Every finding on record at Medilodge of Leelanau

This deficient practice pertains to Intake #3158817.Based on observation, interview, and record review, the facility failed to provide adequate supervision resulting in a fall with injuries for one Resident (#2) of three residents reviewed for accident hazards and supervision. This deficient practice resulted in facial lacerations and broken dentition for Resident #2.Findings include:Resident #2 (R2)Review of R2's Electronic Medical Record (EMR) revealed initial admission to the facility on 1/20/23 with diagnoses including dementia, Alzheimer's disease, and a cognitive communication deficit. Review of Section C: Cognitive Patterns in R2's most recent Minimum Data Set (MDS) assessment, dated 7/31/26, revealed their ability to make decisions regarding tasks of daily life as severely impaired-never/rarely made decisions. Further review of Section GG: Functional Abilities and Goals, revealed R2 was dependent (the caregiver provides 100% of the effort) for functional transfers.Review of an Unwitnessed Fall Report written by Licensed Practical Nurse (LPN) E, dated 6/24/26, read, in part: [CNA (certified nursing assistant] C] entered residents' room and found resident on the floor face down in a pool of blood. Resident was left in wheelchair after dinner in her room the total lift directly placed in front of her. resident presented with a pool of blood coming from her nose with two small lacerations, one presumably from her glasses.the other on her brow.Review of a witness statement written by CNA C on 6/24/26, read, in part: .it was noted by this CNA the total mechanical lift was left in the resident's room directly in front of her.On 8/26/26 at 3:30 PM, a phone interview was conducted with CNA C who verified he discovered R2 on the floor of her room surrounded by blood during the evening of 6/24/26. CNA C stated the total mechanical lift was positioned directly in front of R2 with the lift legs spread out on either side of the wheelchair as if somebody had positioned R2 for a transfer and then left the room. CNA C recalled he later learned CNA I had wheeled R2 back from the dining room and left her in her room unattended. When CNA C was asked if it was common to leave R2 unattended in her room he replied, No. We keep her out where everybody can see her [for increased supervision and safety]. When queried if it is typical to leave equipment in resident rooms when not in use, CNA C stated, No.Review of a witness statement written by LPN D on 6/24/26, read, in part: .[this] nurse ran down to residents' room and found resident face down on the floor with her wheelchair on top of her. The lift was placed directly in front of the resident like someone had started transferring. The lift legs were placed outside of the wheelchair and resident was positioned directly in the center of it. Resident's left side of face was on the ground and a large pool of blood was by the mouth and nose. a laceration was on the bridge of the nose and left eyebrow.On 8/26/26 at 3:16 PM, a phone interview was conducted with LPN D who verified she responded to R2's fall on the evening of 6/24/26. LPN D reiterated the total mechanical lift was left in the room and, it looked like the [lift] was directly in front of her like somebody was about to use it. LPN D continued, I was pretty ticked off about the way [R2] was left [alone in the room with mechanical lift] so when I found out it was CNA I [who left R2], I confronted her. When LPN D was queried as to why she was upset R2 was left in her room alone, she replied, Because we typically keep her out where everybody can see her. LPN D further explained R2 was largely non-verbal and had an impaired safety awareness and was therefore kept in common areas.Review of a witness statement written by CNA F on 6/24/26, read, in part: [Fall code] was heard paged overhead so this CNA made his way over. [R2] was lying face down in front of her wheelchair with the total mechanical lift in front of her.On 8/26/26 at 11:24 AM, an interview was conducted with CNA F who verified CNA I had wheeled R2 back from the dining room and left her unattended in her room. When asked if it's typical to leave lifts in the room with residents, CNA F stated, No. CNA F indicated he was very familiar with R2's care and stated she does not get left alone in her room due to her decreased safety awareness. CNA F stated, I personally would have assisted her to bed right away.On 8/26/26 at 12:38 PM, an unsuccessful phone interview was attempted with CNA I who was no longer employed at the facility.Review of a progress note written by Nurse Practitioner (NP) M on 6/25/26 at 8:00 AM, read, in part: .[R2] is being seen today after a fall yesterday - she was in her wheelchair and fell forward out of her chair landing on her face. She did ship [sic] her left front tooth, sustained lacerations x2 - one to the bridge of her nose and the other to her forehead. She has ecchymoses [bruising] surrounding both eyes and left upper lip with large hematoma [severe bruise] .On 8/26/26 at approximately 11:30 AM, R2 was observed in her room in a geriatric chair (a specialized, padded medical recliner equipped with wheels). R2 was unable to provide details regarding her fall on 6/24/26. A chip was observed in her left front tooth.On 8/26/26 at 3:36 PM, a phone interview was conducted with R2's Durable Power of Attorney (DPOA) H regarding the fall. DPOA H stated, The fall was abnormal, nothing like that had ever happened before.Review of R2's plan of care revealed the following focus: Resident is at risk for falls/injury related to agitation, behaviors.decreased strength and endurance, history of falls, impaired cognition with decreased safety awareness. initiated 8/2/23.The following interventions were listed in R2's plan of care: Ensure the resident's room is free from accident hazards (e.g., providing adequate lighting ensuring there are no trip hazards. initiated 8/2/23. TRANSFERS: with 2 person assist AND use of [total mechanical lift], initiated 11/3/25.On 8/26/26 at approximately 1:45 PM, an interview was conducted with the Director of Nursing (DON) regarding R2's fall on 6/24/26. While the DON stated the facility had no policy against leaving transfer equipment in resident room, she acknowledged leaving R2 unattended in front of a total mechanical was a poor decision given her cognitive status.Review of the facility policy titled, Accidents and Supervision, revised 12/27/23, read, in part: .upon identification of a risk for falls, the following interventions may be considered when developing the baseline or comprehensive care plan for the resident: implement universal environmental interventions that decrease the risk of falling, including, but not limited to: a clear pathway to the bathroom and bedroom doors.all staff are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident. supervision is an intervention and a means of mitigating accident risk. The facility provides adequate supervision to prevent accidents. Adequacy of supervision is: a. defined by the type and frequency, b. based on the individual resident's assessed needs and identified hazards in their environment.

Based on observation, interview, and record review, the facility failed to store medications properly and maintain a clean medication cart for one of two medication carts and two Residents (R24 and R48) of six residents reviewed for medication storage. Findings include:Resident #24 (R24) On 3/23/26 at 11:27 AM, an observation was made of R24 in his room. R24 had a bottle of fluticasone propionate solution nasal spray sitting on top of his nightstand. Resident #48 (R48) On 3/23/26 at 11:21 AM, an observation was made of R48 in her room. R48 had a fluticasone furoate/vilanterol inhaler new inhaler on her bedside table. R48 was asked how long she had the inhaler and replied, It is new. I think it has been about two months. During an interview on 3/23/26 at 12:15 PM, with Registered Nurse (RN) G who was asked about medications left at the bedside and replied, My bad. I left them sitting in there. I went to circle back. I just did not make it back yet. On 3/23/26 at 12:25 PM, an audit was made of medication cart on Wharf unit and was found to be out of compliance with debris in the second drawer and two medications found loose. The two loose medications were identified as famotidine 20 milligrams (mg) and bethanechol chloride 25 mg. Inside the top right small drawer was a medication in medication cup without a label identifying who or what it was. During an interview with RN D on 3/23/25 at 12:28 PM who was asked about the medication cup with the pill inside and replied, I got it ready and she was unavailable to administer. I should have put her name on the medication cup and what it was. I am currently training another nurse and that could have caused an error. RN D was asked about cleaning medication carts and replied, The nightshift nurses are responsible for cleaning medication carts. RN D was asked if she was aware of the small handheld cordless vacuum in the medication room and replied, Yes, I guess maybe I should clean the cart out. An interview was conducted on 3/23/26 at 12:45 PM, with the Director of Nursing (DON) regarding medication storage and replied, (R24) does not have an order for that medication, no care plan or assessed to self-administer medications. (R48) does not have an order for that medication to be left at the bedside. Medications should not be left at the bedside. Medication carts should be cleaned regularly, and no loose pills should be left or debris. Medications should be administered and returned back to the cart such as inhalers, nasal sprays, and insulins. On 3/24/26 at 11:45 AM, an observation was made of the medication cart on Cedar unit and was found to be unlocked and unattended by a nurse. At 11:50 AM, on 3/24/26 Certified Nurse Aide (CNA) K came walking down the unit on Cedar and was asked if he had seen RN F and if nurses usually let medication carts unlocked and unattended and replied, (RN F) was down on the Wharf unit. Nurses do not leave their medication carts unlocked to my knowledge, but that is a big no, no in my book. On 3/24/26 at 12:00 PM, an observation was made of RN F heading down to the Cedar unit. RN F was asked if she normally leaves her medication cart unlocked and unattended and replied slowly, No, I am sorry. On 3/25/26 at 8:50 AM, an interview was conducted with the Regional Director of Operations (RDO) L who was made aware of the medication cart on Wharf being unlocked and unattended and replied, The problem has been addressed and taken care of. Review of policy titled, Medication Storage, dated 1/30/24, read in part Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines: 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts. Review of policy titled, Medication Administration, dated 1/17/23, read in part Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infections. Policy Explanation and Compliance Guidelines.1. Keep medication carts clean, organized, and stocked with adequate supplies.

