITOR UNSECURED EXIT DOORS, AND FAILED TO ENSURE ADEQUATE SUPERVISION WAS PROVIDED TO PREVENT AN ELOPEMENT IN ONE (RESIDENT #6) OF FOUR RESIDENTS REVIEWED FOR ELOPEMENT RISK IN A TOTAL SAMPLE OF 19 RESIDENTS. RESIDENT #6 WAS KNOWN TO BE AT RISK FOR ELOPEMENT, WAS COGNITIVELY IMPAIRED AND MOBILE. ON 6/6/13 AT APPROXIMATELY 10:45 A.M., RESIDENT #6 WAS OBSERVED OUTSIDE OF THE FACILITY, UNSUPERVISED, PROPELLING HIMSELF IN A WHEELCHAIR IN THE BACK PARKING LOT TOWARDS AN ALLEY. AT THE TIME OF THE INCIDENT, THE FIRE DOORS TO THE SERVICE HALLWAY AND THE DOORS LEADING OUTSIDE OF THE FACILITY WERE BOTH LEFT/PROPPED OPEN WHILE A VENDOR TRUCK DRIVER WAS DELIVERING SUPPLIES. THE BACK PARKING LOT IS SURROUNDED BY A WOODED/HILLY TERRAIN. THE AMOUNT OF TIME RESIDENT #6 WAS LEFT UNSUPERVISED BY THE FACILITY IS UNKNOWN. THIS DEFICIENT PRACTICE RESULTED IN IMMEDIATE JEOPARDY TO THE HEALTH AND SAFETY OF RESIDENT #6. ON 6/19/13 AT 4:30 P.M., THE FACILITY WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT WAS IDENTIFIED ON 6/19/13 AND BEGAN ON 6/6/13 WHEN THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION, FAILED TO DEVELOP AND IMPLEMENT A PLAN OF CARE ADDRESSING ELOPEMENT RISK BEHAVIORS, AND FAILED TO ENSURE A DOOR MONITORING SYSTEM WAS FUNCTIONING TO PREVENT RESIDENT #6 FROM EXITING THE FACILITY WITHOUT THEIR KNOWLEDGE. DURING THE COMPLETION OF THE EXTENDED SURVEY ON 6/19/13 THROUGH 6/20/13, THE IMMEDIATE JEOPARDY WAS REMOVED ON 6/20/13 BY THE FOLLOWING FACILITY ACTIONS: -RECORD REVIEWS CONFIRMED THE DEVELOPMENT OF ELOPEMENT RISK ASSESSMENT CRITERIA AND DOCUMENTATION THAT ALL RESIDENTS IN THE FACILITY WERE ASSESSED TO DETERMINE THEIR ELOPEMENT RISK. -RECORD REVIEWS CONFIRMED THAT ALL RESIDENTS WHO WERE DETERMINED AT RISK FOR ELOPEMENT HAD CARE PLANS DEVELOPED OR REVISED TO ADDRESS IDENTIFIED RISK FACTORS. -RECORD REVIEWS VERIFIED THE FOLLOWING FACILITY POLICIES WERE DEVELOPED, REVIEWED AND/OR REVISED: "ELOPEMENT POLICY", "RESIDENT OBSERVED LEAVING THE BUILDING", "FAMILY/LEGAL REPRESENTATIVE NOTIFICATION", "PHYSICIAN NOTIFICATION", "ACCIDENT/INCIDENT-INVESTIGATING AND REPORTING", "ELOPEMENT RISK ASSESSMENT FORM", "DELIVERY SIGN IN SHEET". -INTERVIEWS WITH LICENSED NURSING STAFF AND CERTIFIED NURSE AIDES (CNAS) VERIFIED THE FACILITY HAD BEGUN THE EDUCATION REGARDING THE NEW AND REVISED POLICIES AND RESPONSIBILITIES. -REVIEW OF WRITTEN PLAN FOR IMMEDIATE JEOPARDY REMOVAL REFLECTED BY 6/21/13 AT 5:00 P.M., 85% OF STAFF EXPECTED TO HAVE MANDATORY INSERVICES REGARDING REVISION/DEVELOPMENT OF POLICIES AND BY 6/27/13, THE REMAINING STAFF WILL HAVE COMPLETED THE MANDATORY INSERVICE TRAINING PRIOR TO BEGINNING WORK. -OBSERVATION AND RECORD REVIEW VERIFICATION THAT RESIDENT #6 IS