Every finding on record at Medilodge of Marshall

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 91 residents who consume food, resulting in the increased likelihood for improper mechanical dish machine sanitization rinse water pressure, cross-contamination, and bacterial harborage.Findings include: On 06/16/2026 at 9:05 A.M., An initial tour of the food service was conducted with Dietary Manager V, Registered Dietician O, and Registered Dietician in Training N. The following items were noted:The wall/floor juncture [NAME] tile was observed soiled with accumulated and encrusted food residue, adjacent to the mechanical dish machine. The heavily soiled surface measured approximately 25 feet in length. Dietary Manager V indicated she would have dietary staff thoroughly clean and sanitize the wall/floor juncture [NAME] tile as soon as possible.The 2022 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. Cleaning of the physical facilities is an important measure in ensuring the protection and sanitary preparation of food. A regular cleaning schedule should be established and followed to maintain the facility in a clean and sanitary manner. Primary cleaning should be done at times when foods are in protected storage and when food is not being served or prepared.The mechanical dish machine pounds-per-square inch (psi) gauge was observed to read 33 (psi) during the final rinse cycle. Dietary Manager V indicated she would contact the contractual vendor for necessary repairs as soon as possible.The 2022 FDA Model Food Code section 4-501.113 states: The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch). If the flow pressure of the final sanitizing rinse is less than that required, dispersion of the sanitizing solution may be inadequate to reach all surfaces of equipment or utensils.The mop closet interior entrance door surface was observed (etched, scored, particulate). Registered Dietician O stated: I will place the issue on my phone., indicating the issue would be entered into the electronic maintenance system for tracking and correction.The 2022 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. Poor repair and maintenance compromises the functionality of the physical facilities. This requirement is intended to ensure that the physical facilities are properly maintained to serve their intended purpose.On 06/18/2026 at 12:30 P.M., Record Review of the Policy/Procedure entitled: Kitchen Sanitation dated 7/01/2025 revealed under Policy: The food service area shall be maintained in a clean and sanitary manner. Record review of the Policy/Procedure entitled: Kitchen Sanitation dated 7/01/2025 further revealed under Policy Explanation and Compliance Guidelines: (1) All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. (2) All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 91 residents, resulting in the increased likelihood for cross-contamination, and bacterial harborage.Findings include: On 06/16/2026 at 1:35 P.M., An environmental tour of the facility Laundry Service was conducted with Account Manager (Contractual Service Name) W. The following items were noted:Clean Laundry Room:Twelve acoustical ceiling tiles were observed stained from previous moisture leaks. Account Manager (Contractual Service Name) stated: I don't do ceiling tiles, that's maintenance.1 of 2 overhead light fixture clear plastic lens covers were observed soiled with accumulated and encrusted dust/dirt deposits.Two 12-inch-wide by 12-inch-long vinyl flooring tiles were observed (etched, scored, particulate). The concrete subsurface was also observed chipped and missing, creating two holes. The two holes measured approximately 5-inches-wide by 6-inches-long by 1-inch-deep and 4-inches-wide by 6-inches-long by 1-inch-deep respectively. Account Manager (Contractual Service Name) indicated he would contact maintenance for necessary repairs as soon as possible.1 of 2 hand sink basins were observed soiled with accumulated and encrusted dirt deposits. Account Manager (Contractual Service Name) W indicated he would have staff thoroughly clean and sanitize the soiled sink basin as soon as possible.On 06/16/2026 at 1:48 P.M., An environmental tour was conducted with Account Manager (Contractual Service Name) W. The following items were noted:A-HallThe interior entrance door surface was observed (etched, scored, particulate), within the soiled and clean linen rooms.The floor machine storage room overhead light was observed non-functional.B-HallThe interior entrance door surface was observed (etched, scored, particulate), within the soiled and clean linen rooms. Account Manager (Contractual Service Name) stated: We don't paint, that's maintenance.C-HallThe interior entrance door surface was observed (etched, scored, particulate), within the soiled and clean linen rooms.D-HallThe interior entrance door surface was observed (etched, scored, particulate), within the soiled and clean linen rooms.On 06/18/2026 at 1:30 P.M., Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 3/12/2022 revealed under Policy: A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable for residents, staff, and the public. Record review of the Policy/Procedure entitled: Preventative Maintenance Program dated 3/12/2022 further revealed under Policy Explanation and Compliance Guidelines: (1) The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner.On 06/18/2026 at 1:45 P.M., Record review of the Policy/Procedure entitled: Routine Cleaning and Disinfection dated 2/1/2022 revealed under Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible.On 06/18/2026 at 2:00 P.M., Record review of the Electronic Maintenance Tracking System work orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on observation, interview, and record review, the facility failed to ensure wound care orders were implemented upon readmission from the hospital for one (R2) of 19 reviewed. Findings include: Review of the medical record revealed R2 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included actinomycotic sepsis, chronic osteomyelitis, COPD, cellulitis of right lower limb, and venous insufficiency. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/7/26 revealed R2 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Nurses' Note dated 6/2/26 revealed resident went to wound clinic appointment this morning and has a low blood pressure. Wound clinic sent resident to ER to get evaluated. A second Nurses' Note dated 6/2/26 revealed R2 was admitted to the hospital due to an infected wound. Review of the hospital Discharge summary dated [DATE] revealed R2 had right medial/lateral ankle ulcers and right tibial ulcers that required wound care treatment every three days or as needed for drainage. On 06/16/2026 at 11:53 AM, R2 was observed in bed. R2 reported she returned from the hospital on 6/12/26. R2 reported she was currently on intravenous antibiotics due to a wound infection in her right leg that was down to the bone. R2 reported the dressing on her right leg wounds should have been changed on 6/13/26, but it had not been completed. An observation of the dressing on R2's right leg revealed the dressing was dated 6/10/26. In an interview on 06/16/2026 at 3:38 PM, Licensed Practical Nurse (LPN) M reported they were assigned to care for R2. LPN M reported R2 had two wounds on her right lower legs that required dressing changes every other day. When asked what R2's current wound care orders were, LPN M looked in R2's medical record and reported he could not locate any current wound car orders. LPN M then notified Unit Manager (UM) F of the missing orders. On 06/16/2026 at 3:44 PM with LPN M, it was confirmed that R2's right leg dressing was dated 6/10/26. R2 reported to LPN M that the dressing was supposed to be changed on 6/13/26, but it was not. In an interview on 06/17/2026 at 9:13 AM, UM F reported the admitting nurse should have written wound care orders upon R2's readmission. UM F reported management staff would then review the orders on the next business day (Monday, 6/15/26), but that was not done since he did not work on 6/15/26. UM F reported as of 6/16/26, R2 had every other day wound care orders in place. In an interview on 06/17/2026 at 11:33 AM, Director of Nursing (DON) B reported it was the expectation that the admitting nurse enter wound care orders upon readmission and then those orders be reviewed on the next business day. DON B reported there was not a manager in the building on 6/15/26 to review the orders.

Based on observation, interview, and record review the facility failed to obtain consent prior to the initiation of a mood stabilizer and anti-depressant medication and subsequent dosage increase in two (Resident #1, #63) out of five reviewed for medication review. Findings include: Resident #1 (R1) Review of the medical record revealed R1 was admitted [DATE] with diagnoses that included metabolic encephalopathy (any diffuse disease or condition that alters brain function), pneumonia (pneumonia), Chronic Obstructive Pulmonary Disease (COPD), hypertension, insomnia, gastro-esophageal reflux, hyperlipidemia (high fat content in blood), heart disease, acquired absence right leg below right knee, depression, anemia (low number of red blood cells), anxiety, bipolar disorder (manic/depression), post-traumatic stress disorder (PTSD), peripheral vascular disease (PVD), sleep apnea, and hepatitis (inflammation of liver). Review of R1's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/15/2026, revealed a Brief Interview of Mental Status Score (BIMS) of 10 (moderate cognitive impairment) out 15. Review of R1's medical record revealed physician order, Quetiapine Fumarate Oral Tablet 300 MG (milligrams) give 2 tablets by mouth at bedtime for depression related to other bipolar disorder. R1's medical record did not reveal any documentation for consent to demonstrate that resident has had risk and benefits for the use of psychoactive medication explained and had given consent for its use. During an interview on 06/17/2026 at 01:27 p.m. Director of Nursing (DON) C confirmed that R1 was receiving psychoactive medication for the treatment of depression. DON C confirmed that R1 had not been provided the facility Consent to Use of Psychoactive Medication Therapy of the use of the anti-depressant. DON C explained that R1 should have had a risk and benefits of the anti-depressant explained to him and signed a consent if he wanted to continue with psychoactive medication treatment. DON C could not explain why R1 document entitled, Consent to Use of Psychoactive Medication Therapy had not been provided on admission when the anti-depressant was ordered. DON C explained that the required document had just been provided to R1 during the survey. During observation and interview on 06/17/2026 at 01:44 p.m. R1 was observed lying down in bed. R1 explained that someone came to his room today and explained the risk and benefits of medication that he was taking. R1 explained that he now signed the document giving consent that the medication could be given to him for the treatment of depression. Resident #63 (R63) Review of the medical record reflected Resident #63 (R63) was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Alzheimer's disease, vascular dementia, and major depressive disorder. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/12/26, reflected R63 scored 08 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 6/16/2026 at 9:28 AM, R63 was observed self-propelling himself into his room. R63 spoke when greeted and was pleasantly confused. Review of the Physician orders revealed R63 had an order for Donepezil (Aricept-used to treat mild, moderate, and severe dementia related to Alzheimer's disease) HCl Oral Tablet 5 milligrams (mg) from 9/8/2025 to 3/31/2026. Further review of R63's Physician orders revealed the order for Donepezil (Aricept) HCl Oral Tablet dosage increased from 5mg to 10 mg on 4/1/2026. Review of R63's Psychoactive Medication Therapy Consent for Donepezil (Aricept) HCl Oral Tablet 10 mg revealed the consent was not signed by the medical power of attorney until 6/17/26, despite being an active order since 4/1/26. Review of R63's Physician orders revealed R63 had an order for Sertraline HCl Tablet 25 MG active from 11/19/2025 to 5/29/26. Further review of R63's Physician orders revealed the order for Sertraline (anti-depressant) HCl Oral Tablet dosage increased from 25 MG to 50 MG (Sertraline HCl) on 5/30/2026. Review of R63's Psychoactive Medication Therapy Consent for Sertraline HCl Oral Tablet revealed the consent was not signed by the medical power of attorney until 6/17/26, despite being an active order since 5/30/2026. In an interview on 6/17/26 at 1:27 PM, Director of Nursing (DON) B stated that the process for psychotropic medication consents would be to have a consent signed by the resident or the medical power of attorney if the resident is unable to make their own decision prior to the start of the medication or prior to the dosage change of the medication. DON B acknowledged that R63's psychoactive medication consents were not completed timely when the two medication dosages increased.

Based on observation, interview and record review, the facility failed to ensure accuracy of the Minimum Data Set (MDS) assessment for one (R8) of 19 reviewed. Findings include: Review of the medical record reflected R8 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included nontraumatic subarachnoid hemorrhage (type of stroke with bleeding in the space between the brain and tissues that cover the brain) from the left middle cerebral artery, type 2 diabetes and chronic kidney disease. The Quarterly MDS, with an Assessment Reference Date (ARD) of 4/30/26, reflected R8 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 06/17/2026 at 12:55 PM, R8 was observed seated in a wheelchair, in their room. The Annual MDS, with an ARD of 1/28/26, reflected coding of No for question A1500, Preadmission Screening and Resident Review (PASRR) .Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? In an interview on 06/17/2026 at 12:47 PM, MDS Nurse P reported R8's MDS, with an ARD of 1/28/26, should have been coded as yes for question A1500. MDS Nurse P reported R8's level II screening was uploaded to the medical record on 7/15/25 and was available for review at the time of the annual MDS for 1/28/26.

Based on observation, interview and record review, the facility failed to conduct care conference meetings for one (R33) of 19 reviewed. Findings include: Review of the medical record reflected R33 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage (bleeding in the brain, caused by rupture of a damaged blood vessel in the head) affecting the left non-dominant side. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/24/26, reflected R33 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 06/16/2026 at 12:01 PM, R33 was observed lying in bed, watching TV. R33's medical record reflected their most recent care conference meeting was on 10/8/25. In an interview on 06/17/2026 at 1:02 PM, MDS Nurse P reported care conferences were held around the same time of quarterly MDS assessments. Documentation of R33's care conferences since 10/8/25 was requested at time of the interview. In an interview on 06/17/2026 at 1:50 PM, MDS Nurse P reported they could not locate care conference documentation since 10/8/25. MDS Nurse P reported care conferences were supposed to be held every three months. Attendees included a nurse, the Business Office Manager, Social Work, Activities, Dietary and Therapy. It was reported the resident and family were also invited.