Based on observation, interview, and record review, the facility failed to ensure accurate and standards of practice of medication administration for two Residents (R47 and R59) of four residents reviewed for medication administration with 4 errors out of 29 opportunities resulting in a medication error rate of 14%. Findings include:Resident #47 (R47)On 3/24/26 at 8:06 AM, an observation was made of Registered Nurse (RN) F during a medication pass with R47. RN F prepared R47's medications and went to administer the medications to R47 in her room which included oral pills and subcutaneous insulin. R47 asked RN F if her diuretic was within the medication cup and RN F replied, Yes. R47 asked RN F to remove the medication from the cup, and she would take it after her appointment when she later returned to the facility. RN F left R47's room and returned to her medication cart. RN F opened her medication cart to visually see what the diuretic looked like and proceeded to look through R47's pills unable to identify the diuretic in R47's medication cup. While RN F went through R47's medication cup she touched three pills with her bare hands. RN F then returned to R47's room and administered R47 her medications including the diuretic without R47 knowing the medication was still in the cup. RN F was interviewed on 3/24/26 at 8:06 AM, during the preparation of R47's medications and asked where R47's nasal spray fluticasone propionate suspension was and replied, I am not sure. I guess I will have to go get a new one from back-up supply. During R47's medication preparation on 3/24/26 at 8:06 AM, RN F failed to clean the hub of the insulin lispro pen and primed the pen with two units of insulin holding the pen horizontal and not vertical. During the administration of R47's insulin lispro RN F held the injection site for two seconds and when RN F pulled R47's insulin pen away from her skin there was a drop of blood that immediately appeared from the injection site. (Error #1) On 3/24/26 at 8:30 AM, this surveyor performed a medication reconciliation of R47's medication administration record and identified the following errors:R47's diuretic (bumetanide) was signed out as being held and was given. (Error #2)R47's nasal spray was omitted and not given. (Error #3) An observation was made of the Cedar medication cart on 3/24/26 at 8:45 AM and lacked R47's nasal spray. On 3/24/26 at 9:15 AM, an interview was conducted with RN F who was asked if she replaced and dispensed R47's nasal spray and replied, No, I did not. I have to strike that out. On 3/24/26 at 9:30 AM, an interview was conducted with the Director of Nursing (DON) who was asked about medication administration and what her expectations were and replied, To follow the five or six rights of medication administration. Double check the orders while preparing medications. The DON agreed RN F improperly primed and prepared the insulin pen and failed to hold the insulin injection site for ten seconds. The DON stated, Medications should not be touched with bare hands. Resident #59 (R59)During a medication preparation for R59 on 3/25/26 at 7:50 AM, an observation was made of RN J preparing medications for R59. During medication preparation RN J dispensed one enteric coated aspirin 81 milligrams (mg) for R59 in a medication cup along with R59's other medications. RN J finished preparing R59's medications and was going to dispense R59's medications. RN J was asked if he had the correct aspirin type and went to double check the order. RN J replied, No, I do not. I need to replace the aspirin with a chewable form. (Error #4) On 3/25/26 at 8:50 AM, an interview was conducted with the Regional Director of Operations (RDO) L who was made aware of the medication administration error rate who replied, Yes, we knew this was going to be an issue because of yesterday. Review of policy titled, Medication Administration, dated 1/17/23, read in part Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infections. Policy Explanation and Compliance Guidelines.1. Keep medication carts clean, organized, and stocked with adequate supplies.11. Compare medication source with MAR to verify resident name, medication name, form, dose, route, and time of administration.b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. c. If other than PO route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye, ear, rectal, etc.).17. Sign MAR after administrated.20. Correct any discrepancies and report to nurse manager. Review of insulin lispro pen instructions obtained from website: https://pi.lilly.com/insulin-lispro-kwikpen-us-ifu.pdf, date retrieved 3/26/26, read in part .Preparing your pen.Step 1.wipe the rubber seal with an alcohol swab.Priming your pen.Step 7 Hold your pen with the needle pointing up.Giving your injection.Step 11 Insert the needle into your skin. Push the dose knob all the way in. Continue to hold the dose knob in and slowly count to 5 before removing the needle.

Based on observation, interview and record review, the facility failed to provide restorative therapy services per the resident care plan for one Resident (R63) of one resident reviewed for restorative therapy. Findings include: Revealed admission to the facility on [DATE] with diagnoses including cerebral infarction. R63's 2/27/26 Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 6/15 indicative of moderate cognitive impairment. In Section O of the 2/27/26 MDS assessment, R63 received four days of Passive Range of Motion (PROM) and three days of splint or brace assistance.On 3/23/26 at 11:50 AM, R63 was observed sleeping in her bed with a hospital gown. It was observed that a wool therapy carrot (a specialized orthosis designed to position severely contracted hands) was on R63's bedside table. Residents' left hand noted to be severely contracted with no open space or view of R63's fingernails.On 3/24/26 at 9:51 AM, R63 was observed laying in bed, finishing her breakfast and drinking her coffee. An interview was conducted with R63 who asked why she was at the facility. It was noted that a wool therapy carrot was sitting on her bedside table. R63 was observed to only use her right hand for eating and drinking, with her left hand showing a severe contracture.On 3/25/26 at 9:25 AM, an interview was conducted with Therapy Director M regarding R63's contracture restorative therapy services. Therapy Director M stated that R63 was discharged from restorative therapy on 3/5/26 and was never placed back on until last night (3/24/26). Therapy Director M explained that R63 was discharged from restorative therapy so she could be evaluated from the therapy department for her contracture but was not picked up by therapy services. Therapy Director M confirmed that R63 should have been placed back on restorative therapy and had not received any range of motion or splint assistant services since 3/5/26.On 3/25/26 at 9:51 AM, an interview was conducted with Restorative Aide N regarding R63's contracture and restorative therapy services. Restorative Aide N stated that she had a meeting with the Director of Nursing (DON) on 3/4/26 and discussed discharging R63 from restorative so therapy could evaluate and possible treat R63's left hand. Restorative Aide N stated that the next time she came to work with R63, she was unable to pull her medical records, indicating that she was not on restorative therapy services, and therefore, did not perform any PROM or splint assistance. Restorative Aide N stated that R63 is willing to participate in restorative therapy services with her, but it does take timeReview of R63's Progress Notes dated 3/3/26 and written by Occupational Therapist (OT) O read, in part, OT screen completed for L (left) hand contractures. Pt (patient) does not tolerate any passive movement of L fingers, unable to place washcloth or any other object in between fingers and palm.therapy indicated Y/N (Yes/No): (left blank) If therapy indicated, specify discipline(s) PT, OT and/or ST (Physical Therapy, Occupational Therapy, Speech Therapy): (left blank).Review of R63's Care Plans read, in part, Resident would benefit from a restorative rang of motion program related to contracture, decreased strength in lower extremities, decreased strength in upper extremities, hemiplegia, limitation in range of motion.interventions: observed for changes in ROM and report to nurse and Physician/Therapy as appropriate, passive range of motion to left lower extremities and left upper extremities in all planes 1 set of 20 reps.Provide range of motion program LUE/LLE (Left Upper Extremity/Left Lower Extremity) ROM Supine 3x (times) a week x 20 minutes to tolerance.

Based on interview and record review, the facility failed to observe the consumption of medication for one Resident (R6) of one resident reviewed for quality of care. This deficient practice resulted in R6 consuming acetic acid with medications. Findings include:This citation pertains to intake 2788510 Resident #6 (R6) Review of a complaint received on 2/25/26 filed with the State Agency (SA) read in part, Complainant states a nurse.gave him his fluid, Acidic Acid, on 02/22/26, in a regular cup and didn't tell him what it was so he drank it. The acidic acid was for flushing out his catheter . On 3/23/26 at 4:00 PM, an interview was conducted with Registered Nurse (RN) G about R6 and receiving acetic acid and replied, (R6) was very upset about the situation and that is why I got called to talk with him and calm him down. What happened was (RN F) was training and brought in (R6's) medication including oral pills, a glass of water, and a glass of acetic acid in the same glass the water was in, so both glasses were identical with clear fluid. (RN F) forgot something and left (R6) with the medication and the glasses of clear fluid. (R6) took his medication after (RN F) left his room. (R6) took his medication with the acetic acid and not the water because he was not instructed on which glass was which and neither was labeled. The acetic acid was not even drawn up in a sterile manner. We are supposed to use the syringe we are flushing with or a sterile collection cup. On 3/24/26 at 9:45 AM, an interview was conducted with RN D who was orienting RN F on the day of the incident with R6. RN D stated, I got the acetic acid ready and (RN F) prepared (R6's) medications. I was not aware that she had gotten water for his medications. (RN F) did not even tell me what happened and I was unaware that (R6) drank his acetic acid flush with his medication. RN D was asked if she had witnessed RN F perform an indwelling catheter flush while RN F was on orientation and replied, No, I just explained the procedure to her. I did not know she was going to leave all the stuff in the room with him. During an interview on 3/24/26 at 12:05 PM with R6 in his room, R6 proceeded to tell this surveyor about the day of the incident when he drank acetic acid with his medications. R6 stated, (RN F) came into my room and gave me two glasses with clear liquid and set them on my bedside table on the right side of my bed with a cup of medications. (RN F) then left the room without witnessing me taking my medications. While I was taking my medications, I quickly became aware that what I was drinking was not water. I threw it out after that. I was told she forgot something and left my room to go get it. I became upset after that. (RN F) returned to my room after that and I told her to get out and not to return. She makes mistakes all the time. Once she brought me the wrong meds. I don't want her helping me. I don't trust her. They better keep her away from me. On 3/24/26 at 12:30 PM, an interview was conducted with the Director of Nursing (DON) who was asked if she was aware of the incident with RN F and R6 and replied, Yes, I did some reeducation with (RN F) and other staff. Review of RN Fs nursing competencies on 3/24/26 at 1:00 PM, revealed that RN F lacked any check off for flushing urinary catheters. Review of RN Fs personnel file revealed that RN F was on an extended orientation process.