BEING VISUALLY MONITORED EVERY 15 MINUTES AND AN ELOPEMENT PREVENTION PLAN OF CARE WAS DEVELOPED. -OBSERVATION BY SURVEYOR # THAT THE OUTER KEY PAD TO THE BACK DOOR WAS SWITCHED OFF, NECESSITATING THE NEED FOR VISITORS/VENDORS TO RING TO ENTER THE FACILITY AND ELIMINATE THE RISK OF THE DOORS BEING PROPPED OPEN WITHOUT STAFF BEING PRESENT. -OBSERVATION THAT A SIGN WAS POSTED AT EXIT DOORS TO ALERT STAFF AND VISITORS TO BE MINDFUL OF RESIDENTS WHO MAY BE EXIT SEEKING. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, DEFICIENT PRACTICE REMAINED AT AN ISOLATED LEVEL WITH POTENTIAL FOR MORE THAN MINIMAL HARM PENDING: - COMPLETION OF SAFETY AND ELOPEMENT TRAINING OF ALL STAFF. - VALIDATION BY THE STATE AGENCY OF THE FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH ENSURING ADEQUATE SUPERVISION AND AN EFFECTIVE DOOR MONITORING SYSTEM TO PREVENT RESIDENTS FROM EXITING THE FACILITY WITHOUT PROPER AUTHORIZATION TO ENSURE THEIR SAFETY AND WELL-BEING. FINDINGS INCLUDE: ACCORDING TO A WRITTEN WITNESS STATEMENT AUTHORED BY FACILITY COOK "I", ON 6/6/13 AT APPROXIMATELY 10:45 A.M., RESIDENT #6 WAS OBSERVED OUTSIDE OF THE FACILITY, PROPELLING HIMSELF IN A WHEELCHAIR IN THE BACK PARKING LOT TOWARDS AN ALLEY. FACILITY COOK "I" DOCUMENTED RESIDENT #6 WAS ASKED WHAT HE WAS DOING, TO WHICH RESIDENT #6 REPLIED, "GOING HOME". THIS WITNESS STATEMENT REVEALED AT THE TIME OF THE INCIDENT, THE FIRE DOORS TO THE SERVICE HALLWAY AND THE DOORS LEADING OUTSIDE WERE BOTH LEFT OPEN WHILE A VENDOR TRUCK DRIVER WAS DELIVERING SUPPLIES. THIS WITNESS STATEMENT ALSO DOCUMENTS THERE WAS NO ONE ELSE IN THE AREA WHERE RESIDENT #6 WAS LOCATED. THE ADMISSION MINIMUM DATA SET (MDS) assessment dated [DATE], REVEALED RESIDENT #6 IS A [AGE] year OLD MAN admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. THIS MDS SHOWED RESIDENT #6'S BRIEF INTERVIEW OF MENTAL STATUS (BIMS) SCORE OF 3/15, WHICH INDICATED HE WAS SEVERELY IMPAIRED. THIS MDS REVEALED RESIDENT #6 NEEDED LIMITED ASSIST OF ONE WITH TRANSFERS AND AMBULATION IN ROOM. RESIDENT #6 DID NOT AMBULATE IN CORRIDOR DURING THIS REVIEW PERIOD. THE "NURSE'S NOTES" DATED 3/16/13 REVEALED RESIDENT #6 WAS "MORE ALERT TODAY, ABLE TO VERBALIZE NEEDS...". THE "NURSING NOTES" DATED 3/18/13, READ, "ABLE TO VERBALIZE BUT NOT ABOUT CURRENT EVENTS." THE NURSING NOTES DATED 3/26/13, READ, "(RESIDENT #6) WALKING AROUND IN ROOM. AGITATED. STATED, 'I HAVE TO GET OUT OF HERE!'". THE NURSING NOTES DATED 4/2/13 AT 0600 REVEALED "RESIDENT (#6) WAS NOT IN HIS BED....WE FOUND HIM ASLEEP IN ROOM 28 IN THE LAZ-BOY CHAIR, HE DIDN'T KNOW HOW HE HAD GOTTEN THERE." THE NURSING NOTES DATED 4/10/13 READ, "CARE PLAN REVIEWED, NO NEW INTERVENTIONS IMPLEMENTED AT THIS