Based on observation, interview, and record review, the facility failed to ensure physician ordered medication monitoring was completed for one (R45) of five reviewed. Findings include: Review of the medical record revealed R45 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes mellitus. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/35/26 revealed R45 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 06/16/2026 at 12:35 PM, R45 was observed seated in her wheelchair at a dining room table with two other residents. R45 was overheard mentioning that she did not get a bedtime snack last night and her sugar was low this morning. On 06/16/2026 at 1:40 PM, R45 was observed seated in her wheelchair in her room. R45 reported there had been a few nights where she did not receive a bedtime snack, including last night. Review of the Physician's Orders revealed R45 was on multiple medications for diabetes including Jardiance, Metformin, Novolog insulin, and Toujeo insulin. Review of the Physician's Order dated 4/7/26 revealed an order for HgbA1c (test to show average blood sugar levels over the last two to three months) one time a day every 6 months starting on the 8th. Review of R45's medical record revealed a HgbA1c test was not completed. In an interview on 06/17/2026 at 9:13 AM, Unit Manager (UM) F reported R45 did not have a HgbA1c completed as ordered by the physician. UM F reported the facility changed laboratory companies earlier in the year and it's possible R45's order did not get entered into the new laboratory system. In an interview on 06/17/26 at 11:33 AM, Director of Nursing (DON) B reported she was not able to locate HgbA1c test results for R45.

This citation pertains to intake numbers 2790883 and 2790891.Based on observations, interviews, and record review, the facility failed to protect the residents' right to be free from physical abuse by a resident.Findings Include:Review of the medical record reflected Resident #4 (R4) was admitted to the facility on [DATE], with diagnoses that included pseudobulbar effect (a neurological condition causing sudden uncontrollable episodes of laughing or crying), mild cognitive impairment, chronic motor or vocal tic disorder, and severe intellectual disabilities. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/9/26, reflected R4 was marked as rarely/never understood on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record reflected Resident #5 (R5) was admitted to the facility on [DATE], with diagnoses that included adjustment disorder with depressed mood, generalized anxiety disorder, and unspecified intellectual disabilities. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/16/26, reflected R5 scored 9 out of 15 (moderately impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R5 was independent with ambulation with the use of an assistive device. Review of the medical record reflected R6 was admitted to the facility on [DATE], with diagnoses that included post-traumatic stress disorder, unspecified dementia, and anxiety disorder. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/1/26, reflected R6 scored 0 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 5/20/26 at 2:28 pm, R4 was observed in bed. During an interview attempt, a certified nursing assistant stated that R4 was nonverbal and would not be capable of communicating back. On 5/20/26 at 12:50 PM, R5 was observed walking unassisted into the dining room using a walker. Review of R4's care plan revealed Resident has behavior(s) related to mild cognitive impairment, chronic motor or tic disorder as evidenced by: family reported combativeness as a usual behavior upon admission, screams and yells intermittently for attention, refusing care, throwing things, hitting and reaching out for attention. physical aggressive at times. Call lights being on will aggravate resident Date Initiated: 11/20/2024 . Review of a behavioral health services note stated the following; SEVERE INTELLECTUAL DISABILITIES Status: Severe, Chronicity Level: Chronic: Severe baseline cognitive and communication impairment continues to limit assessment; patient was unable to provide history today. Staff continue to report that yelling is her primary means of communication and can be attention-seeking. Patient requires ongoing 24-hour supervision and structured behavioral supports in the skilled nursing facility setting, including one-to-one staffing during dining per behavioral escalation on 5/5/2026. Continue current psychiatric regimen as above and ongoing behavioral monitoring and documentation by staff . Review of a Nurses' Note Dated 1/27/2026 at 12:55 PM reflected writer notified by staff that resident was hit by another resident [R5] in back oh head. as per head-to-toe assessment, not observed any bruises/pain/open injuries or any discomfort . brought resident in front of nursing station forobservation [sic]. notified to abuse coordinator . The incident that occurred on 1/27/26 was reported to the State Agency. Review of MI-FRI (Michigan-Facility Reported Incident) 00063325, 24-hour report, revealed an incident summary (provided by Nursing Home Administrator G, that is no longer employed by the facility as of 05/19/2026) which stated, Allegation of resident-to-resident abuse. Resident [5] is alleged to have hit Resident [4]. Residents separated and safe in the facility. Both residents assessed and free of injury. Interventions in place. Notifications in progress. Investigation underway . Review of an Incident report dated 1/27/26 at 12:30 PM stated staff observed R5 enter the dining room where R4 was seated and hit [R4] in the back of the head and continued walking away. Certified Nursing Assistant Q reported, via the same incident report, that R4 was in the dining room yelling and as [R5] was coming into the dining room he lightly hit [R4] on the back of the head as he told her to knock it off . In an interview on 5/21/26 at 10:23 am, R5 reported stated that he doesn't like noisy people or people yelling in the hall. R5 stated that sometimes he will get up and slam his door during the night because of the person that yells out. R5 stated he thinks it is the same person that yells out in the dining room and stated she makes noises all the time. Review of the incident investigation revealed a lack staff interviews, assessments of like/other residents that had the potential to be impacted and did not contain documentation that incident had been reported to the police department. Review of R4's Care Plan revealed an added intervention dated 1/28/26 staff sit with resident during mealtimes and do not bring resident to dining room until tray is served. Review of a Nurses' Note dated 2/12/2026 at 5:51 PM revealed 'Resident was in the dining room before dinner meal was passed and she was screaming. Another resident came up and hit her in the face. The resident who hit her was removed from the dining room and the don, on call and admin was notified . Inquiries from current staff revealed no knowledge of this incident. The Nurses' Note dated 2/12/26 documented R4 was in the dining room before R4's tray was served when R4 was struck in the face by another resident. This demonstrated the failure to follow the care plan designed to reduce the risk of a resident-to-resident incident. Review of a Nurses' Note dated 5/5/2026 5:53 PM revealed [R4] hit another resident in the dining area today. She should be kept out of the dining area until staff is able ro [sic] be 1 on 1 with her . Review of an Incident Report dated 5/5/26 revealed a CNA came running to the nurses station stating that [R4] hit another resident [R6] and the other resident [R6] grabbed her hand and pushed her hand back. The same incident report stated, in the other info section, [R4] hits when others gets close enough to her. She was in the dining room celebrating her birthday with her family. After the family left, [R4] remaining in the dining area awaiting dinner. [R4] should be kept separated from others when she is on 1 on 1 in dining room. On 5/20/26 at 3:53 pm, Licensed Practical Nurse (LPN) R stated that R4 was taken into the dining room for a birthday party with her family and when they left, they left R4 in the dining room. LPN R stated that a CNA reported to her that R6 hit R4. LPN R stated that she immediately called former NHA G to report the abuse allegation. In an interview on 5/20/26 3:11 pm, Director of Nursing (DON) B stated that she was aware of the incident that occurred on 5/5/26. DON B reported that the incident was discussed during morning meeting. R4 was in the dining room and R6 self-propelled in the vicinity of R4. R4 reached out and hit R6. The team discussed an intervention of ensuring R4 was not left unattended in the dining room. DON B confirmed that former NHA G was immediately notified of the abuse allegation. The incident that occurred on 5/5/26 between R4 and R6 again demonstrated the failure to follow the care plan designed to reduce the risk of a resident-to-resident incident. Further review of R5's Care plan revealed no additional intervention after the 5/5/26 incident to ensure the safety of R4 was maintained as well as the safety of others. Review of the medical record reflected R16 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia. R16 no longer resided in the facility. Review of a Nurses' Note dated 4/27/26 at 8:13 am revealed [R16] was observed in a yelling argument with [R5]. [R5] closed fist hit [R16] in the upper back. [R16] reporting, [R16] stated he came to dining room to have a quiet cup of coffee, [R5] had phone blaring and refused to turn it down. This agitated [R16] who grabbed the phone off the table, turned it off and tossed it on the chair. (R5] stood and hit him. Residents were separated, skin and pain assessed, no issues noted .'. In an interview on 5/21/26 at 10:23 am, R5 stated that he doesn't like noisy people or people yelling in the hall. R5 stated that sometimes he will get up and slam his door during the night because of the person that yells out. R5 stated he thinks it is the same person that yells out in the dining room and stated she makes noises all the time (mimicked a grunting noise). R5 recalled a separate incident which he described as one guy was mouthy and tried to shut my phone off. I said try it. He tried it and I hauled off and hit him right across the back. Review of R5's Care Plan reviewed a Focus area which stated Resident has behavior(s) as evidenced by: verbally aggressive toward other, name calling of staff members. Resident punches walls and/or doors when he is upset. Refusing medications. Not following prescribed diet, hoarding sugar, salt, cream, pepper and old metal spoons. Can become agitated by excessive noises. Resident has repeatedly cut wander guard bracelet off despite education and direction. Date Initiated: 11/25/2024 Revision on: 03/02/2026. One of the interventions stated Be aware of loud residents in the vicinity and attempt to redirect if becomes agitated. Date Initiated: 01/28/2026. Review of the facilities policy titled Abuse, Neglect, and Exploitation defines abuse as the willful infliction of injury which can include certain resident to resident altercations. Physical abuse includes but is not limited to hitting, slapping, punching, biting and kicking. Reporting/Response: Immediately, but not later than two hours if the events that cause the allegation involve abuse. Resident #2 (R2) Review of the medical record revealed R2 was admitted to the facility 06/30/2025 with diagnoses that included adjustment disorder with mixed anxiety and depresses mood, Alzheimer's Disease, osteoarthritis (wearing of cartilage between bone joints), dementia, depression, repeated falls, hypertension, and anxiety. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/06/2026, revealed R2 had a Brief Interview of Mental Status (BIMS) of 7 (severe cognitive impairment) out of 15. Section GG-Functional Abilities, with the same ARD of 01/06/2026, revealed that R2 was independent with wheelchair mobility. Resident #3 (R3) Review of the medical record revealed R3 was admitted to the facility 05/05/2023 with diagnoses that included Huntington's Disease (a progressive genetic disorder which leads to the breakdown of nerve cells in the brain), encephalopathy (broad term for any disease, damage, or malfunction of the brain), psychosis (loss of contact with reality), dysphagia (difficulty swallowing), restlessness and agitation, urinary retention, and chorea (neurological movement disorder characterized by involuntary, irregular, and unpredictable muscle movements). The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/2026, revealed R3 had a Brief Interview of Mental Status (BIMS) that could not be completed because R3 is rarely/never understood. R3's medical record revealed that he was discharged from the facility 05/02/2026. Review of facility incident report (for event that occurred 02/16/2026 at 05:00 pm) revealed Pt (R2) was rolling herself down A hall. Pt (R3) sitting near the nurses station leaned out of his chair and struck the other Pt (R2) on the side of the head near her eye. The same incident report revealed immediate action taken Pt (R2) evaluated raised bump forming on right side of Pts (R2) head near upper portion of eye, broken skin noted where Pt(R2) was struck. Pt (R2) eyes PERRLA (Pupils Equal, Round, Reactive to Light, and Accommodation). No complaint of headache at this time. Pt (R2) states pain is minimal but she was just surprised. Review of MI-FRI (Michigan-Facility Reported Incident) 00063610, 24 hour report, revealed that the facility reported the incident on 02/17/2026 at 11:43 a.m. The same document included an incident summary (provide by Nursing Home Administrator G, that is no longer employed by the facility as of 05/19/2026) which stated, Pt (R2) was rolling herself down A hall. Pt (R3) witting near the nurses' station leaned out of his chair and struck the other Pt (R2) on the head near her eye. Scratch 2/16/2026to area, minimal pain. Pt (R3) placed on 1 to 1. Both Pt. (R2 &R3) cont. to reside at center and are safe. Investigation started. 5 day to follow. Review of the MI-FRI 00063610, 5 day investigation, revealed Correction Action (s) Taken: Following the incident, staff immediately intervened and separate the residents, moving he victim, (name of R2) to another area and evaluating her injuries, which included applying a bandage to her laceration and initiating neuro checks. To ensure ongoing facility safety and prevent further incidents, the initiator (name of R3), was promptly placed on 1:1 observations whenever he is out of his room. Review of R3's medial record did not have demonstration that R3 was placed on 1:1 supervision after this incident. R3's plan of care revealed a problem statement that stated Resident has behavior related to Huntington's Disease as evidence by: physically aggressive, hitting others, refuses medications, refuses showers, ambulates and transfers self despite redirection and offered assistance, and wanders. Interventions included: staff to be aware of proximity to resident, 1:1 staff as needed. During an interview on 05/21/2026 at 11:33 a.m. Registered Nurse (RN) H explained that he had been the nurse that witnessed the altercation between R2 and R3 on 02/16/2026 at 05:00 p.m. RN H explained that he witnessed R2 propelling herself down the hall. RN H explained that as R2 got closer to R3 he witnessed R3 reaching out and clocking R2. RN H was asked to clarify what clocking R2 meant. RN H explained that R3 had deliberately hit R2 with a closed fist and even knocked her glasses off her face and he witnessed her head go backward from the force. RN H explained that R3 was taking back to his room but could not answer if he was placed on 1:1 supervision. RN H explained that he assessed R2' and she had a lump under her eye and the skin was broken. RN H' explained that he knew this was not the first time R3 had altercations with other residents and explained that he had a history of placing a staff member in a head lock. During observation and interview on 05/21/2026 at 01:19 p.m. R2 was observed sitting in her wheelchair in her room. R2 was asked about the event that occurred with another resident on 02/16/2026. R2 explained that she remembered the incident and that a man had punched her in the face, right under her right eye. R2 explained that it had caused her to have a 'black eye. R2 was asked to rate the pain on a scale of 1-10, with 1 being the least pain and 10 being the most pain, the pain from being punched on that date. R2 explained that her pain was a 5 on that date, but that it still bothered her at times. R2 was asked to explain why her eye still bothered her and she responded, Because someone knocked by face in. No bruising was observed on R2's face at this time. Resident #6 (R6) Review of the medical record revealed R6 was admitted to the facility 09/23/2025 with diagnoses that included encephalopathy (broad term for any disease, damage, or malfunction of the brain), chronic obstructive pulmonary disease (COPD), unsteadiness on feet, generalized muscle weakness, depression, anxiety, conversion disorder (a condition where a person experiences real physical symptoms that cannot be explained by an underlying medical disease) with seizures or convulsions, bladder cancer, adjustment disorder, gastro-esophageal reflux disease, hypertension, hyperlipidemia (high fat content in blood), obstructive sleep apnea, dementia with behavioral disturbances, urinary retention, enlarged prostate, post-traumatic stress disorder, and hypothyroidism (low thyroid hormone). The Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 04/01/2026, revealed R6 had a Brief Interview of Mental Status (BIMS) of 00 (severe cognitive impairment) out of 15. Review of R3 incident report, 01/28/2026 at 03:00 p.m., revealed CNA (Certified Nursing Aide) reported that another resident (R6) was wheeling into this residents room and this resident hit the other resident (R6) in the face. A scratch was present on the left side of eye of the other resident (R6). Review of R6 incident report, 01/28/2026 at 03;00 p.m., revealed CNA (Certified Nursing Aide) reported resident (R6) was wheeling into other residents (R3) room, resident in the room (R3) hit this resident (R6) in the face, a scratch was present on left side of eye with slight blood present. Review of MI-FRI (Michigan-Facility Reported Incident) 00063344, 24 hours report, revealed Allegation of resident to resident physical contact. Resident (initials of R6) wheeled himself into Resident (initials of R3) room. Resident (initials of R3) is alleged to have hit Resident (initials of R6). Date and time of the incident reported to be 01/28/2026 at 03:25 p.m. Review of the MI-FRI 00063344, 5 day investigation, revealed Correction Action (s) Taken: Care plans for bother resident we updated and stop sign was added to make the room less appealing: The section entitled Conclusion revealed Not verified- the allegation was refuted by evidence collected during the investigation. During observation and attempted interview on 05/20/2026 at 03:26 p.m. R6 was observed sitting up in his wheelchair in the hallway. R6 did not respond to verbal questions.