Based on observation, interview, and record review, the facility failed to perform Activity of Daily Living (ADL) care (finger and toenail trimming services) for one resident (R12) of one resident reviewed for ADL care. Findings include: Review of R12's Electronic Medical Record (EMR) revealed admission to the facility on 1/28/25 with diagnosis of malignant neoplasm of brain. R12's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3/15, indicative of severe cognitive impairment. On 03/23/2026 at approximately 11:50 AM, R12 was observed sitting in her room. An interview was attempted with R12, but she was unable to answer questions appropriately. It was observed that R12 was not wearing any socks or shoes at the time of the interview, and R12's fingernails and toenails appeared to be very long. On 03/24/2026 at 1:07 PM, R12 was observed to be walking down the hallway returning her lunch tray. R12 was not wearing any socks or shoes and had visibly long fingernails and toenails with debris noted underneath the nails. An interview was conducted with Certified Nurse Aide (CNA) B on R12's nails. CNA B stated that R12 receives hospice services who are supposed to trim R12's nails. However, the staff from hospice have not been routinely coming to the facility. CNA B confirmed that R12's fingernails and toenails were approximately a quarter inch in length. On 3/24/26 at approximately 1:30 PM, an interview was conducted with the Nursing Home Administrator (NHA) and Assistant Nursing Home Administrator/Registered Nurse (RN) E regarding R12's nail length. The NHA confirmed that the hospice staff that was to routinely come to the facility was replaced and they would investigate R12's nails further. On 3/24/26 at 2:22 PM, an interview was conducted with Assistant Nursing Home Administrator (NHA)/RN E who confirmed that R12's nail length for both finger and toenails are extremely long and were attempted to be trimmed but will need an order for podiatry to assess R12's nails. Review of R12's Care Plans read, in part, Resident has an ADL self-care performance deficit related to malignant neoplasm of the brain, epilepsy, communication deficit .Trim resident's fingernails and toenails biweekly and PRN (as needed) date initiated: 2/26/25 .

Based on interview and record review, the facility failed to ensure a recapitulation of stay and the Long-Term Care Ombudsman were notified of a resident's discharge from the facility for one Residents (#74) of two residents reviewed for discharge practices.Findings include: Resident #74 (R74)Review of R74 Electronic Medical Record (EMR) revealed the resident was discharged from the facility on December 31, 2025, in police custody. Review of R74's EMR indicated there was not a recapitulation (a summary of the main points of the resident's treatments) of stay completed. Review of the documentation provided to the Long-Term Care Ombudsman in December 2025 indicated they were not notified of the resident's discharge from the facility. On 3/24/26 at 12:10 PM, an interview was conducted with the Nursing Home Administrator (NHA), when asked what discharges are expected to be on the Ombudsman list, he stated I have always been told emergency transfers only.On 3/24/26 at approximately 2:30 PM, during an interview with the Director of Nursing (DON) when asked if a recapitulation of stay was completed for R74, the DON stated the facility had a call with fellow department heads from sister facility's regarding R74's discharge, but there was never a recapitulation of stay completed.Review of the facility's policy titled Transfer and Discharge (including AMA) last revised on 10/30/23 indicated in part: .7. Emergency Transfers/Discharges-initiated by the facility for medical reasons, or for immediate safety and welfare of a resident.h. Document assessment findings and other relevant information regarding the transfer in the medical record.k. Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list.

This citation pertains to intake number 2711126Based on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident. This deficient practice resulted in Resident 1 (R1) inappropriately touching Resident 2 (R2) causing R2 to feel mental trauma based on the reasonable person concept.Findings include:Review of the facility's Investigation Summary/Action Taken report dated 1/7/26 read, in part, During routine cares on the AM (morning) of 12/30/25 resident, [name], reported to CNA (Certified Nurse Aide) A, that he observed a male resident, (R1), fondling a female resident, (R2), several weeks ago.he witnessed two instances, about four weeks ago that were two days apart. The first instance he witnessed (R1) squeeze (R2's) breast over her clothes at the puzzle table then rub her thigh.the second instance that occurred approximately two days later, (R1) squeeze (R2's) breast over the clothes then lift her shirt and bounce her breast in the hallway next to the therapy gym.(R1) admitted to lifting (R2's) shirt and touching her breasts. A personal protection order was issued on behalf of R2 on 12/30/25 citing that R1 had a reasonable apprehension of sexual assault because the respondent has sexually assaulted the petitioner or threatened the petitioner with sexual assault.Review of R1's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with diagnosis including hydronephrosis (swelling of the kidney). R1 was cognitively intact and responsible for his own medical and financial decisions.Review of R2's EMR revealed admission to the facility on 1/24/24 with diagnosis including cerebral palsy and developmental disorders of speech and language. R2 was non communicative and had a legal guardian/conservator for her medical and financial decisions.Review of an interview statement by R1, conducted with the Nursing Home Administrator (NHA) and Director of Nursing (DON) read, in part, 12/30/25.When (R1) was asked to describe the incident, he responded, 'Well sometimes your hand rubs against her (R2). He reported that this touching happened over her clothes, except one instance when he pulled up her (R2) top. When asked to describe this incident, he replies, 'It was very quick, take a look, let her go.'R2 denied touching any other resident.Review of the facility's Abuse, Neglect and Exploitation policy reviewed 1/10/24 read, 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 ad prevent abuse, neglect, exploitation, and misappropriation of resident property.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:Notification to police and R2 guardian on 12/30/25Notification to Nurse Practitioner B on 12/30/25, conducted a visit to R2 citing she physically and psychologically appears to be well with no changes. I do not have any immediate concerns medically that require any changes at this timePsychosocial follow-ups were initiated on R2 and increased observations1:1 supervision on R1 until removal from facility on 12/31/25Interview and Education with all staff to ensure no other instances of abuse have been noticed and what to do if you suspect abuse. No significant findings were identified.Residents with BIMS (Brief Interview of Mental Status) score of greater than 12 interviewed to identify if they have witnessed or had been victim to inappropriate touching or any other safety concerns. No significant findings were identified. Education to residents on who and when to report abuseResidents with BIMS score of less than 12 were assessed for pain and skin with no significant findingsR1 was served an order of protection and was not legally permitted to remain on the property. Was given order summary, prescription medications on hand, dressing change supplies, and list of upcoming appointments. R1 was educated on dressing change procedure prior to exiting the facility on 12/31/25Abuse Policy and Procedure reviewed by NHA and deemed appropriate.QAPI (Quality Assessment and Process Improvement) completed on 1/20/26 and found no significant findingsThe facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This deficiency pertains to Intake MI00147043 Based on observation, interview, and record review, the facility failed to maintain sufficient staff for four (Resident #8, #37, #41, and #63) of seventeen residents reviewed for staffing. Findings include: Resident #37 (R37) An interview was conducted on 12/9/24 at 12:13 PM with R37, who stated the quality of care has gone down since last year. R37 stated they constantly witnessed one nurse taking care of half the building. One nurse for both Orchard and Wharf, and one nurse for Cabin and Cedar. R37 stated the facility never really has four nurses at the same time and stated that it seemed there were a lot of call ins from the Certified Nursing Aides (CNAs) and it screws everything up. R37 then stated there were times Residents could not have lunch in the dining room because the facility did not have the help to assist the residents. Resident #41 (R41) While conducting an interview on 12/9/24 at 3:11 PM, R41 stated there were long waits for call lights to be answered and they were only getting one shower a week. R41 stated, during a conversation with the Nursing Home Administrator (NHA), R41 was told residents should expect a wait time of 15 minutes or less for call light responses. R41 felt current wait times were unsafe and informed the NHA, the described 15-minute wait time was often exceeded. On 12/9/24 the following observations were made: 3:25 PM upon exiting room [ROOM NUMBER], call lights for rooms [ROOM NUMBERS] were on. The unidentified CNA assigned to the hallway was located in the shower room with another resident and no other staff were in the hallway. 3:34 PM the resident of 214 (Resident #11) R11 started calling out for someone to help. 3:35 PM the unidentified CNA came out of shower room with another resident they had just showered who was being propelled in a wheelchair. 3:38 PM the unidentified CNA entered room [ROOM NUMBER] and found R11 on floor. The unidentified CNA asked a passing unidentified kitchen staff if they knew how to call code white, and the unidentified kitchen staff indicated he was unable to. The unidentified CNA then went to nurse's desk to page overhead for help. 3:40 PM, facility staff responded to overhead page and arrived at room [ROOM NUMBER] to address the fall. Three staff determined they were not needed, left the room and walked past two other call lights without answering them. 3:41 PM an unidentified CNA entered room [ROOM NUMBER] to answer call light, 16 minutes after initial observation of call light being on. 4:02 PM while passing room [ROOM NUMBER], R11 was observed on the floor again, the call light was not on, and no staff were in hallway. On 12/11/24 at 10:30 AM during the resident council, all in attendance raised concerns about staffing, expressing there were long wait times for call lights to be answered. Resident #63 (R63) stated there is not enough staff in the dining room to provide proper assistance with eating, to feed R11, who was R63's blind spouse. R63 stated, when he tries to assist with feeding R11, the facility staff yell at R63, stating it is the facility staff's job. R63 then stated, if the facility could not assist R11, it was R63's job to do so as R11's spouse. R63 stated, R11 would only get cold food or barely eat if it was not for R63's help. Resident #8 (R8) stated, due to the lack of staff in the dining room, R8 observed other residents who would eat food off other resident's plates, and those residents that needed assistance waited a long time to eat. R37 stated, when staff are in the dining room to assist with meals, that means there are no staff on the floor to assist residents who were not in the dining room with their needs, such as eating or answer their call lights. All residents who attended the meeting agreed this made them feel unsafe. During an interview on 12/11/24 at 1:18 PM, Licensed Practical Nurse (LPN) B stated there were not enough CNAs and nursing staff to care for the level of acuity of the residents in the facility. LPN B stated, between 6:00 AM and 8:30 AM there are just six staff members to care for all the residents. LPN B stated, during the 6-8:30 AM time, it was expected of staff that all residents would be gotten up, dressed, and to breakfast during that time, as well as medications passed. LPN B stated, if facility staff voiced concerns about staffing, the facility's corporate management would tell them they had bad attitudes. LPN B stated they felt the current NHA and (Director of Nursing) DON were not being allowed to staff according to the needs and acuity of the residents. Review of the facility's policy Call Lights: Accessibility and Timely Response, dated 12/28/23 read in part . 6. Ensure the call system alerts staff members directly or goes to a centralized staff work area. 7. Any staff member who sees or hears an activated call light is responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. The facility staff did not follow this policy when they walked by two call lights without answering them.