TIME." THE NURSING NOTES DATED 4/11/13 READ, "INSISTING HE HAS TO SHOW UP FOR WRESTLING PRACTICE TONIGHT. ANGRY... NEEDED HIS COACH... TO KNOW HE'LL BE THERE...". NURSING NOTES DATED 4/17/13 REVEALED "(RESIDENT #6) ANXIOUS, LOOKING FOR MOTHER...", AND ON 4/23/13, THE NOTE READ, "RESTLESS, VERY ANXIOUS EARLY A.M., LOOKING FOR CAR KEYS...". ON 5/18/13, THE NURSING NOTES READ "STATES HE NEEDS TO CALL HIS WORK PLACE, THEY WILL WONDER WHERE HE IS." THE NURSE CONTINUES TO EXPLAIN TO HIM WHERE HE IS AND THE NOTE CONTINUES AND READ, "NO ACKNOWLEDGEMENT OF THIS INFO (INFORMATION) THE RESIDENT (#6) CONTINUES TO ASK HOW TO GET TO THE LOWER LEVEL OR HOW TO GET OUT TO HIS CAR." THE NURSING NOTES DATED 5/27/13 READ, "WANTED TO KNOW HOW TO GET OFF THIS ISLAND...". THE NURSING NOTES DATED 6/6/13, READ, "RESIDENT (#6) OBSERVED BY DIETARY STAFF IN FACILITY BACK PARKING LOT...". THERE WAS ANOTHER INCIDENT OF EXIT SEEKING BEHAVIOR WHICH WAS RECORDED IN THE NURSING NOTES DATED 6/11/13 AT 2200 (10:00 P.M.) WHICH REFLECTED AT APPROX 9:00 P.M. (SUNSET), RESIDENT #6 PUT ON HIS COAT AND, "...WANTED TO KNOW WHAT DOOR WAS UNLOCKED..." THESE NURSES NOTES REFLECT RESIDENT #6 DESIRED TO GO TO A STORE TO GET A BEER. THE NURSING NOTES DEMONSTRATED RESIDENT #6'S CONTINUED ELOPEMENT RISK FROM ADMISSION TO THE TIME HE SUCCESSFULLY ELOPED ON 6/6/13. FURTHERMORE, THE NURSING NOTES CONTINUED TO REVEAL RESIDENT #6'S DESIRE TO EXIT THE FACILITY AFTER THE ELOPEMENT. THE RECENT QUARTERLY MDS assessment dated [DATE], REVEALED RESIDENT #6 HAD AN IMPROVED BIMS SCORE OF 10/15 INDICATING MODERATE COGNITIVE IMPAIRMENT AND HE DISPLAYED BEHAVIORS THAT INCLUDED WANDERING AND DELUSIONS, WHICH WERE NOT PRESENT ON THE 3/15/13 ASSESSMENT. ACCORDING TO THE 6/11/13 MDS ASSESSMENT, RESIDENT #6 CURRENTLY NEEDED ONLY SUPERVISION WITH TRANSFERS (NO PHYSICAL HELP REQUIRED) AND SUPERVISION ONLY WITH AMBULATION IN THE CORRIDOR. THIS MDS SHOWED RESIDENT #6 WAS NOT STEADY WITH BALANCE. THE MDS ASSESSMENT (DATED 6/11/13) REFLECTS RESIDENT #6 USED AN ASSISTIVE DEVICE OF A WALKER AND/OR WHEELCHAIR TO AID IN AMBULATION. THESE IMPROVEMENTS IN RESIDENT #6'S FUNCTIONAL ABILITIES, IN ADDITION TO HIS DOCUMENTED RISKY BEHAVIORS, REVEALED RESIDENT #6 WAS AT INCREASED RISK FOR ELOPEMENT. ON 6/19/13, A REVIEW OF RESIDENT #6'S MEDICAL RECORD REVEALED THE FACILITY HAD NOT DEVELOPED A PLAN OF CARE FOR RESIDENT #6'S ON-GOING EXIT SEEKING BEHAVIORS. ON 6/20/13 AT 1:30 P.M., OBSERVATION BY SURVEYOR # SHOWED THE FIRE DOOR TO THE SERVICE CORRIDOR (BELIEVED TO BE THE EXIT DOOR AND ROUTE WHICH RESIDENT #6 TOOK ON 6/6/13 WHEN HE ELOPED FROM THE FACILITY) WAS EQUIPPED WITH A KEYCODED LOCK. BEYOND THE DOOR, THE CORRIDOR WAS APPROXIMATELY 25 FOOT IN LENGTH