This citation pertains to intake number 2801450 Based on interview and record review, the facility failed to ensure appropriate urostomy care for one resident (resident #7) out of three reviewed, resulting in a hospitalization for a diagnosis of septic shock secondary to a urinary tract infection. Findings include:Review of the medical record reflected Resident #7 (R7) was admitted to the facility on [DATE], with diagnoses that included neuromuscular dysfunction of bladder and paraplegia. R7 no longer resided in the facility.On 5/27/26 at 3:04 PM, R7s Family Member (FM) S stated that she frequently visited R7 at the facility when he resided there and expressed concerns regarding the provision of urostomy care. FM S reported several occasions observing towels on the floor covered in urine and R7's urostomy pouch so full of pee that the seams would give away. R7 stated that the facility reduced the frequency of urostomy pouch changes and reported R7's urostomy pouches were dirty which she believed contributed to recurrent urinary tract infections. FM S stated they had several meetings with facility staff and filled out grievance forms related to these concerns, however, no changes occurred. Review of R7's Physician Orders revealed the following:An order stating change ileovesicotomy (surgical procedure that creates a connection between the ileum, part of the small intestine, and the urinary bladder) with [NAME] premier urostomy pouch every evening shift every 3 day(s) related to NEUROMUSCULAR DYSFUNCTION OF BLADDER, UNSPECIFIED . This order was discontinued on 7/23/2024 and changed to Change ileovesicotomy with [NAME] premier urostomy pouch as needed which was an active order until R7 discharged from the facility to the hospital on 2/12/26.Review of the Electronic Medical Record did not provide a rational for why the order for the pouch change was changed from every three days to as needed. Additionally, the medical record did not define the criteria or circumstances under which a pouch change would be considered necessary. Further review of the Physician orders and Care plan revealed no documented guidance regarding the frequency for emptying R7's urostomy pouch. Review of the Treatment Administration Record for the months of December 2025, January and February 2026 revealed that R7's urostomy pouch was documented as changed a total of two times during that period. A Nurses' Note dated 2/12/26 at 10:36 am stated this morning, as per assessment resident (R7) is alert but disoriented, confused and abnormal vitals like bp (blood pressure) 125/90 pulse 134 respiration 22 temp is 103.3 and 02 (oxygen saturation) is 88 (percent) so started o2 (oxygen) on 5 lit (liters) by nasal cannula, after few min o2 raised 95%. covid test is negative. as per notified to residents' sister, want to send in ER for further evaluation and treatment .A Nurses Note dated 2/12/2026 at 12:39 PM stated per phone conversation with [FM], resident admitted to hospital for sepsis, UTI and possible Pneumonia . Review of R7's hospitalization paperwork revealed R7 was diagnosed and admitted for septic shock secondary to urinary tract infection and bacteremia. In an interview on 5/28/26 at 11:41 am Certified Nursing Assistant (CNA) O recalled R7 and stated that R7's urostomy bag frequently became detached requiring nursing staff to put the bag back on but in the meantime, staff would use towels to collect and clean up the urine. CNA O stated that R7 was not typically on her assignment however, she would assist with answering call lights and care and had observed R7's urostomy bag full of urine and bulging on multiple occasions. CNA O stated that R7's room frequently smelled of urine and attributed these observations to a lack of timely urostomy bag emptying and the use of spilled urine. In an interview on 5/28/26 at 12:28 PM Licensed Practical Nurse (LPN) P confirmed that it was the standard of care to change a urostomy pouch every 3 days or as needed to empty the urostomy pouch every shift and as needed. LPN P reviewed R7's electronic medical record and confirmed there were no physician orders, care plan interventions, or certified nursing assistance tasks regarding the frequency of changing the urostomy pouch or emptying the pouch. According to the Wound, Ostomy and Continence Nurses Society (WOCN), urostomy pouching system should be changed every three to seven days or sooner if leaking occurs. The WOCN further identifies inadequate urostomy management, including leaving a urostomy bag unemptied for too long can increase the risk of urinary tract infections (UTIs) and other complications. Bacteria can enter the urinary system through the stoma or ureters, especially if urine remains stagnant in the pouch. Stagnant urine is more likely to harbor bacteria, which can travel to the ureters and kidneys, causing infection.

This citation pertains to intake 2801450. Based on interview and record review, the facility failed to notify the resident representative of a change in condition for one (R7) of four reviewed. Findings include:Review of the medical record reflected R7 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included paraplegia and neuromuscular dysfunction of the bladder. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/9/26, reflected R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). According to the medical record, R7 had a Legal Guardian/Conservator in place. R7 discharged to the hospital on 2/12/26 and did not return to the facility. A Progress Note for 2/10/26 at 5:53 PM reflected R7 was lethargic, tired, sleeping all day and refused a meal. According to the note, R7 reported they were ok, needed to sleep and refused to go to the hospital. A Progress Note for 2/12/26 at 10:36 AM reflected R7 was alert but disoriented, confused and had abnormal vital signs, including a temperature of 103.3 (degrees Fahrenheit), a pulse of 134 (beats per minute), a respiratory rate of 22 (breaths per minute) and an oxygen saturation of 88 (percent). The note reflected R7 was placed on oxygen, tested for COVID-19 and transferred to the emergency room (ER).A grievance form, dated 2/12/26, included documentation that R7's Guardian was frustrated about not being contacted first, when R7 was transferred to the hospital. In an interview on 5/28/26 at 10:42 AM, Registered Nurse (RN) M reported if a resident was not their own responsible party, they were to call the responsible party to ask about sending a resident to the ER for evaluation. In an interview on 5/28/26 at 12:36 PM, Unit Manager (UM) P reported R7's Legal Guardian should have been notified when R7 was transferred to the hospital on 2/12/26. In the event the Legal Guardian was unavailable, the notification should have been made to the next emergency contact. UM P indicated there should have been documentation if they attempted to call the Guardian but could not reach them. According to R7's medical record, a family member, who was not listed as being R7's Legal Guardian, was notified of their transfer to the ER. The medical record did not reflect that R7's Legal Guardian was notified of the transfer.