Based on interview and record review, the facility failed to conduct and document an annual facility wide assessment resulting in the potential for inadequate resources to meet the needs and care for all 68 facility residents. On 12/9/24 during the entrance conference at 11:50 AM the Nursing Home Administrator (NHA) was asked for a copy of the Facility Assessment. The NHA provided a Facility Assessment Tool for 7/2023 through 6/2024. The NHA was asked if there were any updates to the facility assessment to meet the requirement of being reviewed and updated annually. During a follow-up interview on 12/10/24 at 3:20 PM, the NHA stated all files provided were the most current. Review of the Facility Assessment tool section titled Average Daily Census Analysis indicated the patient population had an average of 63 which did not reflect the current resident population.

Based on interview and record review, the facility failed to update infection control policies annually. This deficient practice has the potential to affect all 68 residents regarding infection control practices. Findings include: On 12/10/24 at 3:20 PM, a review of the infection control policies was completed. The following infection control policies were found not to be updated annually: a. COVID-19 (virus capable of severe respiratory illness) Vaccination policy last updated on 10/20/23; b. Influenza (flu) Vaccination policy last updated on 10/26/23; c. Pneumococcal (pneumonia) Vaccine (Series) last updated on 10/30/23; d. Water Management Program undated and no last updated date; e. Transmission-Based (Isolation) Precautions last updated on 5/22/23; f. Laundry last updated on 10/26/23 and; g. Handling Clean Linen last updated on 10/30/23. On 12/11/23 at 12:21 PM, an interview was conducted with License Practical Nurse (LPN)/Infection Preventionist (IP) B who was asked if she was aware infection control policies should be updated annually and replied, No I was not aware that the policies needed to be updated annually. There have been three different IP managers in the last year and there are other management and corporate people that are in it and behind the scenes. On 12/10/24 at 3:20 PM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked if the provided infection control policies were the most recent up to date policies for infection control The NHA replied, Yes, those are the most updated policies we have.

Based on interview and record review, the facility failed to administer a COVID-19 vaccination as requested by one Resident (R14) of five residents reviewed for immunizations. Findings include: Resident #14 (R14) R14 was interviewed on 12/9/24 at 3:03 p.m. R14 said she asked for a COVID-19 vaccination when she received the influenza vaccination in September 2024. R14 said, I never got the COVID shot. R14 said she contracted COVID-19 in the facility in November. R14 said she would still like to have the COVID-19 vaccination. A grievance resolution form Quality Assistance Form was submitted to the facility by R14's daughter on 11/12/24. The form documented R14's daughter was requesting an antiviral medication for R14 and was inquiring regarding the timing of the COVID-19 vaccine. The form documented a physician was notified and resident is eligible for booster, will order 3 mo [months] past COVID infection. The immunization history in R14's medical record revealed she received the Influenza Vaccination on 9/18/24. The COVID-19 vaccination status in the medical record was documented as pending immunization. The medical record documented R14 tested positive for COVID-19 on 11/11/24. The most recent COVID-19 vaccination was documented as being administered on 1/23/24. The Director of Nursing (DON) was interviewed on 12/11/24 at 8:32 a.m. The DON said she ordered the COVID-19 vaccine from the facility's contracted pharmacy but R14's dose was not included when the vaccines were delivered. The DON said she re-ordered the vaccine for R14, but it wasn't delivered in the second delivery either. The DON said she had to reorder the vaccine for R14 a third time but R14 contracted COVID-19 in the meantime. The DON said R14's physician ordered the vaccine to be administered in February, 90 days after the resident contracted COVID-19. On 12/11/24 at 11:42 a.m. The DON was asked regarding the process, what the facility does if there is concerns with pharmacy delivery. The DON said the facility utilized a local pharmacy as a back-up when they have concerns with ordered medications or concerns with delivery by their contracted pharmacy. The DON confirmed they had not attempted to secure a COVID-19 vaccine dose for R14 from the back-up pharmacy when it was not delivered from the contracted pharmacy. The DON confirmed she did not contact the health department to determine alternative source options to secure the vaccine R14 had requested since September 2024. The Centers for Disease Control (CDC) recommendations for COVID-19 vaccination (https://www.cdc.gov/covid/vaccines/stay-up-to-date.html) state, in part: .The COVID-19 vaccine helps protect you from severe illness, hospitalization , and death .Getting the 2024-2025 COVID-19 vaccine is especially important if you: .are [AGE] years and older . are living in a long-term care facility .People ages 65 and older are up to date when you have received: 2 doses of any 2024-2025 COVID-19 vaccine 6 months apart. While it is the recommended to get 2024-2025 COVID-19 vaccine doses 6 months apart, the minimum time is 2 months apart, which allows flexibility to get the second dose prior to typical COVID-19 surges . The facility policy COVID-19 Vaccination dated as revised 10/20/23 read, in part: .The facility may administer the vaccine directly or the vaccine may be administered indirectly through an arrangement with a pharmacy partner or local health department .

Based on interview and record review, the facility failed to offer snacks in the evening for three Residents (#6, #22, and #31) of eighteen residents reviewed for evening snacks. Findings include: Resident #6 (R6) During an interview on 12/10/24 at 2:45 PM, R6 was asked if a bedtime snack was provided at bedtime. R6 stated, I did not get offered a bedtime snack last night on 12/9/24. Dietary staff wheel out the snack cart and place it in front of the nurse's station. The Certified Nurse (CNA) just leaves it sit there in front of the nurse's station and never pass out or offer snacks each night. It happens quite frequently that snacks are not passed out. Sometimes it is a free-for-all where some residents can get to the snacks and others can't. Then it becomes an infection control issue when you don't know where other resident hands have been. I would like a snack at night because I am diabetic and need a snack. The facility needs to have different snacks. I would prefer some grapes, and we never get them. The facility just basically gives us what they want, and we are not asked what we prefer. The choices we get are not very healthy. We get only two choices. We can only get one tiny snack, and it is not enough, especially not for me. Review of R6's Minimum Data Set (MDS) assessment, dated 9/2/24, revealed a diagnosis that included diabetes mellitus. R6 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, reflective of intact cognition. Review of R6's task list for nutrition - HS [at bedtime] snack: routine, dated 11/12/24 through 12/10/24, revealed the following, no bedtime snack offered on 11/14/24, 11/22/24, 12/1/24, 12/5/24, and 12/6/24. Resident #22 (R22) During an interview on 12/10/24 at 3:05 PM, R22 was asked if a bedtime snack was provided. R22 stated, Snacks were not offered last night on 12/9/24. I would have liked a fig [NAME], but no one came by and offered a snack. I do not care for most of the things that are offered. I wished they would have a little more variety such as Oreo's, ice cream, or a banana. The apples that they bring by for snacks are yucky and look bad. I prefer fresh apples and not ones in a pre-made plastic package. Review of R22's MDS assessment, dated 11/19/24, revealed a diagnosis that included type 2 diabetes mellitus. R22 scored 15 out of 15 on the BIMS assessment, reflective of intact cognition. Review of R22's task list for nutrition - HS snack: routine, dated 11/12/24 through 12/10/24, revealed the following, no bedtime snack offered on 11/14/24, 11/20/24, 11/22/24, 12/1/24, 12/5/24, and 12/6/24. Resident #31 (R31) During an interview on 12/9/24 at 12:06 PM, R31 was asked if a bedtime snack was provided. R31 stated, The cookie jar needs tongs. I have seen other residents' just reach in the cookie jar bare-handed. That is so disgusting. We are to get snacks each night between 7 and 8 in the evening. There are not a whole lot of choices with the snack cart. I would like to see healthier choices such as fresh fruit. The prepackaged apple slices are yucky and brown. I need apple sauce because I can't chew an apple slice. They do not update the snacks that are offered. They are the same old snacks, and we get only two choices and if we don't like them, we just don't get a snack. I have brought it up in Resident Council that more options to honor preferences would be nice. Or a larger variety of snacks so we have more choices, but nothing ever happens. We just get what they say we get. I'm not happy with the snack choices. Review of R31's MDS assessment, dated 9/22/24, revealed a diagnosis that included diabetes mellitus. R31 scored 15 out of 15 on the BIMS assessment, reflective of intact cognition. Review of R31's task list for nutrition - HS snack: routine, dated 11/12/24 through 12/10/24, revealed the following, no bedtime snack offered on 11/14/24, 11/22/24, 12/1/24, 12/5/24, and 12/6/24. Review of R31's care plan, dated 6/17/24, read in part, .Focus: Resident is at risk for altered nutritional status related to BMI [body mass index] >70, CHF [congestive heart failure] T2DM [type 2 diabetes mellitus] .edentulous .Intervention .Other: (Specify) Offer HS snack . On 12/11/24 at 1:35 PM, an interview was conducted with Dietary Manager (DM) A and was asked who prepares the evening snack carts and what they looked like. DM A replied, They are plastic, and have three drawers to store snacks for residents. We have two, one for each side of the building. The dietary staff stocks them up with snacks depending on what day it is depends on what they are stocked with. DM A was asked how long ago the snack list was created and replied, I am not sure, but it has been that way for awhile now. Review of the undated snack list, revealed the following, Monday: Fig [NAME] or saltines, Tuesday: Potato chips or apple slices, Wednesday: Banana or graham crackers, Thursday: Assorted cookies or saltines, Friday: Apple slices or goldfish crackers, Saturday: Banana or assorted cookie, and Sunday: Oatmeal cream pie or graham crackers. Review of policy titled, Offering/Serving Bedtime Snacks, dated 8/29/24, read in part, Policy: It is the practice of this facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences and requests at bedtime on a daily basis .Policy Explanation and Compliance Guidelines: 1. The nursing staff offers bedtime snacks to all residents in accordance with the resident's needs, preferences and requests on a daily basis. 2. All diabetic or special diet bedtime snacks are labeled and dated. Each label contains the resident's name and room number .