WITH CLOSED DOORS LEADING INTO THE DIETARY UNIT ON ONE SIDE AND AN EMPLOYEE DINING ROOM AND BOILER ROOM ON THE OTHER. AT THE END OF THE CORRIDOR, ANOTHER KEYCODED LOCKED DOOR WAS IN PLACE, EXITING ONTO A PAVED PARKING AREA FOR SERVICE VEHICLES. THE PARKING AREA HAD AN INCLINE UP TO A PAVED ALLEYWAY ON THE LEFT AND RIGHT AND ANOTHER NARROW PAVED STREET WITH A STEEP INCLINE UP TO THE LOCAL ACUTE CARE HOSPITAL. OBSERVATION SHOWED A RESIDENTIAL AREA WITH LARGE WOODED LOTS. DURING AN INTERVIEW ON 6/18/13 AT 3:30 P.M., WITH A FAMILY MEMBER (FM #1) WHO IS THE RESIDENT'S DURABLE POWER OF ATTORNEY (DPOA) - FM #1 STATED THAT SHE MOVED RESIDENT #6 FROM ILLINOIS TO THE FACILITY IN MICHIGAN. FM #1 EXPLAINED RESIDENT #6 IS UNFAMILIAR WITH THE AREA AND IS ALWAYS ATTEMPTING TO LEAVE TO GO HOME OR ATTEMPTING TO GO TO WORK. FM #1 STATED THIS BEHAVIOR HAS BEEN PRESENT SINCE ADMISSION AND CONTINUES AS OF THIS DATE (6/18/13). FM #1 STATED SHE WAS UNAWARE OF RESIDENT #6 EXITING THE FACILITY UNATTENDED. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 6/19/13 AT 12:00 P.M., THE DON STATED (WHEN ASKED FOR THE INCIDENT/ACCIDENT REPORT INVOLVING RESIDENT #6'S ELOPEMENT ON 6/6/13), "NO, WE DIDN'T DO ONE... MY UNDERSTANDING WAS THEY SAW HIM LEAVE." AFTER THE DON REVIEWED THE NURSING NOTES RECORDED IN RESIDENT #6'S MEDICAL RECORD, SHE STATED, "YEAH, YOU ARE RIGHT, NO ONE SAW (RESIDENT #6) EXIT THE FACILITY." THIS SURVEYOR THEN ASKED HOW THE FACILITY COULD DETERMINE RESIDENT #6 WAS ONLY OUT OF THE FACILITY FOR "LESS THAN 5 MINUTES", AS DOCUMENTED IN THE NURSING NOTES DATED 6/6/13 AT 12:30 P.M. THE DON RESPONDED BY STATING THE FACILITY COULD NOT DETERMINE THE TIME, BECAUSE THEY DID NOT INVESTIGATE THE INCIDENT. THE DON STATED THE FACILITY COULD NOT STATE THE AMOUNT OF TIME RESIDENT #6 WAS GONE BY ANY FACTUAL EVIDENCE. DURING THE INTERVIEW, THE DON CONFIRMED THERE WAS NO CARE PLAN IN PLACE FOR SUPERVISION OF RESIDENT #6 RELATED TO HIS EXIT SEEKING BEHAVIORS. DURING THE INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 6/19/13 AT 12:00 P.M., THIS SURVEYOR ACKNOWLEDGED THE FACILITY HAS SEVERAL ASSESSMENT FORMS, I.E. FALLS RISK ASSESSMENTS, PAIN ASSESSMENTS, SKIN ASSESSMENTS AND HYDRATION ASSESSMENTS, HOWEVER, THIS SURVEYOR COULD NOT FIND AN ELOPEMENT RISK ASSESSMENT IN RESIDENT #6'S MEDICAL RECORD. THE DON HAD NO IMMEDIATE RESPONSE AND THEN STATED THE FACILITY DID NOT HAVE AN ELOPEMENT RISK ASSESSMENT FOR RESIDENT #6. THE INTERVIEW CONTINUED AND THE DON CONFIRMED THE ELOPEMENT INCIDENT WAS NOT COMPLETELY INVESTIGATED NOR WAS AN ASSESSMENT COMPLETED TO DETERMINE RISK FACTORS FOR RESIDENT #6. A REVIEW OF THE FACILITY'S POLICY TITLED "ELOPEMENTS", UNDATED, READ, "NURSING PERSONNEL MUST REPORT AND INVESTIGATE ALL REPORTS OF MISSING RESIDENTS. 