This citation pertains to intake numbers 2788433 and 2790891.Based on observations, interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.Findings Include:Review of the medical record reflected Resident #4 (R4) was admitted to the facility on [DATE], with diagnoses that included pseudobulbar effect (a neurological condition causing sudden uncontrollable episodes of laughing or crying), mild cognitive impairment, chronic motor or vocal tic disorder, and severe intellectual disabilities. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/9/26, reflected R4 was marked as rarely/never understood on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record reflected Resident #5 (R5) was admitted to the facility on [DATE], with diagnoses that included adjustment disorder with depressed mood, generalized anxiety disorder, and unspecified intellectual disabilities. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/16/26, reflected R5 scored 9 out of 15 (moderately impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R5 was independent with ambulation with the use of an assistive device. Review of the medical record reflected R6 was admitted to the facility on [DATE], with diagnoses that included post-traumatic stress disorder, unspecified dementia, and anxiety disorder. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/1/26, reflected R6 scored 0 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of R4's care plan revealed Resident has behavior(s) related to mild cognitive impairment, chronic motor or tic disorder as evidenced by: family reported combativeness as a usual behavior upon admission, screams and yells intermittently for attention, refusing care, throwing things, hitting and reaching out for attention. physical aggressive at times. Call lights being on will aggravate resident Date Initiated: 11/20/2024 . Review of a behavioral health services note stated the following; SEVERE INTELLECTUAL DISABILITIES Status: Severe, Chronicity Level: Chronic: Severe baseline cognitive and communication impairment continues to limit assessment; patient was unable to provide history today. Staff continue to report that yelling is her primary means of communication and can be attention-seeking. Patient requires ongoing 24-hour supervision and structured behavioral supports in the skilled nursing facility setting, including one-to-one staffing during dining per behavioral escalation on 5/5/2026. Continue current psychiatric regimen as above and ongoing behavioral monitoring and documentation by staff . The incident that occurred on 1/27/26 was reported to the State Agency. Review of MI-FRI (Michigan-Facility Reported Incident) 00063325, 24-hour report, revealed an incident summary (provided by Nursing Home Administrator G, that is no longer employed by the facility as of 05/19/2026) which stated, Allegation of resident-to-resident abuse. Resident [5] is alleged to have hit Resident [4]. Residents separated and safe in the facility. Both residents assessed and free of injury. Interventions in place. Notifications in progress. Investigation underway . Review of an Incident report dated 1/27/26 at 12:30 PM stated staff observed R5 enter the dining room where R4 was seated and hit [R4] in the back of the head and continued walking away. Certified Nursing Assistant Q reported, via the same incident report, that R4 was in the dining room yelling and as [R5] was coming into the dining room he lightly hit [R4] on the back of the head as he told her to knock it off . In an interview on 5/21/26 at 10:23 am, R5 reported stated that he doesn't like noisy people or people yelling in the hall. R5 stated that sometimes he will get up and slam his door during the night because of the person that yells out. R5 stated he thinks it is the same person that yells out in the dining room and stated she makes noises all the time. Review of R4's Care Plan revealed an added intervention dated 1/28/26 staff sit with resident during mealtimes and do not bring resident to dining room until tray is served. Review of a Nurses' Note dated 2/12/2026 at 5:51 PM revealed 'Resident was in the dining room before dinner meal was passed and she was screaming. Another resident came up and hit her in the face. The resident who hit her was removed from the dining room and the don, on call and admin was notified . Inquiries from current staff revealed no knowledge of this incident. Review of the Michigan-Facility Reported Incident system revealed no submission for this incident and as a result, no corresponding investigation. The Nurses' Note dated 2/12/26 documented R4 was in the dining room before R4's tray was served when R4 was struck in the face by another resident. This demonstrated the failure to follow the care plan designed to reduce the risk of a resident-to-resident incident. Review of a Nurses' Note dated 5/5/2026 5:53 PM revealed [R4] hit another resident in the dining area today. She should be kept out of the dining area until staff is able ro [sic] be 1 on 1 with her . Review of an Incident Report dated 5/5/26 revealed a CNA came running to the nurses station stating that [R4] hit another resident [R6] and the other resident [R6] grabbed her hand and pushed her hand back. The same incident report stated, in the other info section, [R4] hits when others gets close enough to her. She was in the dining room celebrating her birthday with her family. After the family left, [R4] remaining in the dining area awaiting dinner. [R4] should be kept separated from others when she is on 1 on 1 in dining room. On 5/20/26 at 3:53 pm, Licensed Practical Nurse (LPN) R stated that R4 was taken into the dining room for a birthday party with her family and when they left, they left R4 in the dining room. LPN R stated that a CNA reported to her that R6 hit R4. LPN R stated that she immediately called former NHA G to report the abuse allegation. In an interview on 5/20/26 3:11 pm, Director of Nursing (DON) B stated that she was aware of the incident that occurred on 5/5/26. DON B reported that the incident was discussed during morning meeting. R4 was in the dining room and R6 self-propelled in the vicinity of R4. R4 reached out and hit R6. The team discussed an intervention of ensuring R4 was not left unattended in the dining room. confirmed that former NHA G was immediately notified of the abuse allegation. The incident that occurred on 5/5/26 between R4 and R6 again demonstrated the failure to follow the care plan designed to reduce the risk of a resident-to-resident incident. Further review of R5's Care plan revealed no additional intervention after the 5/5/26 incident to ensure the safety of R4 was maintained as well as the safety of others. Review of the Michigan-Facility Reported Incident system revealed no submission for this incident. Review of the medical record reflected R16 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia. R16 no longer resided in the facility. Review of a Nurses' Note dated 4/27/26 at 8:13 am revealed [R16] was observed in a yelling argument with [R5]. [R5] closed fist hit [R16] in the upper back. [R16] reporting, [R16] stated he came to dining room to have a quiet cup of coffee, [R5] had phone blaring and refused to turn it down. This agitated [R16] who grabbed the phone off the table, turned it off and tossed it on the chair. (R5] stood and hit him. Residents were separated, skin and pain assessed, no issues noted .'. In an interview on 5/21/26 at 10:23 am, R5 reported stated that he doesn't like noisy people or people yelling in the hall. R5 stated that sometimes he will get up and slam his door during the night because of the person that yells out. R5 stated he thinks it is the same person that yells out in the dining room and stated she makes noises all the time (mimicked a grunting noise). R5 recalled a time one guy was mouthy and tried to shut my phone off. I said try it. he tried it and I hauled off and hit him right across the back. Review of the Michigan-Facility Reported Incident system revealed no submission for this incident. Review of R5's Care Plan reviewed a Focus area which stated Resident has behavior(s) as evidenced by: verbally aggressive toward other, name calling of staff members. Resident punches walls and/or doors when he is upset. Refusing medications. Not following prescribed diet, hoarding sugar, salt, cream, pepper and old metal spoons. Can become agitated by excessive noises. Resident has repeatedly cut wander guard bracelet off despite education and direction. Date Initiated: 11/25/2024 Revision on: 03/02/2026. One of the interventions stated Be aware of loud residents in the vicinity and attempt to redirect if becomes agitated. Date Initiated: 01/28/2026. Review of the facilities policy titled Abuse, Neglect, and Exploitation defines abuse as the willful infliction of injury which can include certain resident to resident altercations. Physical abuse includes but is not limited to hitting, slapping, punching, biting and kicking. Reporting/Response: Immediately, but not later than two hours if the events that cause the allegation involve abuse. Resident #2 (R2) Review of the medical record revealed R2 was admitted to the facility 06/30/2025 with diagnoses that included adjustment disorder with mixed anxiety and depresses mood, Alzheimer's Disease, osteoarthritis (wearing of cartilage between bone joints), dementia, depression, repeated falls, hypertension, and anxiety. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/06/2026, revealed R2 had a Brief Interview of Mental Status (BIMS) of 7 (severe cognitive impairment) out of 15. Section GG-Functional Abilities, with the same ARD of 01/06/2026, revealed that R2 was independent with wheelchair mobility. Resident #3 (R3) Review of the medical record revealed R3 was admitted to the facility 05/05/2023 with diagnoses that included Huntington's Disease (a progressive genetic disorder which leads to the breakdown of nerve cells in the brain), encephalopathy (broad term for any disease, damage, or malfunction of the brain), psychosis (loss of contact with reality), dysphagia (difficulty swallowing), restlessness and agitation, urinary retention, and chorea (neurological movement disorder characterized by involuntary, irregular, and unpredictable muscle movements). The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/2026, revealed R3 had a Brief Interview of Mental Status (BIMS) that could not be completed because R3 is rarely/never understood. R3's medical record revealed that he was discharged from the facility 05/02/2026. Review of facility incident report (for event that occurred 02/16/2026 at 05:00 pm) revealed Pt (R2) was rolling herself down A hall. Pt (R3) sitting near the nurses station leaned out of his chair and struck the other Pt (R2) on the side of the head near her eye. The same incident report revealed immediate action taken Pt (R2) evaluated raised bump forming on right side of Pts (R2) head near upper portion of eye, broken skin noted where Pt(R2) was struck. Pt (R2) eyes PERRLA (Pupils Equal, Round, Reactive to Light, and Accommodation). No complaint of headache at this time. Pt (R2) states pain is minimal but she was just surprised. Review of MI-FRI (Michigan-Facility Reported Incident) 00063610, 24 hour report, revealed that the facility reported the incident on 02/17/2026 at 11:43 a.m. The same document included an incident summary (provide by Nursing Home Administrator G, that is no longer employed by the facility as of 05/19/2026) which stated, Pt (R2) was rolling herself down A hall. Pt (R3) witting near the nurses' station leaned out of his chair and struck the other Pt (R2) on the head near her eye. Scratch 2/16/2026to area, minimal pain. Pt (R3) placed on 1 to 1. Both Pt. (R2 &R3) cont. to reside at center and are safe. During an interview on 05/21/2026 at 11:33 a.m. Registered Nurse (RN) H explained that he had been the nurse that witnessed the altercation between R2 and R3 on 02/16/2026 at 05:00 p.m. RN H explained that he witnessed R2 propelling herself down the hall. RN H explained that as R2 got closer to R3 he witnessed R3 reaching out and clocking R2. RN H was asked to clarify what clocking R2 meant. RN H explained that R3 had deliberately hit R2 with a closed fist and even knocked her glasses off her face and he witnessed her head go backward from the force. RN H explained that R3 was taking back to his room but could not answer if he was placed on 1:1 supervision. RN H explained that he assessed R2' and she had a lump under her eye and the skin was broken. RN H' explained that he knew this was not the first time R3 had altercations with other residents and explained that he had a history of placing a staff member in a head lock. During observation and interview on 05/21/2026 at 01:19 p.m. R2 was observed sitting in her wheelchair in her room. R2 was asked about the event that occurred with another resident on 02/16/2026. R2 explained that she remembered the incident and that a man had punched her in the face, right under her right eye. R2 explained that it had caused her to have a 'black eye. R2 was asked to rate the pain on a scale of 1-10, with 1 being the least pain and 10 being the most pain, the pain from being punched on that date. R2 explained that her pain was a 5 on that date, but that it still bothered her at times. R2 was asked to explain why her eye still bothered her and she responded, Because someone knocked by face in. No bruising was observed on R2's face at this time. During an interview on 05/21/2026 at 01:33 p.m. Regional Director of Operations also Nursing Home Administrator (NHA)A confirmed that the NHA G had not notified the state agency within 2 hours as required and had not contacted the police as required. NHA could not explain why NHA A had not reported the incident within 2 hours and report to the police as required.