Based on interview and record review, the facility failed to ensure Medication Regimen Reviews (MRRs) were addressed by the physician and maintained in the clinical record for one Resident (#9) of five residents reviewed for MRRs. Findings include: Resident #9 (R9) The pharmacist's documentation in R9's medical record revealed the monthly MRRs of 8/30/24 and 11/26/24 resulted in recommendations written to the physician. Neither the pharmacist's written recommendations nor the physician's written responses to the recommendations were in R9's medical record. On 12/10/24 at 1:43 p.m., The Director of Nursing (DON) was asked for the pharmacist's written recommendations and the physician's written responses to the recommendations for 8/30/24 and 11/26/24 for R9. The DON said, I don't know where those are. We looked for them, but couldn't find them. The DON said the physician's written responses to the recommendations were not in the resident's record because she (the DON) had previously been unaware she needed to obtain the written recommendations and provide them to the physician. The policy Addressing Medication Regimen Review Irregularities dated as implemented on 10/30/20 and revised on 12/28/23 read, in part: .4. The pharmacist must report any irregularities to the attending physician, the facility's medical director and director of nursing, and the reports must be acted upon .d. The attending physician must document in the resident medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record .

Based on observation, interview, and record review, the facility failed to provide appropriate catheter care and maintenance for one Resident (#22) of one resident reviewed for catheter care. Findings include: Resident #22 (R22) Review of the Clinical Census report revealed R22 was admitted to the facility on [DATE]. Review of R22's Minimum Data Set (MDS) assessment, dated 11/19/24, revealed a diagnosis that included type 2 diabetes mellitus. R22 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, reflective of intact cognition. During an observation on 12/10/24 at 7:58 AM, an indwelling urinary catheter collection bag was observed hanging from the bottom of R22's bed. R22 was asked how long she had the urinary catheter and replied, Ever since I was at the hospital and then came here for rehab. Review of R22's discharge hospital instructions, dated 7/11/24, read in part, .The patient [R22] has a foley catheter for retention related to GBS [Guillain-Barre syndrome]. Would recommend voiding trail once more sensation is present. Last exchanged 7/2 would recommend monthly exchanges . Review of R22's physician order, dated 7/11/24, revealed the following, Change indwelling Foley catheter. (SPECIFY size:__16_fr [french]; balloon:___10_cc [cubic centimeter]) r/t (related to):__________ PRN (as needed) as clinically indicated: s/s (signs and symptoms) of obstruction (leakage, increased sediment, etc.), infection, or if closed system was compromised. Per recommended montly (sic) catheter change (Acute Care Hospital). Change catheter drainage bag as needed - as needed. No monthly urinary catheter exchange was ordered by the facility physician or nursing. Review of R22's Treatment Administration Record (TAR), dated 7/11/24 through 12/10/24 revealed R22's urinary catheter was not changed monthly in August 2024, September 2024, and October 2024. Review of the progress notes for R22 revealed a urinary catheter was documented as being changed at the facility was on 11/4/24 with no additional information. Procedure tolerance, equipment used, urinary return following insertion, amount used to inflate the balloon used to secure the catheter were all absent from the note. Review of R22's care plan, dated 7/12/24, read in part, .Focus: Resident has a need for indwelling urinary catheter .Goal: Resident will have reduced catheter-related complications .Interventions .Change catheter and drainage system as clinically indicated per order(s) . On 12/11/24 at 10:15 AM, an interview was conducted with Senior Director of Nursing (DON) D who agreed that if R22's discharge recommendations were to change the Foley monthly and assess for return of sensation for a voiding trial, then this should have been completed monthly by nursing and documented. On 12/11/24 at 10:30 AM, an interview was conducted with the DON who also agreed that if nursing was not addressing R22's sensation to void, then the physician should be monitoring. Recommendations should have been followed unless indicated differently by the facility physician. Documentation was requested to support not changing catheter monthly and monitoring of sensation returning for urgency to void for R22 at this time. On 12/11/24 at 1:45 PM, physician progress notes, dated 8/12/24 and 8/14/24, revealed the lack of any voiding trial and implemented urinary catheter change. Physician progress notes, read in part, .Urinary retention .Maintain Foley catheter with routine care, last changed 7/2. Discussed with patient and husband that routine care dictates change of Foley every 30 days . On 12/11/24 at 11:35 AM, an interview was conducted with the Senior DON D who was asked about a policy for inserting a Foley catheter and stated all she could find was a suprapubic (insertion site just above pubic area) catheter insertion. The Senior DON D was then asked what her expectation was and stated that the size, technique, resident tolerance of procedure, balloon size, and if urine was returned should all be documented in the medical record. Review of policy titled, Suprapubic Catheter Change Procedure, dated 1/1/22, read in part, .Documentation of the procedure shall include: a. The type of catheter inserted, including French size and balloon size. b. Amount of fluid used for inflation. c. Ease of insertion or any problems, such as resistance, bleeding, or pain. d. Amount and description of the urine return. e. Resident's response to the procedure.

Based on observation, interview, and record review the facility failed to implement interventions to prevent falls with further injury for one Resident (#3) of three residents reviewed for falls. This deficient practice resulted in the risk for further falls with injury. Findings include: Resident #3 (R3) Review of R3's Progress Notes revealed the following entry: 8/22/24: At 0220 this nurse heard a noise and resident yell out Help. This nurse entered room and noted resident lying on her left side in bathroom doorway with left arm underneath her. Has a basketball size amount of blood from left side of head. Resident states pain in left hip and left arm. Pressure dressing applied to left head laceration. Vitals taken. BP (blood pressure) very high 206/107, other vitals stable. No change from baseline in orientation. PERRLA (Pupils, Equal, Round, Reactive (to), Light, Accommodation). Neuro (neurological) checks WNL's (Within Normal Limit) for this resident. No internal/external rotation of legs. Hips symmetrical. Resident able to move arms and legs without difficulty. 911 called and resident sent to [Hospital Name]. Voicemail left with daughter. Hospice nurse notified. 8/22/24 07:00; ER (emergency room ) provider called and states odontoid (tooth shaped portions extending from the sides of the 2nd cervical vertebra) neck fx (fracture). Has to wear collar to neck at all times except for bathing. Also states resident is not a surgical candidate and is on hospice. admin notified. Daughter also notified. On 12/11/24 at 10:30 a.m. R3 was observed sitting in her recliner wheelchair while her daughter was visiting. R3 was observed wearing regular socks with no grips on the bottom of her feet. An interview was conducted with R3 and her daughter who stated that she had purchased her socks with grips on the bottom of the feet as she does not like the ones provided at the facility. R3's daughter stated that she visits almost daily and has noticed that R3 has not been wearing the socks she has purchased, and they cannot be found in her dresser drawer. R3's daughter expressed concern that R3 could potentially fall and injure herself again. Review of R3's Care Plan read, in part, Resident has an ADL (Activities of Daily Living) performance deficit related to .neck fracture; Revision Date: 8/29/24 .Interventions: Ambulation: Supervision .Transfers: Independent .Resident uses a walker for ambulation/transfer . Resident is at risk for falls/injury related to .history of falls; Revision Date: 12/9/24 .Interventions: Gripper Socks . An interview was conducted with the Director of Nursing (DON) on 12/11/24 at 11:31 a.m. The DON confirmed R3's Care Plans should have been changed to something else as R3 does not like to wear gripper socks. Review of the facility's Fall Prevention Program revised 10/26/23 read, in part, each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. A) Interventions will be monitored for effectiveness. B) The plan of care will be revised as needed. Review of the facility's Accidents and Supervision policy revised 12/27/23 read, in part, Each resident will be assessed for accident risk and will receive care and services in accordance with their individualized care plan. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes .Implementing interventions to reduce hazard(s) and risk(s) .