1. IT IS THE RESPONSIBILITY OF ALL PERSONNEL TO REPORT ANY RESIDENT ATTEMPTING TO LEAVE THE PREMISES, OR SUSPECTED OF BEING MISSING, TO CHARGE NURSE AS SOON AS PRACTICAL...". THE POLICY DOES NOT ADDRESS ASSESSMENT OF RESIDENTS FOR ELOPEMENT RISKS OR TO DEVELOP A PLAN OF CARE TO ENSURE THE FACILITY PROVIDES ADEQUATE SUPERVISION OF RESIDENTS WITH ELOPEMENT RISKS. B. THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT ACCIDENTS (HOT COFFEE SPILL) FOR ONE (RESIDENT #5) OF ONE RESIDENT REVIEWED FOR RISK OF ACCIDENTS WITH "HOT LIQUIDS" IN A TOTAL OF 19 SAMPLED RESIDENTS FROM A FACILITY POPULATION OF 56 RESIDENTS. THIS DEFICIENT PRACTICE RESULTED IN DISCOMFORT TO THE RESIDENT AND HAS THE POTENTIAL FOR FUTURE HOT LIQUID SPILLS. FINDINGS INCLUDE: THE MINIMUM DATA SET (MDS) assessment dated [DATE], FOR RESIDENT #5 REVEALED SHE IS A [AGE] year OLD WOMAN admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THIS MDS ASSESSMENT SHOWED RESIDENT #5 WAS INDEPENDENT WITH EATING AFTER SET UP AND HAD CONSTANT SEVERE PAIN. A "HOT LIQUID SAFETY EVALUATION" DATED 12/31/12, REVEALED RESIDENT #5 TO BE AT RISK FOR INJURY FROM SPILLS OF HOT LIQUID. THE "INTERVENTIONS" DATED 12/31/12 WERE AS FOLLOWS: "-RESIDENT TO USE CUP WITH LID -TEMPERATURE OF LIQUID NOT TO EXCEED 180 DEGREES (FAHRENHEIT (?F)) -RESIDENT TO DRINK HOT LIQUIDS WHILE SITTING AT TABLE ONLY -RESIDENT TO WEAR CLOTHING PROTECTOR/LAP PROTECTOR". A REVIEW OF AN "ACCIDENT/INCIDENT REPORT" DATED 1/31/13 AT 1627 (4:27 P.M.), REVEALED RESIDENT #5 HAD A "BURN 2 CM (CENTIMETERS) X 3 CM" ON THE RIGHT BREAST AND THE AREA APPEARED PINK. THE REPORT SHOWED NO EVIDENCE THAT THE COFFEE TEMPERATURE WAS MONITORED. THE REPORT SHOWED NO EVIDENCE THE SAFETY INTERVENTIONS FOR HOT LIQUIDS WAS COMPLETELY IMPLEMENTED. FURTHERMORE, THE REPORT SECTION TITLED, "RECOMMENDED STEPS TO PREVENT RECURRENCE" DOCUMENTED THAT A SIPPY CUP WITH LID AND STRAW WAS USED, HOWEVER NO ADDITIONAL INTERVENTIONS TO ENSURE RESIDENT #5 WAS ADEQUATELY SUPERVISED FOR SAFETY WHILE HANDLING HOT LIQUIDS WERE DOCUMENTED. THERE WAS NO EVIDENCE THE FACILITY ADDRESSED ADDITIONAL INTERVENTIONS OR REVISED INTERVENTIONS RELATED TO THE ACCIDENT. THE "NURSING NOTES" DATED 1/31/13 READ, "RESIDENT SITTING IN DINING ROOM WITH COFFEE IN A SIPPY CUP (WITH) LID AND STRAW. CNA (CERTIFIED NURSE AIDE) HEARD RESIDENT YELL 'OH NO'... AND SAW SHE (RESIDENT #5) SPILLED COFFEE ON HER RIGHT BREAST... PINK AREA 2 CM X 3 CM ON OUTSIDE OF RIGHT BREAST. COLD COMPRESS APPLIED FOR 20 MINUTES... (ATTENDING PHYSICIAN) CALLED... ORDER RECEIVED TO MONITOR AREA AND USE SOLARCAINE PRN (AS NEEDED)". THERE WAS NO EVIDENCE OF REVIEW OR UPDATE OF THE