This citation pertains to intake numbers 2790883 and 2790891 Based on observation, interview, and record review the facility failed to conduct a thorough abuse investigation for 6 (R2, R3, R4, R5, R6, R16) out of 6 residents reviewed for abuse. Findings include:Review of the medical record reflected Resident #4 (R4) was admitted to the facility on [DATE], with diagnoses that included pseudobulbar effect (a neurological condition causing sudden uncontrollable episodes of laughing or crying), mild cognitive impairment, chronic motor or vocal tic disorder, and severe intellectual disabilities. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/9/26, reflected R4 was marked as rarely/never understood on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record reflected Resident #5 (R5) was admitted to the facility on [DATE], with diagnoses that included adjustment disorder with depressed mood, generalized anxiety disorder, and unspecified intellectual disabilities. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/16/26, reflected R5 scored 9 out of 15 (moderately impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R5 was independent with ambulation with the use of an assistive device. Review of the medical record reflected R6 was admitted to the facility on [DATE], with diagnoses that included post-traumatic stress disorder, unspecified dementia, and anxiety disorder. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/1/26, reflected R6 scored 0 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of a Nurses' Note Dated 1/27/2026 at 12:55 PM reflected writer notified by staff that resident was hit by another resident [R5] in back oh head. as per head-to-toe assessment, not observed any bruises/pain/open injuries or any discomfort . brought resident in front of nursing station forobservation [sic]. notified to abuse coordinator . Review of MI-FRI (Michigan-Facility Reported Incident) 00063325, 24-hour report, revealed an incident summary (provided by Nursing Home Administrator G, that is no longer employed by the facility as of 05/19/2026) which stated, Allegation of resident-to-resident abuse. Resident [5] is alleged to have hit Resident [4]. Residents separated and safe in the facility. Both residents assessed and free of injury. Interventions in place. Notifications in progress. Investigation underway . Review of an Incident report dated 1/27/26 at 12:30 PM stated staff observed R5 enter the dining room where R4 was seated and hit [R4] in the back of the head and continued walking away. Certified Nursing Assistant Q reported, via the same incident report, that R4 was in the dining room yelling and as [R5] was coming into the dining room he lightly hit [R4] on the back of the head as he told her to knock it off . Review of the incident investigation revealed a lack staff interviews, assessments of like/other residents that had the potential to be impacted and did not contain documentation that incident had been reported to the police department. During an interview on 05/20/2026 at 02:51 pm Regional Director of Clinical Services (RDCS) I confirmed that facility investigation file, provided for R4 and R5 incident did not contain adequate witness statements or review of other potential residents that could have been impacted from the event. Review of R4's Care Plan revealed an added intervention dated 1/28/26 staff sit with resident during mealtimes and do not bring resident to dining room until tray is served. Review of a Nurses' Note dated 2/12/2026 at 5:51 PM revealed 'Resident was in the dining room before dinner meal was passed and she was screaming. Another resident came up and hit her in the face. The resident who hit her was removed from the dining room and the don, on call and admin was notified . Inquiries from current staff revealed no knowledge of this incident. Review of the Michigan-Facility Reported Incident system revealed no submission for this incident and as a result, no corresponding investigation. In an interview on 5/20/26 3:11 pm, Director of Nursing (DON) B stated that she was aware of the incident that occurred on 5/5/26. DON B reported that the incident was discussed during morning meeting. R4 was in the dining room and R6 self-propelled in the vicinity of R4. R4 reached out and hit R6. The team discussed an intervention of ensuring R4 was not left unattended in the dining room. confirmed that former NHA G was immediately notified of the abuse allegation. The incident that occurred on 5/5/26 between R4 and R6 again demonstrated the failure to follow the care plan designed to reduce the risk of a resident-to-resident incident. Further review of R5's Care plan revealed no additional intervention after the 5/5/26 incident to ensure the safety of R4 was maintained as well as the safety of others. Review of the Michigan-Facility Reported Incident system revealed no submission for this incident and as a result, no corresponding investigation. Review of the medical record reflected R16 was admitted to the facility on [DATE], with diagnoses that included unspecified dementia. R16 no longer resided in the facility. Review of a Nurses' Note dated 4/27/26 at 8:13 am revealed [R16] was observed in a yelling argument with [R5]. [R5] closed fist hit [R16] in the upper back. [R16] reporting, [R16] stated he came to dining room to have a quiet cup of coffee, [R5] had phone blaring and refused to turn it down. This agitated [R16] who grabbed the phone off the table, turned it off and tossed it on the chair. (R5] stood and hit him. Residents were separated, skin and pain assessed, no issues noted .'. In an interview on 5/21/26 at 10:23 am, R5 reported stated that he doesn't like noisy people or people yelling in the hall. R5 stated that sometimes he will get up and slam his door during the night because of the person that yells out. R5 stated he thinks it is the same person that yells out in the dining room and stated she makes noises all the time (mimicked a grunting noise). R5 recalled a time one guy was mouthy and tried to shut my phone off. I said try it. he tried it and I hauled off and hit him right across the back. Review of the Michigan-Facility Reported Incident system revealed no submission for this incident and as a result, no corresponding investigation. During an interview on 05/21/2026 at 01:33 p.m. Regional Director of Operations also Nursing Home Administrator (NHA) A explained that he was the current Nursing Home Administrator (NHA) at the facility. NHA A explained that the previous NHA G 's last date of employment was 05/19/2026. NHA A explained that he had reviewed the investigation file of the incident that occurred between R4 and R5. NHA A acknowledged the absence of investigations for the abuse allegations that occurred on 2/12/26, 5/5/26 NHA A explained that it was his expectation that the facility investigation should include the following: Resident statements, witness statements, complete incident report, Guardian/DPOA/Responsible Party notified, Physician notified, initial report to state, police notified, root cause determined, Pain assessment completed, skin assessment completed, Physician see the resident, Psychological services to see resident, Medication review, Social work following, and care plan updated. NHA A confirmed that facility had not contacted the police as required, and had not completed an adequate investigation of the incident that had occurred between R4 and R5. NHA A could not explain why a complete investigation had not been conducted for the resident-to-resident altercations between R4, R5, and 16 and the lack of reporting and investigating the abuse allegations involving R4, R6, and R16. Review of the facilities policy titled Abuse, Neglect, and Exploitation defines abuse as the willful infliction of injury which can include certain resident to resident altercations. Physical abuse includes but is not limited to hitting, slapping, punching, biting and kicking. Reporting/Response: Immediately, but not later than two hours if the events that cause the allegation involve abuse. Resident #2 (R2) Review of the medical record revealed R2 was admitted to the facility 06/30/2025 with diagnoses that included adjustment disorder with mixed anxiety and depresses mood, Alzheimer's Disease, osteoarthritis (wearing of cartilage between bone joints), dementia, depression, repeated falls, hypertension, and anxiety. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/06/2026, revealed R2 had a Brief Interview of Mental Status (BIMS) of 7 (severe cognitive impairment) out of 15. Section GG-Functional Abilities, with the same ARD of 01/06/2026, revealed that R2 was independent with wheelchair mobility. Resident #3 (R3) Review of the medical record revealed R3 was admitted to the facility 05/05/2023 with diagnoses that included Huntington's Disease (a progressive genetic disorder which leads to the breakdown of nerve cells in the brain), encephalopathy (broad term for any disease, damage, or malfunction of the brain), psychosis (loss of contact with reality), dysphagia (difficulty swallowing), restlessness and agitation, urinary retention, and chorea (neurological movement disorder characterized by involuntary, irregular, and unpredictable muscle movements). The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/2026, revealed R3 had a Brief Interview of Mental Status (BIMS) that could not be completed because R3 is rarely/never understood. R3's medical record revealed that he was discharged from the facility 05/02/2026. Review of facility incident report (for event that occurred 02/16/2026 at 05:00 pm) revealed Pt (R2) was rolling herself down A hall. Pt (R3) sitting near the nurses station leaned out of his chair and struck the other Pt (R2) on the side of the head near her eye. The same incident report revealed immediate action taken Pt (R2) evaluated raised bump forming on right side of Pts (R2) head near upper portion of eye, broken skin noted where Pt(R2) was struck. Pt (R2) eyes PERRLA (Pupils Equal, Round, Reactive to Light, and Accommodation). No complaint of headache at this time. Pt (R2) states pain is minimal but she was just surprised. Review of MI-FRI (Michigan-Facility Reported Incident) 00063610, 24 hour report, revealed that the facility reported the incident on 02/17/2026 at 11:43 a.m. The same document included an incident summary (provide by Nursing Home Administrator G, that is no longer employed by the facility as of 05/19/2026) which stated, Pt (R2) was rolling herself down A hall. Pt (R3) witting near the nurses' station leaned out of his chair and struck the other Pt (R2) on the head near her eye. Scratch 2/16/2026to area, minimal pain. Pt (R3) placed on 1 to 1. Both Pt. (R2 &R3) cont. to reside at center and are safe. Investigation started. 5 day to follow. Review of the MI-FRI 00063610, 5 day investigation, revealed Correction Action (s) Taken: Following the incident, staff immediately intervened and separate the residents, moving he victim, (name of R2) to another area and evaluating her injuries, which included applying a bandage to her laceration and initiating neuro checks. To ensure ongoing facility safety and prevent further incidents, the initiator (name of R3), was promptly placed on 1:1 observations whenever he is out of his room. Review of R3's medial record did not have demonstration that R3 was placed on 1:1 supervision after this incident. Review of the facility investigation file involving the incident between R2 and R3 on 02/16/2026 at 05:00 p.m. did not include a list of persons interviewed, did not include a review of like/other residents that had the potential to be impacted. During an interview on 05/20/2026 at 02:51 p.m. Regional Director of Clinical Services (RDCS) I confirmed that facility investigation file, provided for R2 and R3 incident on 02/26/2026, did not contain witness statements or review of other potential residents that could have been impacted from the event. During an interview on 05/21/2026 at 11:33 a.m. Registered Nurse (RN) H explained that he had been the nurse that witnessed the altercation between R2 and R3 on 02/16/2026 at 05:00 p.m. RN H explained that he witnessed R2 propelling herself down the hall. RN H explained that as R2 got closer to R3 he witnessed R3 reaching out and clocking R2. RN H was asked to clarify what clocking R2 meant. RN H explained that R3 had deliberately hit R2 with a closed fist and even knocked her glasses off her face and he witnessed her head go backward from the force. RN H explained that R3 was taking back to his room but could not answer if he was placed on 1:1 supervision. RN H explained that he assessed R2' and she had a lump under her eye and the skin was broken. RN H' explained that he knew this was not the first time R3 had altercations with other residents and explained that he had a history of placing a staff member in a head lock. During an interview on 05/21/2026 at 01:33 p.m. Regional Director of Operations also Nursing Home Administrator (NHA) A explained that he was the current Nursing Home Administrator (NHA) at the facility. NHA A explained that the previous NHA G 's last date of employment was 05/19/2026. NHA A explained that he had reviewed the investigation file of the incident that occurred between R2 and R3 on 01/16/2026. NHA A explained that it was his expectation that resident to resident altercations would be reported to the appropriate state agency within 2 hours of the incident. NHA A also explained that the facility investigation should include the following: Residet statements, witness statements, complete incident report, Guardian/DPOA/Responsible Party notified, Physician notified, initial report to state, police notified, root cause determined, Pain assessment completed, skin assessment completed, Physician see the resident, Psychological services to see resident, Medication review, Social work following, and care plan updated. NHA A confirmed that the NHA G had not completed an adequate investigation of the incident that had occurred between R2 and R3 on 01/16/2026. NHA A could not explain why the items listed previously had not been completed by NHA G. Resident #6 (R6) Review of the medical record revealed R6 was admitted to the facility 09/23/2025 with diagnoses that included encephalopathy (broad term for any disease, damage, or malfunction of the brain), chronic obstructive pulmonary disease (COPD), unsteadiness on feet, generalized muscle weakness, depression, anxiety, conversion disorder (a condition where a person experiences real physical symptoms that cannot be explained by an underlying medical disease) with seizures or convulsions, bladder cancer, adjustment disorder, gastro-esophageal reflux disease, hypertension, hyperlipidemia (high fat content in blood), obstructive sleep apnea, dementia with behavioral disturbances, urinary retention, enlarged prostate, post-traumatic stress disorder, and hypothyroidism (low thyroid hormone). The Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 04/01/2026, revealed R6 had a Brief Interview of Mental Status (BIMS) of 00 (severe cognitive impairment) out of 15. Review of R3 incident report, 01/28/2026 at 03:00 p.m., revealed CNA (Certified Nursing Aide) reported that another resident (R6) was wheeling into this residents room and this resident hit the other resident (R6) in the face. A scratch was present on the left side of eye of the other resident (R6). R3's incident report did not contain any witness statements and did not identify the name of the CNA Review of R6 incident report, 01/28/2026 at 03;00 p.m., revealed CNA (Certified Nursing Aide) reported resident (R6) was wheeling into other residents (R3) room, resident in the room (R3) hit this resident (R6) in the face, a scratch was present on left side of eye with slight blood present. R6's incident report did not contain any witness statements and did not identify the name of the CNA. Review of the MI-FRI 00063344, 5 day investigation, revealed Correction Action (s) Taken: Care plans for bother resident we updated and stop sign was added to make the room less appealing: The section entitled Conclusion revealed Not verified- the allegation was refuted by evidence collected during the investigation. Review of the facility investigation file for the resident to resident altercation between R3 and R6 did not reveal witness statements or interviews, any documentation demonstrating that the police were notified, no conclusion summary. During an interview on 05/20/2026 at 02:51 p.m. Regional Director of Clinical Services (RDCS) I confirmed that facility investigation file, provided for R3 and R6 incident on 01/28/2026 , did not contain witness statements, review of other potential residents that could have been impacted from the event, identification of the who witness had been, and a summary of the investigation. During an interview on 05/21/2026 at 01:33 p.m. Regional Director of Operations also Nursing Home Administrator (NHA) A explained that he was the current Nursing Home Administrator (NHA) at the facility. NHA A explained that the previous NHA G 's last date of employment was 05/19/2026. NHA A explained that he had reviewed the investigation file of the incident that occurred between R3 and R6 on 01/28/2026. NHA A explained that it was his expectation that the facility investigation should include the following: Residet statements, witness statements, complete incident report, Guardian/DPOA/Responsible Party notified, Physician notified, initial report to state, police notified, root cause determined, Pain assessment completed, skin assessment completed, Physician see the resident, Psychological services to see resident, Medication review, Social work following, and care plan updated. NHA A confirmed that facility had not contacted the police as required, and had not completed an adequate investigation of the incident that had occurred between R3 and R6 on 01/28/2026. NHA A could not explain why a complete investigation had not been conducted for the resident to resident altercations between R3 and R6.