This deficiency pertains to MI00147043 Based on interview and record review, the facility failed to provide necessary showers during preferred times for two Residents (#6 and #22) of eighteen residents reviewed for ADL's (Activities of Daily Living). Findings include: Resident #6 (R6) Review of R6's Minimum Data Set (MDS) assessment, dated 9/2/24, revealed a diagnosis that included diabetes mellitus. R6 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment, reflective of intact cognition. During an interview on 12/10/24 at 9:10 AM R6 was asked about staffing. R6 replied, There are not enough aides. I am only to have a female caregiver and there was a time about a week ago there were no female aides working, just the nurse was a female. I feel degraded. On 12/10/24 at 2:45 PM, during a follow-up interview R6 was asked about showers and replied, There is something wrong with the boiler. The water is cold and when that happens the staff must go reset it. I have to wait to take a shower. I prefer showers first thing in the morning, but if the boiler is not working properly then I have to wait. I have to wait for staff to reset it and for it to heat back up. I may refuse a shower if I have to wait so long and then I just don't feel like doing it in the afternoon. The boiler has not been working properly for about a month. I am not very happy about the boiler not working properly. Review of R6's task list for shower/bathe self (Prefers: shower Wednesday and Saturday AM), dated 11/16/24 through 12/11/24, revealed the following: a.) On 11/16/24 - resident refused at 1:59 PM; b.) On 11/20/24 - completed at 1:59 PM (late); c.) On 11/23/24 - completed at 1:16 PM (late); d.) On 11/27/24 - completed at 9:00 AM; e.) On 11/30/24 - completed at 1:59 PM (late); f.) On 12/4/24 - completed at 3:18 PM (late); g.) On 12/7/24 - completed at 12:36 PM and (late); h.) On 12/11/24 - completed at 8:22 AM. Resident #22 (R22) Review of R22's MDS assessment, dated 11/19/24, revealed a diagnosis that included type 2 diabetes mellitus. R22 scored 15 out of 15 on the BIMS assessment, reflective of intact cognition. During an interview on 12/10/24 at 7:58 AM, R22, who was asked about showers replied, There are times when the staff is short or too busy to provide a bed bath which I prefer twice a week. At times I only get one bath a week then two and vice versa. There are times that I have to beg for a bed bath. Last Saturday I had to beg for a bed bath. Review of R22's task list for shower/bathe on Wednesday/Saturday PM's, dated 11/16/24 through 12/4/24, revealed R22 did not receive a shower/bathe between 11/20/24 through 11/26/24 and 12/4/24 and 12/10/24. On 12/11/24 at 3:30 PM, an interview was conducted with Maintenance Assistant F who was asked if the boiler was working properly. Maintenance Assistant F replied, No, we have to reset it. It normally happens on the weekends. The Nursing Home Administrator (NHA) has educated some of the Certified Nurse Aides (CNA) on how to reset it if it happens on the weekends when we are not here. We have a work order in for it. We have already had someone out to look at it, but it is still not fixed. When the one goes out the back-up one is not triggered to go on and it should. Residents are having to wait for the water to heat back up. It has been like this for about a month. 49397 Resident #41 (R41) During an interview on 12/9/24 at 3:11 PM, R41 stated there were weeks the facility staff are offering only one shower a week, which made her feel unclean. R41 stated their showers were to be on Tuesdays and Fridays. R41's care plan indicated Resident has an ADL self-care performance deficit related to left sided hemiplegia (one sided paralysis) with neglect, chronic pain, anxiety depression. BATHING: 1 person assist. BED MOBILITY: 1 person assist PERSONAL HYGIENE: 1 person assist. A review of Electronic Medical Record (EMR) indicated R41's shower schedule was Tuesdays and Fridays, with preference for late afternoons between 7:00 PM and 9:00 PM. Shower logs indicated R41 had one shower during the weeks of 9/16/24, 9/23/24, 10/7/24, 10/14/24, 10/21/24, and 12/3/24. R41 did not have any shower during the week of 11/11/24, a refusal by R41 was noted on 11/12/24 at 9:59 PM which was outside of R41's preferred time, without documentation of another shower being offered. Review of policy titled, Activities of Daily Living, dated 12/28/23, read in part, Policy: The facility takes measures to minimize the loss of residents' functional abilities, including activities of daily living (ADL's). Activities of Daily Living include the ability to: 1. Bathe, dress, and groom .Policy Explanation and Compliance Guidelines .3. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .

Based on interview and record review, the facility failed to ensure written bed-hold information was provided to two Residents/Representatives (#22 & #57) of three residents reviewed for written notice of bed hold. Findings include: Resident #22 (R22) Review of R22's electronic medical record (EMR), communication form and progress note, dated 9/15/24, read in part, .hypoxia [ an absence of enough oxygen in the tissues to sustain bodily functions]/oxygen needs . Review of the Clinical Census report revealed R22 was hospitalized from 9/15/24 through 9/25/24. Review of R22's EMR revealed there was no Bed Hold Authorization form completed. During an interview on 12/10/24 at 2:09 PM, the Nursing Home Administrator (NHA) was asked who was responsible for the bed hold authorization form and replied, Nursing is responsible for the SBAR (Situation, Background, Assessment, Recommendation), transfer form, and the bed hold authorization. Then the medical records staff is responsible to uploading the bed hold into the EMR. During an interview on 12/10/24 at 2:30 PM, Medical Records Staff C confirmed there was no bed hold notice provided at the time of transfer and none was scanned into the EMR for R22 on 9/15/24. Resident #57 (R57) Review of R57's EMR, progress note, dated 9/1/24, read in part, Resident is following another resident around holding a pillow above her head as if he is going to attack her .Resident is blocking the hallway, not letting staff or residents threw (sic). Resident slapped the RN (Registered Nurse) twice and tried to stab her with his fingernails. Resident is trying to hit staff with his sandals .RN is transferring resident to (Local Hospital) for further evaluation. EMS (Emergency Medical Services) has been called and resident has been transferred out. Review of the Clinical Census report revealed R57 was hospitalized from 9/1/24 through 9/9/24. Review of R57's EMR revealed there was no Bed Hold Authorization form completed. During an interview on 12/10/24 at 2:30 PM, Medical Records Staff C confirmed there was no bed hold notice provided at the time of transfer and none was scanned into the EMR for R57 on 9/1/24. An interview was conducted with the Director of Nursing (DON) on 12/11/24 at 12:30 PM. The DON stated nurses are responsible at the time of transfer to provide the resident and /or the representative with the bed hold policy as well as filling out the SBAR and transfer form. The DON also stated that the forms are to be scanned into the EMR. Review of the policy titled, Bed Hold Notice Upon Transfer, dated 2/1/22, read in part, Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed .

Based on observation, interview, and record review, the facility failed to ensure medications were properly secured, physician's orders for self-administration of medications were clarified, and residents were adequately assessed for self-administration of medications for two Residents (R14 and R46) of three residents reviewed for self-administration of medications. Findings include: Resident #14 (R14) On 12/9/24 at 1:03 p.m., a clear plastic medication cup containing two medication tablets was observed on the over bed table in R14's room. R14 confirmed the nurse brought the cup of medications to the room and placed them on the table before exiting the room. A bottle labeled acetaminophen 500 mg (milligrams) was observed on the nightstand in R14's room. R14 said the bottle contained her pain medication, and she kept the bottle of medication in her room on the nightstand. The bottle was approximately half filled with white, circular tablets. When R14 was asked if the nurses followed up with her to ask her if she took her medications, R14 said, No. I think they just know I take it. On 12/10/24 at 8:01 a.m., the bottle of Acetaminophen was again observed on the nightstand in R14's room. On 12/11/24 at 10:34 a.m., two clear plastic medication cups were observed on R14's bedside table next to an untouched meal tray. One cup contained eight medication tablets and the other contained a white powder. R14's medical record revealed a Self-Administration of Medication evaluation completed on 11/29/24. The evaluation documented R14 as self-administering all scheduled medications. The evaluation further documented R14 had a secured, locked location to store the medications. R14's medical record contained a physician's order that read staff to set up evening medications, resident is able to self administer [sic] in the evening for MED PASS [sic]. There was no physician's order for R14 to self-administer medications during any other part of the day. The medical record of R14 had a physician's order that read resident may keep Tylenol [acetaminophen] at bedside in lock box for self-administration. A care plan for self-administration of medications was in R14's medical record. The care plan did not address the storage expectations for the acetaminophen. The care plan did not specify how the nurses were to administer medications ordered during day shift medication administration. The care plan interventions included only the following interventions: - Assist in securing medication after administration as needed - Document on MAR (Medication Administration Record)/TAR (Treatment Administration Record) resident administered medications after verification of administration with each ordered timeframe - Notify physician/NP (Nurse Practitioner)/PA (Physician Assistant) of any concerns related to self-administration of medication(s) - Periodically review with resident on proper storage of drug to prevent unauthorized access - Periodically review with resident on purpose and side-effects of medication(s) as needed The Director of Nursing (DON) was interviewed on 12/11/24 at 11:42 a.m. The DON said the acetaminophen should not have been on the nightstand in R14's room. The DON said R14 kept medication in a drawer in her room, and the drawer should be locked. The DON said residents who self-administer medications are required to have a physician's order to self-administer and the directive for self-administration should be documented in each physician's order for each medication order for which the resident self-administers. The DON reviewed the physician's orders and Medication Administration Record of R14 and confirmed each order did not contain the directive for self-administration. The DON did not provide a rationale when asked why there was a physician's order for self-administration for the evening medication pass, but not a self-administration order for day shift administration. The DON was asked where the nurses were documenting the self-administration of medications for the day shift. The DON confirmed the MAR did not contain documentation for self-administration on the day shift. 34568 Resident #46 (R46) On 12/9/24 at approximately 1:00 p.m., R46 was observed sitting in her recliner chair in her bedroom. R46 had her right hand holding her feeding tube (a device used to deliver nutrition, hydration and medications into the stomach) and was using her left hand to gather a syringe that was placed in a pink water cup. R46 stated that she administered her own water flushes through the tube. On 12/11/24 at 10:32 a.m., R46 was observed sitting in her recliner chair. On the table to the left of her chair was four plastic syringes and two cups of water. R46 stated that these were to be used by her for her next water flush. Review of R46's December 2024 MAR revealed the following orders: Enteral (through a tube) Feed Order one time a day Flush tube with (90) ML's (milliliters) H2O (water) before and after every feed (180 ml total) Start Date: 9/4/24 The times to complete this order were at 7:00 a.m., 10:00 a.m., 1:00 p.m., 5:00 p.m., and 10:00 p.m. Enteral Feed Order every shift flush tube with 50 ML H20 before and after medication administration and feedings Start Date: 9/1/24 .Check placement before administration of meds (medications)/tube feedings/water flushes every evening shift Start Date: 12/10/24 In review of R46's MAR, there was no physician order for R46 to self-administer her own water flushes. Review of R46's Assessments revealed that R46 had not been assessed to safely provide her own water flushes. Review of R46's Care Plans read, in part, .Resident is at risk for fluid volume deficit related to g (gastrostomy or stomach tube)-tube, swallowing problem so is NPO (nothing by mouth) All fluids provided by staff vis [sic] PEG tube; Date Initiated: 9/10/24 . An interview was conducted with the DON on 12/11/24 at approximately 11:30 a.m. The DON stated that the facility did not want R46 to administer her own flushes, but they were having difficulty addressing this with R46. The DON stated that R46 had a history of retrieving syringes out of the trash can or taking used syringes from her roommate. The DON confirmed that R46 did not have a physician order or Self-Administration of Medication assessment for her water flushes. The DON also did not explain why staff had not taken measures to prevent access to the medication/flush syringe. The policy Medication - Resident Self-Administration of dated as revised 1/30/24 read, in part: .2. The resident's preference will be documented on the appropriate form and placed in the medical record. 3. When determining if self-administration is clinically appropriate for a resident, the interdisciplinary team should at a minimum consider the following .d. The resident's capability to follow directions .5. Upon notification of the use of bedside medication by the resident, the medication nurse records the self-administration on the MAR .7. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms .Lockable drawers or cabinets are required only if locked storage is ineffective .13. The care plan must reflect resident self-administration and storage arrangements for such medications.