RESIDENT'S "HOT LIQUIDS SAFETY" CARE PLAN. THE "NURSING NOTES" DATED 2/1/13, REVEALED THE BURN AREA SHOWED "NO REDNESS OVER (RIGHT) BREAST AREA... (RESIDENT #5) DENIES ANY PAIN OR DISCOMFORT OVER AFFECTED AREA". A REVIEW OF AN "ACCIDENT/INCIDENT REPORT" DATED 2/9/13 AT 1815 (6:15 P.M.), REVEALED "RESIDENT (#5) SPILT 'WARM' COFFEE FROM SIPPY CUP ON HER LAP". HOWEVER, THERE WAS NO EVIDENCE THE COFFEE TEMPERATURE WAS BEING MONITORED OR THE TEMPERATURE OF THE COFFEE AT THE TIME OF THE SPILL. THERE WAS NO DOCUMENTATION TO SHOW WHETHER THE "HOT LIQUID" CARE PLAN INTERVENTIONS WERE APPROPRIATELY IMPLEMENTED FOR RESIDENT #5. THE "RECOMMENDED STEPS TO PREVENT RECURRENCE" ON THE INCIDENT/ ACCIDENT REPORT DATED 2/09/13 READ, "PUT ICE CUBES IN COFFEE". HOWEVER, THIS INTERVENTION WAS NOT ADDED TO THE RESIDENT'S PLAN OF CARE FOR "HOT LIQUIDS SAFETY". THE "NURSING NOTES" DATED 2/9/13 READ, "SPILT WARM COFFEE ON HER LAP... NO REDNESS OR PAIN...". FOLLOWING THIS EVENT, THERE WERE NO REVISIONS OR ADDITIONS TO THE RESIDENT'S "HOT LIQUID" CARE PLAN DEMONSTRATING AN INCREASE IN SUPERVISION TO ENSURE RESIDENT #5'S SAFETY WHILE DRINKING HOT LIQUIDS. DURING AN INTERVIEW WITH RESIDENT #5 ON 6/19/13 AT 9:50 A.M., THIS SURVEYOR ASKED IF SHE COULD REMEMBER THE COFFEE SPILLS EARLY IN THE YEAR AND SHE STATED, "YEAH, I SPILLED COFFEE ON ME... NOW I GET COLD COFFEE AND I HATE IT... ACCIDENTS HAPPEN... IT WAS AN ACCIDENT... WHY DO I HAVE TO DRINK COLD COFFEE?" WHEN ASKED IF SHE REMEMBERED IF THE BURN WAS PAINFUL, SHE STATED, "I CAN'T REMEMBER IF IT HURT...". DURING AN INTERVIEW ON 6/19/13 AT 11:55 A.M., WITH THE DIRECTOR OF NURSING (DON), SHE CONFIRMED THE INCIDENT REPORTS (DATED 1/31/13 & 2/9/13) DID NOT DESCRIBE INTERVENTIONS IN PLACE AT THE TIME OF THE INCIDENT. THE DON STATED, "I SEE... THERE IS NO DOCUMENTATION IF THESE INTERVENTIONS WERE IN PLACE... YEAH, OR WHAT WAS DONE TO PREVENT FURTHER SPILLS." THE DON STATED THE NURSING NOTES MAY REVEAL FURTHER INFORMATION. A REVIEW OF THE RESIDENT'S NURSING NOTES FOR JANUARY-FEBRUARY, 2013 SHOWED NO FURTHER DESCRIPTION OF ANY INTERVENTIONS FOR RESIDENT #5 AT THE TIME OF THE TWO INCIDENTS, EXCEPT USE OF A SIPPY CUP WITH A LID AND STRAW. THE DON STATED, "I SEE THIS IS A HUGE PROBLEM ...ONE THAT NEEDS TO BE FIXED." CERTIFIED DIETARY MANAGER (CDM) "E" WAS INTERVIEWED BY SURVEYOR # ON 6/20/13 AT 11:50 A.M. THE CDM STATED THAT DIETARY STAFF PERIODICALLY CHECK THE TEMPERATURES OF THE COFFEE MACHINE, BUT THEY DO NOT LOG ANY OF THE TEMPERATURES TAKEN. THEREFORE, THERE IS NO RECORD OF THE COFFEE TEMPERATURES AT THE TIME OF THE INCIDENTS ON 1/31/13 OR ON 2/9/13, NOR COULD THE FACILITY SHOW EVIDENCE THAT RESIDENT #5 WAS BEING SERVED COFFEE AT 180?F OR LESS. ( ) --