This citation pertains to intake 2741317. Based on observation, interview and record review, the facility failed to conduct root cause analysis and develop interventions to prevent falls for one (R1) of three reviewed for falls. Findings include:Review of the medical record reflected R1 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included hypothyroidism, low back pain and Alzheimer's. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/21/26, reflected R1 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R1 was always incontinent of bowel and bladder, and a trial of a urinary toileting program had not been attempted.On 5/21/26 at 11:23 AM, R1 was observed seated in a wheelchair, in the dining room, self-propelling with their feet. Non-skid socks were observed on both feet. Anti-rollback brakes were observed on the wheelchair.An Incident Report, for an unwitnessed fall on 2/2/26 at 12:00 PM, reflected R1 was observed sitting on the floor and stated they were walking to the bathroom. According to the report, R1 was cleaned and changed, after the fall.R1's Care Plan reflected an intervention for a medication review, which was initiated 2/2/26 and revised 2/3/26. An Incident Report, for an unwitnessed fall on 3/6/26 at 3:35 AM, reflected R1 was lying on their right side, near the foot of the bed, with non-skid socks on. R1 stated, I think I fell. Upon assessment, R1 was observed to have redness to their left elbow and an abrasion to their right upper back. R1 was incontinent at the time of the fall.R1's Care Plan reflected an intervention for rearranging furniture, dated 3/6/26.An Incident Report, for an unwitnessed fall on 3/24/26 at 3:00 AM, reflected R1 was sitting on their buttocks, near the head of the bed. Non-skid footwear was in place, and the bed was in the lowest position and locked. R1 was unable to give a description of what they were doing at the time of the fall. It was documented that R1 had an episode of bowel incontinence. The Incident Report reflected the intervention was to place a fall mat next to the bed. R1's Care Plan reflected an intervention for a floor mat at the left side of the bed, which was initiated on 3/24/26 and revised and resolved (changed/removed) on 3/30/26. An intervention for the bed against the wall to promote independence and clutter reduction was initiated on 3/26/26 and revised 4/30/26. An Incident Report, for an unwitnessed fall on 3/27/26 at 4:10 PM, reflected R1 was sitting on the floor, with their legs extended and gripper socks in place. As an intervention, R1 was placed in their wheelchair and escorted in front of the nursing station for observation. R1's Care Plan reflected an intervention to remove the mat from the side of the bed was initiated on 3/27/26. The intervention was revised and resolved on 4/17/26. An Incident Report, for an unwitnessed fall on 5/7/26 at 4:40 AM, reflected when going in for a two-hour check and change, staff observed R1 seated in front of their wheelchair. The floor around R1 was wet, and a broken water glass was beside them. R1 was wearing non-skid socks, and their wheelchair was locked. The report reflected there was a scant amount of blood from an undetermined source from R1's mouth. The report reflected R1 was incontinent at the time of the fall.R1's Care Plan reflected an intervention was initiated on 5/8/26 for a bedside floor mat to the left side of the bed, when R1 was resting in bed.In an interview on 5/27/26 at 2:24 PM, Director of Nursing (DON) B reported she would assume R1 was incontinent at the time of the fall on 2/2/26, due to notation that R1 was cleaned and changed. DON B stated if the fall involved incontinence, a medication review would not have addressed the root cause, but it may have assisted. During the same interview, DON B reported there was an episode of incontinence at the time of R1's fall on 3/6/26. DON B reported the bed was moved against the wall as an intervention. Regarding R1's fall on 3/24/26, DON B reported there was a pattern with the time of morning for R1's falls. DON B reported R1 was incontinent of bowel, and the intervention was to place a fall mat next to the bed. DON B stated a fall mat would not prevent a fall but may help prevent an injury. During the interview on 5/27/26 at 2:24 PM, DON B reported she did not see an intervention after R1's fall on 3/27/26, other than moving R1 to the nursing station for observation. DON B acknowledged that she would have expected to see an additional intervention. Regarding R1's fall on 5/7/26, DON B reported R1 was incontinent at 4:40 AM, and she would have expected a different intervention than placing a mat at the side of the bed. DON B reported the facility should have identified a root cause sooner and been more proactive in preventing falls.

This citation pertains to intake number 3013328 Based on observation and interview, the facility failed to ensure meals were served in a manner that maintained an appetizing appearance and palatability. Findings include:On 5/21/26 at 11:46 am a test tray was provided to the survey team. The stated lunch meal, per the facility provided menu, consisted of stuffed pepper casserole, buttered corn, and mocha fudge cake. The meal provided was observed to be stuffed pepper casserole, corn and not mocha fudge cake but rather a pistachio cake. The stuffed pepper casserole lacked an appetizing appearance, as it consisted primarily of rice and a meat sauce, and did not contain visible peppers. the casserole was tasted and determined to lack flavor. The corn lacked flavor as well. The meal served did not match the posted menu and overall deemed unappealing in appearance and palatability. In an interview on 5/21/26 at 2:19 pm, Resident #11 was interviewed regarding the lunch meal. Resident #11 rated the stuffed pepper casserole as nasty with no flavor.

This citation pertains to intake number 3013328 Based on observation, interview, and record review the facility failed to honor resident food preferences in one (Resident #12) out of three reviewed for food preferences. Findings include:Review of the medical record reflected Resident #12 (R12) was admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/20/26, reflected R12 scored 9 out of 15 (moderate impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).On 5/20/26 at 11:13 am, R12 was observed in her room reviewing a stack of paperwork. R12 was groomed, appropriately dressed, and answered questions appropriately. R12 was sharing her frustration regarding dining staff not following her tray ticket, which lists her food dislikes. R12 showed me her tray ticket from her breakfast meal, which had a list of dislikes on it. One if the dislikes listed was pork. During the interview, R12's lunch tray was delivered. R12 lifted the cover on her plate and an observation of ham on her lunch plate was made. R12 abruptly stopped the Certified Nursing Assistant who delivered her tray and requested an alternative main entree. R12 confirmed that she did not like pork, which included the ham that was delivered on her plate and confirmed that this had been discussed with dietary staff on more than one occasion.

This citation pertains to Intake 2728065.Based on observation, interview, and record review, the facility failed to administer medications as ordered for one (R2) of three reviewed.Findings include:Review of the medical record revealed R2 was admitted to the facility on [DATE] with diagnoses that included necrotizing fasciitis, major depressive disorder with anxiety, and type 2 diabetes. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/25 revealed R2 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 2/11/26 at 8:40 AM, R2 was observed sitting on the edge of their bed, eating breakfast. R2 reported they had concerns that their pain medications were occasionally administered late. Review of the Physician's Order dated 12/30/25 revealed an order for oxycodone (opioid pain medication) 10 milligrams (mg) every four hours. Review of the Medication Administration Record (MAR) revealed R2's oxycodone was scheduled to be administered every day at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. Review of the Controlled Substance Records for R2's oxycodone 10 mg revealed the oxycodone was often signed out outside of the ordered 4 hours, which included but was not limited to the following: 1/18/26 at 9:58 PM and 1/19/26 at 12:16 AM (2 hours and 18 minutes between doses)1/19/26 at 7:15 AM and 1/19/26 at 12:00 PM (4 hours and 45 minutes between doses)1/19/26 at 12:25 AM and 1/20/26 at 5:15 AM (4 hours and 50 minutes between doses)1/20/26 at 3:00 PM and 1/20/26 at 8:03 PM (5 hours and 3 minutes between doses) and 1/20/26 at 9:52 PM (1 hour and 49 minutes between doses) 1/24/26 4:07 AM and 1/24/26 at 9:00 AM (4 hours and 53 minutes between doses)1/24/26 at 7:52 PM and 1/24/26 at 11:25 PM (2 hours and 33 minutes between doses)1/26/26 at 4:30 AM and 1/26/26 at 9:15 AM (4 hours and 45 minutes between doses)1/26/26 at 8:25 PM and 1/26/28 at 11:20 PM (2 hours and 55 minutes between doses)1/27/26 at 11:17 PM and 1/28/26 at 4:45 AM (5 hours and 28 minutes between doses)1/28/26 at 9:15 AM and 1/28/26 at 11:00 AM (1 hour and 45 minutes between doses) and 1/28/26 at 4:10 PM (5 hours and 10 minutes between doses)2/3/26 at 4:47 AM and 2/3/26 at 7:56 AM (3 hours and 9 minutes between doses)2/4/26 at 11:56 AM and 2/4/26 at 5:17 PM (5 hours and 21 minutes between doses)2/10/26 at 5:00 AM and 2/10/26 at 7:01 AM (2 hours and 1 minute between doses)2/10/26 at 3:30 PM and 2/10/26 at 8:41 PM (5 hours and 11 minutes between doses)2/11/26 at 8:01 AM and 2/11/26 at 11:00 AM (2 hours and 59 minutes between doses) and 2/11/26 at 4:13 PM (5 hours and 13 minutes between doses)2/12/26 at 5:00 AM and 2/12/26 at 7:01 AM (2 hours and 1 minute between doses) and 2/12/26 at 12:10 PM (5 ours and 9 minutes between doses) In an interview on 2/12/26 at 11:32 AM, Registered Nurse (RN) I nurses often work two halls and as a result, medications were administered late. In an interview on 2/12/26 at 3:11 PM, Director of Nursing (DON) B reported the Controlled Substance Records should reflect the time the nurse pulled the medication out of the medication cart for administration to the resident. DON B reported if a medication was ordered every 4 hours, it would be expected that staff signed it out every 4 hours for administration unless the resident refused the medication. DON B reviewed R2's Controlled Substance Records and agreed R2's oxycodone was signed out as administered outside of the ordered every 4 hours.

This citation pertains to Intake: 2644057Based on observation, interview, and record review the facility failed to prevent the development of pressure ulcers for one resident (#4) out of three residents with pressure ulcers reviewed, resulting in the development of two unstageable pressure ulcers and one stage 3 pressure ulcer. Findings Included:Resident #4 (R4)Review of the medical record revealed R4 was admitted to the facility 05/03/2025/ with diagnoses that included chronic obstructive pulmonary disease (COPD), chondrocostal junction syndrome (inflammation and pain where ribs connect to cartilage), obesity, anxiety, mild neurocognitive disorder (a stage where there's a noticeable decline in memory), neuromuscular dysfunction of bladder (nerve damage between brain and bladder causing urinary incontinence, retention, urgency, or a weak stream), depression, anemia (low red blood cell count), hypothyroidism (low thyroid hormone), insomnia, hypertension, sleep apnea, gastro-esophageal reflux, and osteoarthritis (degenerative joint disease). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/06/2025, revealed a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. Section M-Skin condition of the MDS, with the same ARD, revealed R4 had one stage 3 pressure ulcer present on upon admission and one unstageable pressure ulcer that was not present on admission. Review of R4's medical record revealed the following pressure ulcers:Unstageable right heel wound (caused by brace) facility acquired. Original acquired date of 12/15/2025 with measurements 4.6 cm (centimeters) in length by 1.6 centimeters in width. Most recent measurements 12/29/2025, 2.5 cm in length and 3.0 cm in width.Unstageable right heel superior facility acquired. Original acquired date of 12/08/2025 with measurement 2.9cm in length by 1.9cm in width and 0.1 cm in depth. Most recent measurement , now stage 3 pressure ulcer, 12/29/2025 6.5cm in length by 3.0cm in width and 0.3 cm in depth. Unstageable right medial malleolus facility acquired. Originally acquired date of 12/08/2025 with measurements of 1.4cm length by 0.8cm in width. Most recent measurements, 12/29/2025 5cm in length by 3.8 cm in width. Review of R4's medical record revealed treatment orders that included: Right heel: (medial cleanse with wound wash, pat dry, apply calcium alginate to wound bed and cover with bordered gauze dressing. In the morning every Monday (Mon), Wednesday(Wed), Friday(Fri) for wound care. Start date of 12/15/2025. Order was still in place as of 12/29/2025. Review of Treatment Record revealed treatment was not completed 12/15/2025, 12/19/2025, 12/24/25.Right heel: cleanse with wound wash, pat dry. Apply betadine to areas of dark/redness. Cover with bordered gauze dressing. In morning every Mon, Wed, Fri for wound care. Start date of 11/05/2025 and still in place as of 12/29/2025. Review of Treatment Record revealed treatment was not completed 12/10/2025, 12/15/2025, 12/19/2025, 12/24/2025.Right heel: cleanse with wound wash, pat dry. Apply calcium alginate to wound bed that is open, cover with silicone super absorbent dressing. In the morning every Mon, Wed, Fri for wound care. Start date of 12/17/2025 and still in place as of 12/29/2025. Review of Treatment Record revealed treatment was not completed 12/19/2025 and 12/24/2025.Right medial malleolus: cleanse with wound wash, pat dry. Apply iodine to area and cover with bordered gauze dressing. In the morning every Mon, Wed, Fri for wound care. Start Date of 12/15/2025 and still in place 12/29/2025. Review of Treatment Record revealed treatment was not completed 12/15/2025, 12/19/2025 and 12/24/2025.Right medial malleolus: clean with wound wash, pat dry apply iodine to wound bed and cover with bordered gauze. In morning every Mon, Wed, Fri for wound care. Start date of 12/15/2025 and still in place 12/29/2025. Review of Treatment Record revealed treatment was not completed 12/15/2025, 12/19/2025 and 12/24/2025.Right medial malleolus: cleanse with wound wash, pat dry. Apply medihoney to calcium alginate and then apply to wound bed. Cover with bordered gauze dressing. In the morning every Mon, Wed, Fri for wound care. Start date of 12/17/2025 and still in place 12/29/2025. Review of Treatment Record revealed treatment was not completed 12/19/2025 and 12/24/2025In an interview on 12/29/2025 at 11:06 a.m. Wound Nurse (WN) E explained that she was responsible for the oversight of pressure wounds at the facility. WN E explained that R4 had a pressure wound to her right heel, a pressure wound to her right medial malleolus, and her right heel superior. WN E was asked to explain why there were three different orders for R4's right heel. After review of the right heel orders WN E explained that some of the orders should have been deleted but WN E could not explain which orders were correct at this time. WN E was asked to explain why there were three different orders for the R4's right medial malleolus. After review of the right medial malleolus orders WN E explained that some of the orders should have been deleted. WN E could not explain which orders were correct at this time. WN E was asked to review the R4's Treatments Records for December of 2025. WN E was asked to explain why the treatments were not completed to the right heel and the right medial malleolus, as ordered, on the dates listed above. WN E could not provide an explanation as to why the treatments had not been completed. During observation and interview on 12/29/2025 at 12:35 p.m. R4 was observed lying down in the bed. An alternating air mattress was observed to be in use and R4's right foot was elevated on a pillow. R4 explained that she had several pressure wounds to her right foot and that they were caused by a boot that she had to wear when she first arrived at the facility. R4 explained that she currently does not wear the boot. On 12/29/2025 at 01:40 p.m. R4 was observed lying down in bed. Wound Nurse (WN) E was observed explaining to R4 that she would be changing her wound dressing to her right boot. WN E removed the right heel dressing which was dated 12/26/2025. The wound was observed to have eschar tissue and WN E informed this surveyor that the right heel was an unstageable wound. WN E was observed to measure the right heel and found it to me 2.5 centimeters (cm) in length x 3cm in width and had no depth. wipe the wound with wound wash. The right heel wound was cleansed with wound wash and betadine was applied. WN E was then observed to place a boarder gauze over the right heel wound. WN E was observed to removed R4's right superior heel dressing, dated 12/26/2025, the dressing was observed to have a large amount of yellowish/greenish drainage and a foul odor was present. The wound was cleansed with wound wash. WN E then was observed to measure the right superior heel wound and found to be 6.5cm in length x 3cm in width x0.3cm in depth. WN E explained that the right superior heel wound was now classified as a stage 3 pressure ulcer. The wound bed was observed to be pink with granulation tissue present. WN E applied calcium alginate and medihoney. WN E was then observed to place a boarder gauze over the right superior heel wound. WN E was then observed to remove the right medial malleolus dressing, dated 12/26/2025. The wound site was observed with slough tissue in the wound bed and appeared to be unstageable. WN E was observed to cleanse the right medial malleolus wound site with wound wash. WN E was observed to measure the right medial malleolus wound site and was observed to be 5.0cm in length x 3.8cm in width and no depth. WN E was observed to apply calcium alginate and boarder gauze. WN E was observed to use appropriate infection control standards during all dressing changes. R4 rated her pain as between 7 and 9 out of a possible 10at the conclusion of the dressing changes.