This citation pertains to intake: MI00146857 Based on interview and record review, the facility failed to report an allegation of staff to resident sexual abuse to the State Agency (SA) for one Resident (R900) of three residents reviewed for abuse. Findings include: Review of the complaint filed with the SA on 9/10/24 read, in part, .Complainant states the facility therapist (Occupational Therapist (OT) C) had been having sex with Resident (R900). Complainant states everyone knew about it and staff member [Certified Nurse Aide (CNA) D] went to the administrator about it . An interview was conducted with the Nursing Home Administrator (NHA) on 9/12/24 at 9:00 a.m. The NHA was asked if any abuse allegations were brought to him within the last 30 days. The NHA stated there were none reported in the last 30 days. An interview was conducted with CNA D on 9/12/24 at approximately 10:30 a.m. CNA D stated that while outside of the facility on 8/29/24, she was told that OT C and R900 were having sex. CNA D stated she reported this information directly to the NHA on 8/30/24 when she returned to work. An interview was conducted with the Director of Nursing (DON) on 9/12/24 at 10:54 a.m. The DON stated CNA D did report an allegation of sexual abuse between OT C and R900. The DON stated that the facility's legal team was contacted because it was believed R900 had been on a leave of absence (LOA) from the facility when the allegation occurred. The DON stated the legal team felt this was not reportable to the SA. This Surveyor requested the incident/accident report and interview statements from the DON. On 9/12/24 at approximately 11:05, the DON and NHA brought the file which contained one interview between the NHA and R900. There were no further interviews or witness statements. The NHA stated he misunderstood the request for abuse allegations in the last 30 days this morning and confirmed an allegation of sexual abuse was brought forward to him on 8/30/24 from CNA D. The NHA confirmed the facility did not report this allegation to the SA. Review of the facility's Abuse, Neglect and Exploitation policy dated 1/10/24 read, in part, .Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes as required by state and federal regulations: immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .

Based on observation, interview, and record review, the facility failed to provide adequate supervision to assure resident safety during a transport for one Resident (#31) of six residents reviewed for safety. This deficiency practice resulted in Resident #31 unbuckling her seatbelt causing her to fall and sustain a right tibia and fibula fracture and the potential for other residents using the facility transportation service to be not adequately supervised. Findings include: Review of Resident #31's Face Sheet revealed admission to the facility on [DATE] with diagnoses including: Cerebral infarct (infarct is also known as a stroke), [CONDITION(S)] disease, hypertension, [CONDITION(S)], and [CONDITION(S)] and [CONDITION(S)] following other [CONDITION(S)] disease affecting right dominant side. The Plan of Care indicated that Resident # 31 needed two people assist with activities of daily living and used a wheelchair for ambulation. On 09/12/21 at 2:42 PM, an interview was conducted with Resident #31 in their room, and she was asked if she had any recent falls. Resident #31 was unable to describe if she had any recent falls. Resident #31 was noted to have a Brief Interview for Mental Status (BIMS) score of 03 out of 15 on minimum data set (MDS) assessment indicator within the survey shell, indicating she was cognitively impaired. Resident # 31 was observed lying in bed, appeared pale in color, a facial grimace, and periodically moaned and motioned towards her right leg with her arm. During record review, a Progress Note was found for Resident # 31 dated 06/22/21 which read, resident left building with transport and one additional staff member for a dental consultation at regional medical center. She left the building in a tilt back w/c (wheelchair), paperwork and medications sent with resident for her appointment. Staff will await her return. Further record review, a pertinent fall charting was found for Resident # 31 dated 06/22/21 which read, during transport, resident slid out of her chair falling on to her right knee. Fall was witnessed by 2 staff members who were with her during the transport for an appointment to regional medical center. During an interview on 09/13/21 at approximately 11:00 AM, the Director of Nursing (DON) was asked about the fall for Resident # 31 and why it was not reported to the state agency (SA). The DON said that at the time Resident # 31 was alert and oriented and she had no change in her functional status. An incident report for Resident # 31's fall on 06/21/21 was requested and received on 09/13/21. Review of the Fall Investigation Report for Resident # 31 dated 06/21/21 read in summary that Resident # 31 unbuckled their own seatbelt because their bottom hurt, and then slid out of their wheelchair during transport, and indicates they were intercepted to the floor by CNA B. Review of Resident # 31's Fall Investigation Summary dated 06/24/21 indicated that Resident # 31 was being transported to a dental appointment for 1:30 PM on 06/21/21 down state and left the facility at approximately 5:45 AM. Resident # 31 while in transport unbuckled at approximately 7:35 AM, and then had lunch at approximately 11:15 AM indicating some slight swelling on Resident # 31 right knee with some discomfort. DON notified with instructions to send to emergency department if pain or swelling worsens. At approximately 12:20 PM CNA B, CNA C, and Resident # 31 arrived at the dental appointment and at that time Resident # 31's right knee was checked and found to have become worse with increased swelling and pain. The dental office according to the Fall Investigation Summary dated 06/24/21 recommended to send the Resident # 31 to the local emergency room for an evaluation and arrived at the emergency room at approximately 3:30 PM. Review of Resident # 31 x-ray, dated 06/22/21 and timed 4:41 PM, read: acute nondisplaced fracture of the proximal tibial shaft of the right and there is also an acute, nondisplaced fracture of the proximal shaft of the right fibula (part of the lower leg bones that projects out from the lower knee). Also, record review of Resident # 31 after care summary from and emergency room visit on 06/22/21 indicating an additional medication of [MEDICATION(S)] 5/325 milligrams (narcotic used for pain control) to take one tablet every six hours if needed for pain by mouth and to call for a follow up visit to orthopedic the next day to make an appointment for some time between the next five to seven days. An attempt was made to obtain the emergency room visit report on Resident #31 on 09/13/21 during an interview with the NHA, but she did not have a copy of this record on file and was unable to obtain the emergency room visit report prior to the exit conference time. Review of Resident # 31 Progress Note - Skin dated 07/08/21 which read resident went to orthopedic yesterday, splint was removed, and a new brace was applied. It was noted that this appointment took place 15 days after Resident # 31's emergency room visit. Interview on 09/13/21 at 4:45 PM with Certified Nursing Assistant (CNA) B was conducted regarding the fall incident with Resident # 31 on 06/21/21. CNA B was able to provide the same information from the incident report. CNA B was asked if she was given training on where to sit while assisting with transports and she stated no. CNA B was asked why she sat where she was seated during transport and stated that she just made a judgement call and wanted to be between the driver and the resident to facilitate communication. CNA B was asked if she received any post incident training and she stated that she did and she was now to sit as close to the resident as possible during transport. CNA B was asked if she could see the resident from where she was sitting on the transport bus, and she stated that she could not entirely unless she unbuckled herself and got out of her seat. On 09/13/21 at approximately 5:30 PM an interview with Nursing Home Administrator (NHA) was conducted. When asked if the staff riding in the transport van were trained on where to sit during a transport with residents who required a second staff member, the NHA stated that there was no specific education. Review of Resident #31's care plan, initiated 03/07/18, indicated that she was at risk for falls related to: incontinence, paralysis, and history of falls. Goals which read .the resident will not sustain a serious injury through the review and the resident will be free of further falls, target dated 09/13/21. Interventions included: .anticipate and meet the resident's needs based on nursing assessment, provide activities of interest, provide activities per the activity care plan to minimize falls, initiated on 03/07/2018. Review of the facility policy and procedure titled Fall Prevention Program (Implement dated 01/01/21 and revised on 10/30/20) read in part: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services consistent with professional standards of practice, to prevent new pressure ulcers from developing for one Residents (#31) of four residents reviewed for pressure ulcers. This deficient practice resulted in harm to Resident #31 with the development of three new pressure injuries, delayed healing with lack of pressure injury prevention interventions, and increased pain. Findings include: Review of Resident #31's medical record revealed admission to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She was noted to need two person assist with activities of daily living and used a wheelchair for ambulation. Resident #31 was noted to have a Brief Interview for Mental Status (BIMS) score of 03 out of 15 on Minimum Data Set (MDS) assessment, indicating she was cognitively impaired. On 09/12/21 at 2:42 PM, an interview was conducted with Resident #31 in their room, and she was asked if she had any open areas or sores. Resident #31 was unable to answer if she had any open areas or sores. Record review, of Resident #31's Braden Scale for Predicting Pressure Sore Risk, completed on 06/05/21, indicated a score of 14, which is a moderate risk for developing pressure ulcers. Review of Resident # 31's Progress Notes dated 07/08/21 read in part: one on her right heel unstageable pressure ulcer 2.2x2.5 centimeter (cm), and the other on her right lateral malleolus (part of the tibia leg bone that projects out from the ankle) suspected deep tissue injury (SDTI) 0.9x0.8cm.Care plan interventions: Initiated - low air loss mattress added today, new brace yesterday and may be removed for bathing and skin checks.Current treatment: Right lateral malleolus and right heel: skin prep every shift. Review of Resident # 31's Referral to Physician dated 07/07/21 documented Resident # 31 was seen for a right tibia fracture on 07/07/21 with an up dated diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review on Resident #31's Progress Notes dated 07/15/21 revealed only one open area on the right heel an unstageable pressure ulcer measuring 2.6 x 3.1cm. The documentation indicated healing of the pressure ulcer compared to the last skin assessment on 07/08/21, which also included right malleolus suspected deep tissue injury (SDTI) 0.9 x 0.8cm. There was no further documentation of the SDTI. Review of Resident #31's Progress Notes from 07/26/21 indicated she was placed under Hospice care and chart orders reviewed related to a decline in the resident related to her fracture, pressure ulcers, and pain. The Progress Note on 07/27/21 from the facility physician indicated no plan for further orthopedic follow-up in the setting of hospice care. Review of Resident #31's Progress Notes revealed: Skin dated 09/10/21 which read, in part, right heel last week per skin documents reads: 3.1 x 2.9cm; this week is 1.3 x 0.8cm indicating improvement. Right lateral calf medical device deep tissue injury last week 6.8 x 3.5 x 0.3cm this week is 8.2 x 3.5 x 0.3cm right medial calf last week 1.3 x 1.2cm. On 09/13/21 at approximately 4:30 PM an interview with the Director of Nursing (DON) was conducted regarding Resident #31 and her three pressure ulcers. The DON communicated that the heels up cushion was applied to initially help heal the heel wound, but it was adding pressure to the splint on the back side of the right leg, and thus caused the other two pressure ulcers on the right lower leg. A phone interview was attempted on 09/13/2021 at 5:21 PM with the family member (FM) E, the DPOA (Durable Power of Attorney) of Resident # 31, to see if they had any concerns regarding the care being provided to Resident # 31. A message was left and no call was returned prior to survey exit on 09/14/21. On 09/14/21 at approximately 11:45 AM a wound dressing change was observed on Resident #31 completed by RN D. The resident was noted to have increased pain during the dressing change. Resident #31 was observed grimacing and moaning of pain during the time of the dressing change. On 09/14/21 at 1:00 PM an interview was conducted with Registered Nurse (RN) A (wound nurse) regarding Resident #31 and her three pressure ulcers. When asked if Resident #31's pressure ulcers were avoidable or unavoidable, RN A stated the pressure ulcers would not have occurred if [Resident #31] had not fallen and fractured her right tibia. Facility policy on Pressure Injury Prevention and Management dated 01/01/2021 and was reviewed on 09/14/21 found to read, policy - this facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. Policy Explanation and Compliance Guidelines - the facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; modifying the interventions as appropriate.

Based on interview and record review, the facility failed provide adequate supervision and assessment to prevent further falls for one Resident with history of falls (#701) out of 4 Residents reviewed for falls in a total sample of 4 residents. This deficient practice resulted in a fall with injury, including hematoma and facial fractures. Findings include: A review of Resident #701's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission assessment dated [DATE] revealed the following: Required one person for transfers, was oriented to person, place and time, and had reactive pupils. The mobility section on this Admission Assessment was incomplete. The Admission Assessment also revealed, .had bruises from recent fall at home on deck ., showing that the facility was aware of Resident #701's history of falls. Further review of the assessment section revealed no Admission Falls Assessment had been completed. A review of the Care Plan for Resident #701 revealed no care plan for Fall Risk. A review of the Radiology Report dated 6/4/17 for Resident #701 revealed, .Transported from (Name of Facility) after a fall . There is a nondisplaced fracture invovling the right zygomatic arch. This is new since the previous study . There is a right parietal scalp hematoma . There is an acute small left posterial parietal subdural hematoma, which is new since the previous exam . The radiology report revealed Resident #701 was found with facial fractures and a subdural hematoma. A review of the 6/4/17 Clinical Follow-up form revealed the following, At 0045 (12:45 a.m.), (Certified Nurse Aide/CNA A) heard (Resident #701) fall and called a response team. This nurse (Registered Nurse/RN B) and (RN C) Charge Nurse initially assessed (Resident #701). He was found on the floor adjacent to his bed, at an angle, with his head face forward downward and his hip and limbs in somewhat turned/twisted positions. Multiple areas of skin were injured and bleeding or bruised . (Resident #701) was unresponsive for a few minutes with his eyes closed and did not talk when asked questions. Shortly after that, he was not Ox3 (oriented to person/place/time) and was confused, which was a change from before the fall. He did not remember that he fell either. VS (vital signs) were checked and his BP (blood pressure) was elevated and he had a low grade temp (temperature). His pupils were pin-point and did not respond to light . By 2A (2:00 a.m.) after q15' (every 15 minute) VS, his BP was WNL (within normal limits.) .Called (Physician Group) staff On-Call and spoke with (Nurse Practitioner/NP F), at 0245 (2:45 a.m.) to report the fall and received a verbal phone order to transport him to (emergency room ) as non-emergent for further evaluation of possible injuries or to identify potential cause of fall . (EMS) departed with him at 0345 (3:45 a.m.) . On 6/21/17 at 8:41 a.m., a phone interview was conducted with RN B who reported she had been on shift the night of the fall (6/4/17) and had also done some of the admission assessments. When asked if she had done the admission falls assessment, or if one had been done at all, RN B stated, No, I did the skin assessment. RN B was unaware of whether or not an admission fall assessment had been conducted, but reported that she was aware that Resident #701 was a high fall risk.

Based on observation, interview and record review, the facility failed to provide the necessary care and services (transfer in a mechanical lift by two persons and nursing assessment after a fall) in accordance with the comprehensive assessment and plan of care for one (Resident #101) of six sampled residents reviewed for quality of care, out of a facility population of 69 residents. This deficient practice resulted in Resident #101 sustaining a right femoral shaft fracture. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #101 is a [AGE] year old male who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment also identified Resident #101 needing extensive assistance with two plus person physical assist and non-ambulatory. The Care Area Assessment (CAA) for Resident #101 dated 9/5/13 reads, "He is non-ambulatory and requires the use of a (mechanical) lift and the assistance of 2 for transfers and toileting". The "Resident Lifting, Transferring and Repositioning Data Collection" assessment dated [DATE], indicated Resident #101 needed "two assist with (mechanical) lift" for transferring. The care plan dated 9/15/13, identified Resident #101 as a fall/injury risk related to unsteady, weakness, cardiovascular diagnosis, bowel and bladder incontinence and [MEDICAL CONDITION]. The care plan indicated Resident #101 needed to be transferred with two assist using the mechanical lift. The "Care Delivery Guide" with an initiated date of 8/30/12, identified Resident #101 was to be transferred with 2 assist and the use of the mechanical lift. In addition, the Activities of Daily Living/Mobility care plan reads "will transfer with 2 assist with (mechanical) lift". An interview was conducted on 8/18/14 at 11:30 a.m. with Certified Nurse Aide (CNA) "A". CNA "A" described the incident which occurred on 8/6/14 at approximately 8:00 a.m. CNA "A" was showering Resident #101 in the shower room. When he finished showering Resident #101, CNA "A" had Resident #101 stand with his tennis shoes on, holding onto the grab bar with one hand (other hand paralyzed) so he could pull up his shorts, with the shower chair behind Resident #101. CNA "A" then moved the shower chair to the right side of Resident #101, and pulled his wheelchair behind him. As CNA "A" was moving the wheelchair, Resident #101's right leg ([MEDICAL CONDITION]) buckled causing him to fall backwards against his wheelchair and then to the floor. Resident #101's feet did not move because of the grip of the tennis shoes. CNA "A" stated he was trying to pull Resident #101's shorts up while transferring Resident #101 from the shower chair to the wheelchair. CNA "A" indicated he did not use the mechanical lift or request the help of another staff (per the care plan) during the transfer from the shower chair to the wheelchair. After Resident #101 had fallen to the floor, CNA "A" opened the shower room door and called for help. CNA "A" placed the mechanical lift sling under Resident #101. CNA "G" entered the shower room to assist Resident #101 off the floor with the mechanical lift and place him into his wheelchair. CNA "H" also responded to the call for help and assisted with lifting Resident #101 from the floor to his wheelchair. CNA "A" did not report the fall to his charge nurse to assess Resident #101 for injury before lifting him from the floor to his wheelchair. An interview with CNA "G" on 8/18/14 at 1:50 p.m. indicated she assisted CNA "A" in the shower room to lift Resident #101 from the floor to his wheelchair without knowing the charge nurse did not assess Resident #101 for injury. CNA "G" also stated she saw a deformity to Resident #101's right thigh after he was placed in his wheelchair. Furthermore, CNA "G" stated she assists Resident #101 with showers frequently and always uses the mechanical lift with two people during the entire bathing activity. An interview was conducted with Licensed Practical Nurse (LPN) "E" on 8/18/14 at 2:45 p.m. LPN "E" confirmed she was not notified of Resident #101's fall until he was lifted off the floor into his wheelchair. LPN "E" stated when she entered the shower room and saw Resident #101's right thigh, she knew immediately the leg was fractured. LPN "E" also confirmed Resident #101 was to be transferred with the use of the mechanical lift and two people assisting, including transferring from the shower chair to the wheelchair while being bathed. An interview conducted with the Physical Therapist "F" on 8/18/14 at 12:05 p.m., revealed Resident #101 needed "maximum assist to stand", and stated this means "two hands at all times and not letting go of the resident while he is standing." An interview was conducted with the Director of Nursing (DON) on 8/19/14 at 1:30 p.m., who confirmed Resident #101's care plans indicated he needed two person assistance with the use of a mechanical lift for all transfers. The DON stated all residents needed to be assessed by a nurse after falls before being assisted off the floor. The hospital operative/procedure report dated 8/7/14, identified Resident #101 was admitted to the hospital on [DATE], after a fall in which Resident #101 sustained a right femoral shaft fracture. The femoral bone fracture was repaired with an operational procedure of an interamedullary rod held with four screws to hold the bone in place. Resident #101 returned to the facility on [DATE], five days later. Resident #101 was observed on 8/18/14 at 10:30 a.m. in his wheelchair, with two incisions to his right femur area held with sutures. Resident #101 was asked if his leg was hurting and he responded with a "Yes" and pointed to his right leg. ( )