This citation pertains to intake: 2672585Based on observations/interviews/record review, the facility failed to protect the resident's (R2's) right to be free from verbal abuse and physical abuse by a resident.Findings Included:Resident #2 (R2)Review of the medical record revealed R2 was admitted to the facility 11/19/2024 with diagnoses that included pseudobulbar effect (a neurological condition causing sudden uncontrollable episodes of laughing or crying), cognitive impairment, severe intellectual disabilities (significant limitations in mental ability), bipolar disorder, social phobia, hypertension, gastro-esophageal reflux disease, depression, dysphagia, hypothyroidism (low thyroid hormone), obesity, and conversion disorder with seizures or convulsions (a condition where psychological stress or trauma manifest as real physical symptoms affecting movement). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2025 that could not be completed because resident is rarely/never understood.Resident #6 (R6)Review of the medical record revealed R6 was admitted to the facility 03/31/2025 with diagnoses that included hypothyroidism (low thyroid hormone), hyperlipidemia (high fat content in blood), adult failure to thrive, Alzheimer's Disease, low back pain, anemia (low number of red blood cells), constipation, insomnia, depression, weight loss, dementia, vitamin D deficiency, cognitive communication deficit, and morbid obesity. The most recent Minimum Data Set (MDS), with an Assessment Reference Date of 12/02/2025, revealed a Brief Interview of Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15.Review of facility incident report, dated 11/05/2025 at 05:00 p.m., revealed resident (R6) approached in dining room other resident (R2) who was shouting. Other resident (R2) upset resident (R6). Resident (R6) yelled at other resident and started to hit her (R2) in the face multiple times. Left a scratch on another resident's (R2) nose. Staff member approached the situation and redirected resident (R6) to another room. Resident description of the incident report revealed, Resident (R6) sated that other resident (R2) was yelling at her and that's why she hit her.During a telephone interview on 12/29/2025 at 02:33 p.m. Certified Nursing Aide (CNA) C explained that on 11/05/2025 at approximately 5:00 p.m. she had entered the dining room to report off to another certified nursing aide. CNA C explained that while she was talking to the other employee she observed R6 standing beside R2. CNA C explained she then heard R2 starting to yell. CNA C explained that then she witnessed R6 grab R2 by her sweatshirt and then observed R6 hit R2 three to four times on her forehead. CNA C explained that she separated R6 from R2. CNA C explained that she knew R6 had a history of altercations with other residents. CNA C explained that she believed that R6 was not to be left unattended in the dining room and R6 should not be next to other residents while in the dining room. CNA C could not explain that she did not see any other staff member observing R6 in the dining room at the time of the incident.During observation and attempted interview on 12/30/2025 at 08:21 a.m. R6 was observed walking in hall. Observed staff member assist R6 into her room. R6 was asked questions regarding incident with R2. She explained that she recalled pushing someone away from herself but did not recall ever hitting another resident.During observation and attempted interview on 12/30/2025 at 08:26 a.m. R2 was observed lying down in bed. R2 could not be understood when asked questions regarding the incident with R6.Review of R6's facility incident reports revealed the following: 05/25/25 physical aggression-accusation of physical aggression toward another resident, 06/22/2025-physical aggression with another resident in dining room, 6/26/2025-altercation in dining room with another resident grabbing and hitting, 07/20/2025-slapped another resident in the dining room, 08/22/2025- threw plastic coke bottle at another resident in the dining room. 10/26/2025 hit roommate.Review of R6's plan of care revealed at problem statement which stated: Resident has behaviors related to dementia with behavioral disturbances as evidenced by: physical aggressive (yelling and hitting) toward staff, resistant to care, refusing medication, cusses at staff, refuses showers, physical aggressive (yelling and hitting) towards other residents, wandering into residents room, refusing showers. Problem statement revealed last revision 11/06/2025. Interventions reviewed and revealed 1:1 care until infection ruled out, date initiated 6/27/2025 and resolved 07/08/2025. Interventions also included frequent checks on resident, date initiated 07/08/2025, revised 11/03/2025, and resolved 11/03/2025. Further review of R6's plan of care did not include any interventions to prevent altercations in the facility dining room.In an interview on 12/30/2025 at 08:35 a.m. Nursing Home Administrator (NHA) A explained that R6 was sent to the hospital following the altercation on 11/05/2025 and was sent to a Geropsychiatric Unit until R6 returned to the facility on [DATE]. NHA A confirmed that R6 had had previous alterations with other residents while in the dining room. NHA A could not verbalize or present evidence of interventions in R6's plan of care which revealed actions that the facility had taken after each altercation. NHA A could not verbalize or present evidence in R'6's plan of care of interventions that would have been in place prior to the incident on 11/05/2025. NHA A could not verbalize or provide documentation of interventions that were in place to prevent R6's behaviors and potential physical altercations between other residents.Review of facility policy entitled Abuse, Neglect and Exploitation, with an implementation date 07/28/2020 and last revision date of 01/20/2024, revealed section entitled III Prevention of Abuse, Neglect and Exploitation- D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

This citation pertains to intake: 2642660 Based on observation, interview, and record review the facility failed to ensure that Nursing staff followed professional standards for medication administration for one resident (#1) out of three residents reviewed for medication administration. Findings Included:Resident #1 (R1)Review of the medical record revealed R1 was admitted to the facility 02/19/2025 with diagnoses that included depression, thyroiditis (inflammation of the thyroid gland), gastro-esophageal reflux, osteoporosis (weak and brittle bones), dementia, hypercholesterolemia (high cholesterol), sleep apnea, insomnia, chronic pain, dysphagia, and (difficulty swallowing). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2025, did not have a Brief Interview for Mental Status (BIMS) conducted.Resident #7 (R7) Review of the medical record revealed R7 was admitted to the facility 02/07/2025 with diagnoses that included chronic respiratory failure, type 2 diabetes, depression, pain in right hip, post-traumatic stress disorder (PTSD), hypercholesterolemia (high cholesterol), anxiety, adjustment disorder, mild cognitive impairment, dementia, dysphagia (difficulty swallowing), hypertension, and cognitive communication deficit. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/30/2025, revealed a Brief interview for Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15. During a telephone interview on 12/20/2025 at 10:24 a.m. R1 Family member G explained that R1 had received a different resident's medication. R1 Family member G explained that R1 had received insulin and a medication for high blood pressure. R1 Family member G could not list all the wrong medication that had been provided. During observation and interview on 01/06/2025 at 10:21 a.m. R1 was observed lying down in bed. R1 explained that she remembers getting the wrong medication but could not remember the medication or the date that the incident occurred. R1 explained that there was no negative outcome related to receiving the wrong medication. Review of facility medication incident report and provided investigation revealed that on 10/07/2025 at 08:00 a.m. R1 received medication that was not prescribed to her. The incident report stated, wrong medication given to resident, including insulin. (name of Physician Assistant) notified immediately. All medications were reviewed and plan of care established. Resident BS (blood sugar) will be monitored throughout the day along with VS (vital signs). Morning medications held per PA. The medication that was given to R1 was ordered for R7. Review of the investigation provided revealed R1 had received the following medications: Farxia 10mg (milligrams), Hydrochlorothiazide 25mg, Furosemide 20mg, Loaratadine 10mg, Multivitamin adult tab, Potassium Chloride 10 meq (milliequivalent), Tylenol 650mg, Lantus 22 units subcutaneous, and Metoprolol Tartrate 25mg. Review of R1 medical record revealed a program note written by Physician assistant, dated 10/7/2025, which stated [AGE] year old female is seen per nursing report due to reported medication administration error. Nursing staff reports that resident received another residents morning medications. Reviewed medication list that they received which includes the following Farxiga 10mg (milligrams), furosemide 20mg, de hydrochlorothiazide 25mg, Loratadine 10mg, Potassium 10 meq (milliequivalent), metoprolol tartrate 25mg, Lantus 22 units, Tylenol 650mg, and multivitamin. Resident is seen in her room and appears in no acute distress. Vitals are stable and she states that she is feeling well at this time. Advised nursing staff to monitor blood pressure and vitals signs every 6 hours, as well as blood glucose levels every 6 hours.Review of R1's blood sugar levels revealed: Review of blood sugars revealed 10/07/2025 11:58a.m. 126mg/dl (milligrams/deciliter), 10/07/2025 5:26 p.m. 150mg/dl, 10/08/2025 at 00:57 a.m. 218mg/dl, and 10/08/2025 123mg/dl.Review of R1's MAR for October revealed all 0800 medication was held to include Alendronate sodium oral tablet 10mg (milligrams), cholecalciferol tablet 1000 unit give 2 tablet by mouth, Duloxetine HLC oral capsule 60mg, fenofibrate oral tablet 48mg, hydrochlorothiazide 25mg, Losartan potassium oral tablet 50mg. and clonidine HCL 0.2mg, famotidine 20mg. In an interview on 01/06/2026 at 09:04 a.m. Nursing Home Administrator (NHA) A explained that Registered Nurse (RN) H had pulled the medication for R7. NHA A explained that once the medication was pulled from the medication cart RN H gave the medication to Licensed Practical Nurse (LPN) I, who was on orientation, and instructed LPN I to go give the medication to R7. NHA A explained that LPN I went and provided the medication to R1 instead of R7.In an interview on 01/06/2025 at 09:21 a.m. Regional Clinical Consultant F explained that the route cause of the incident was that Licensed Practical Nurse LPN I did not pull the medication herself. Regional Clinical Consultant F explained that Registered Nurse (RN) H pulled the medication from the medication cart. Regional Clinical Consultant F explained that professional practice dictates that the person pulling the medication should be the one providing the medication to the resident. Regional Clinical Consultant F explained that those professional standards were not followed in this incident. Regional Clinical Consultant F also explained that LPN I did not follow the 5 rights while administering R1's medication. Regional Clinical Consultant F explained 5 rights for safe medication administration is widely recognized in healthcare as a standard checklist to reduce medication errors. 5 rights include: right patient/resident, right medication, right dose, right time, and right route. On 01/06/2026 at 09:41 a.m. Registered Nurse (RN) H explained that on 10/07/2025 he was the nurse preceptor (nurse providing orientation a new nurse) for Licensed Practical Nurse (LPN) I. RN H explained that LPN I did not have access to the facility computerized medical record system called PointClickCare(PCC), which would have allowed LPN I to have access to a resident's Medication Administration Record (MAR). RN H explained that because LPN I did not have access to a resident MAR to verify and obtain medication for residents that he removed and documented the administration of the medication for R7. RN H explained that he then provided R7's medication to LPN I to administer to R7. RN H explained that he did not observed LPN I give R7's medication to R1 but was notified after the fact. On 01/06/2025 at 10:45 a.m. in a telephone interview Licensed Practical Nurse (LPN) I explained that she was working on 10/07/2025. LPN I explained that she was being trained by Registered Nurse H on 10/07/2025. LPN I explained that she did not have access to PointClickCare (PCC) and residents Medication Administration Record (MAR). LPN I explained that RN H pulled the medication and documented it as give for R7. LPN I explained that RN H then provided her with R7's medication for administration but that she gave the medication to R1. LPN I explained that she did not follow the 5 rights of medication administration and therefore administered R7's medication to R1 by accident. LPN I explained that she immediately identified the error and took action as explained on R1's incident report.

This citation pertains to intake: 2642660Based on observation, interview, and record review the facility failed to prevent significant medication errors for one resident (#1) out of three residents reviewed for medication errors. Findings Included:Resident #1 (R1)Review of the medical record revealed R1 was admitted to the facility 02/19/2025 with diagnoses that included depression, thyroiditis (inflammation of the thyroid gland), gastro-esophageal reflux, osteoporosis (weak and brittle bones), dementia, hypercholesterolemia (high cholesterol), sleep apnea, insomnia, chronic pain, dysphagia, and (difficulty swallowing). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/25/2025, did not have a Brief Interview for Mental Status (BIMS) conducted.Resident #7 (R7) Review of the medical record revealed R7 was admitted to the facility 02/07/2025 with diagnoses that included chronic respiratory failure, type 2 diabetes, depression, pain in right hip, post-traumatic stress disorder (PTSD), hypercholesterolemia (high cholesterol), anxiety, adjustment disorder, mild cognitive impairment, dementia, dysphagia (difficulty swallowing), hypertension, and cognitive communication deficit. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/30/2025, revealed a Brief interview for Mental Status (BIMS) of 12 (moderate cognitive impairment) out of 15. During a telephone interview on 12/20/2025 at 10:24 a.m. R1 Family member G explained that R1 had received a different resident's medication. R1 Family member G explained that R1 had received insulin and a medication for high blood pressure. R1 Family member G could not list all the wrong medication that had been provided. During observation and interview on 01/06/2025 at 10:21 a.m. R1 was observed lying down in bed. R1 explained that she remembers getting the wrong medication but could not remember the medication or the date that the incident occurred. R1 explained that there was no negative outcome related to receiving the wrong medication. Review of facility medication incident report and provided investigation revealed that on 10/07/2025 at 08:00 a.m. R1 received medication that was not prescribed to her. The incident report stated, wrong medication given to resident, including insulin. (name of Physician Assistant) notified immediately. All medications were reviewed and plan of care established. Resident BS (blood sugar) will be monitored throughout the day along with VS (vital signs). Morning medications held per PA. The medication that was given to R1 was ordered for R7. Review of the investigation provided revealed R1 had received the following medications: Farxia 10mg (milligrams), Hydrochlorothiazide 25mg, Furosemide 20mg, Loaratadine 10mg, Multivitamin adult tab, Potassium Chloride 10 meq (milliequivalent), Tylenol 650mg, Lantus 22 units subcutaneous, and Metoprolol Tartrate 25mg. Review of R1 medical record revealed a program note written by Physician assistant, dated 10/7/2025, which stated [AGE] year old female is seen per nursing report due to reported medication administration error. Nursing staff reports that resident received another residents morning medications. Reviewed medication list that they received which includes the following Farxiga 10mg (milligrams), furosemide 20mg, de hydrochlorothiazide 25mg, Loratadine 10mg, Potassium 10 meq (milliequivalent), metoprolol tartrate 25mg, Lantus 22 units, Tylenol 650mg, and multivitamin. Resident is seen in her room and appears in no acute distress. Vitals are stable and she states that she is feeling well at this time. Advised nursing staff to monitor blood pressure and vitals signs every 6 hours, as well as blood glucose levels every 6 hours.Review of R1's blood sugar levels revealed: Review of blood sugars revealed 10/07/2025 11:58a.m. 126mg/dl (milligrams/deciliter), 10/07/2025 5:26 p.m. 150mg/dl, 10/08/2025 at 00:57 a.m. 218mg/dl, and 10/08/2025 123mg/dl.Review of R1's MAR for October revealed all 0800 medication was held to include Alendronate sodium oral tablet 10mg (milligrams), cholecalciferol tablet 1000 unit give 2 tablet by mouth, Duloxetine HLC oral capsule 60mg, fenofibrate oral tablet 48mg, hydrochlorothiazide 25mg, Losartan potassium oral tablet 50mg. and clonidine HCL 0.2mg, famotidine 20mg. In an interview on 01/06/2026 at 09:04 a.m. Nursing Home Administrator (NHA) A explained that Registered Nurse (RN) H had pulled the medication for R7. NHA A explained that once the medication was pulled from the medication cart RN H gave the medication to Licensed Practical Nurse (LPN) I, who was on orientation, and instructed LPN I to go give the medication to R7. NHA A explained that LPN I went and provided the medication to R1 instead of R7.In an interview on 01/06/2025 at 09:21 a.m. Regional Clinical Consultant F explained that the route cause of the incident was that Licensed Practical Nurse LPN I did not pull the medication herself. Regional Clinical Consultant F explained that Registered Nurse (RN) H pulled the medication from the medication cart. Regional Clinical Consultant F explained that professional practice dictates that the person pulling the medication should be the one providing the medication to the resident. Regional Clinical Consultant F explained that those professional standards were not followed in this incident. Regional Clinical Consultant F also explained that LPN I did not follow the 5 rights while administering R1's medication. Regional Clinical Consultant F explained 5 rights for safe medication administration is widely recognized in healthcare as a standard checklist to reduce medication errors. 5 rights include: right patient/resident, right medication, right dose, right time, and right route. On 01/06/2026 at 09:41 a.m. Registered Nurse (RN) H explained that on 10/07/2025 he was the nurse preceptor (nurse providing orientation a new nurse) for Licensed Practical Nurse (LPN) I. RN H explained that LPN I did not have access to the facility computerized medical record system called PointClickCare(PCC), which would have allowed LPN I to have access to a resident's Medication Administration Record (MAR). RN H explained that because LPN I did not have access to a resident MAR to verify and obtain medication for residents that he removed and documented the administration of the medication for R7. RN H explained that he then provided R7's medication to LPN I to administer to R7. RN H explained that he did not observed LPN I give R7's medication to R1 but was notified after the fact. On 01/06/2025 at 10:45 a.m. in a telephone interview Licensed Practical Nurse (LPN) I explained that she was working on 10/07/2025. LPN I explained that she was being trained by Registered Nurse H on 10/07/2025. LPN I explained that she did not have access to PointClickCare (PCC) and residents Medication Administration Record (MAR). LPN I explained that RN H pulled the medication and documented it as give for R7. LPN I explained that RN H then provided her with R7's medication for administration but that she gave the medication to R1. LPN I explained that she did not follow the 5 rights of medication administration and therefore administered R7's medication to R1 by accident. LPN I explained that she immediately identified the error and took action as explained on R1's incident report.

This citation pertains to intake MI00147874 Based on interview and record review the facility failed to provide Cardiopulmonary Resuscitation (CPR) for 1 resident (R200) of 4 residents reviewed who was a full code resulting in Immediate Jeopardy when CPR efforts were not performed at the time resident R200 was found to have no pulse or respirations and this deficient practice has the potential for 44 facility residents not having there full code status wishes honored. Findings include: Review of the electronic medical record (EMR) revealed that on [DATE] R200 was found unresponsive and with no pulse. According to a nurse progress note created [DATE] at 7:32:02 AM with an effective time of 4:50 AM by Licensed Practical Nurse (LPN) M, the nurse, LPN M, had been notified by Certified Nurse Assistant G that R200 wasn't breathing. LPN M documented that she went to R200's room and found that he was . pale and yellow and lips were blue, skin was cold, no response from resident. LPN M further documented that she checked the code status while the other nurse (LPN D) got the crash cart (a cart with emergency medical equipment) and LPN M called 911. According to LPN M's note the staff placed a backboard underneath the resident and when Emergency Medical Services (EMS) arrived chest compressions (CPR) began and rescue breathing through an ambu bag. (An ambu bag is a hand-held device used to provide positive pressure ventilation to patients who are not breathing). According to EMR review, R200 had an admitted [DATE] and pertinent diagnoses of Obstructive Sleep Apnea (a sleep related breathing disorder) and Morbid Obesity. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R200 scored 15 out of 15 indicating intact cognition on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). EMR review also revealed that Nurse Practitioner (NP) E had written an order stating Full Resuscitate dated [DATE]. On [DATE] at 3:19 PM LPN M was interviewed and explained the exact time R200 was found with no pulse or respirations was not clear in her memory. Go by my notes LPN M said. When asked what the documented time of 4:50 AM reflected said, That must have been when it happened. LPN M said that when R200 was found to be deceased I had the laptop and checked his code status on my laptop; I grabbed it. I had to call 911. No, we hadn't started CPR; we had gotten the backboard under him but hadn't started CPR. LPN M said that compressions and rescue breathing did not begin until Emergency Medical Services (EMS) arrived. When asked how long that period was from the time R200 was found and to the point EMS arrived LPN M estimated it to be about 5 minutes. When queried as to why CPR did not begin before EMS arrived LPN M responded, I can't say. When queried about CPR training LPN M responded, I was trained in CPR and have done it many times. It was difficult getting the backboard under him because of his size. On [DATE] at 3:50 PM LPN D was interviewed about the occurrence on [DATE] when LPN D was called to the room shortly after R200 was found with no pulse or respirations. LPN D said, I think she (LPN M) was on the phone with 911 before I came down with the crash cart. She was in the hall. When asked about the amount of time before EMS arrived LPN D stated, I think it was within 10 minutes of when it all started; the whole process from when I walked out and she said he coded and when EMS arrived was about a 10 minute period. LPN D said that CPR was not in progress prior to the arrival of EMS. When questioned as to why CPR had not been started, LPN D stated, I did everything I could to get it started and explained that LPN M had been standing back rather than . participating. LPN D said the Certified Nurse Assistant (CNA) G had helped LPN D get the backboard underneath R200. LPN D also said the usual process is that a CNA would be the one to call 911. When queried about CPR training LPN D said she had been trained in CPR. When asked if the certification was current LPN D answered that it had not been up to date. I took the class yesterday; ([DATE]) it's probably been a few months overdue. On [DATE] at 10:46 AM after review of the EMS Run Sheet (a medical record for ambulance services) the Director of EMS H was interviewed and verified the timeline of events: EMS received the emergency call on [DATE] at 4:49:29 AM and arrived on scene at 04:52:48. He said someone from the Fire Department was on scene and had started CPR. According to the documentation on the Run Sheet CPR was discontinued at 5:24 AM and R200 was pronounced deceased by Physician C. On [DATE] at 11:18 AM the township Fire Department Chief I was interviewed and said that a fire department member had arrived at 4:51 AM and had initiated CPR which had not been in progress by facility staff. At the time of survey 44 residents were identified as having a full code status and being at risk of an adverse outcome with code status not being honored in the event of cardiac or respiratory arrest. On [DATE] at 11:45 AM CNA G was interviewed about the occurrence of R200's death on [DATE]. Pretty much when I did my last round I walked in and it was around 4:25 or 4:30 AM and I saw he was not breathing CNA G stated. CNA G said at that point I ran out of the room to find the nurse, and grabbed the walkie talkie to establish contact with nurses and that no one responded to the call for a nurse. I ran down A hall CNA G said, explaining that LPN M had been working both A hall and D hall. CNA G said as she ran back to the front desk LPN M was seen coming in the front door. CNA G said, altogether, it had taken a few minutes - probably about 2 to 3 minutes to find the nurse (LPN M) who had been outside on break. CNA G said LPN M then came immediately to the room and upon seeing R200 made the statement that R200 was gone. CNA G said at this point LPN D was in the room and said to LPN M that CPR needed to be done. CNA G said, We rolled him over to get the board under him as LPN C called 911. On [DATE] at 12:55 PM during interview with LPN J the process of Code Blue was asked about: LPN J stated, We call code blue; someone gets the crash cart; someone gets the chart to see if they are CPR; we start CPR right away once we get the backboard or put them on the floor and we have someone at desk calling 911. And added, We do CPR until EMS arrives or we will continue to assist, and we document. We keep track of each thing happening during the code. On [DATE] at 2:00 PM during subsequent interview with the NHA and DON the process of Code Blue was discussed: The DON stated, If I find a resident unresponsive, check airway breathing, circulation, check code status; start CPR immediately and have a timeline being documented and someone delegated to call 911. Review of documents submitted by the facility: LPN D's CPR certification expired [DATE] and was renewed [DATE]. Review of the facility policy with a revision date of [DATE] and titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) with a revision date of [DATE] states in part, If a resident experiences cardiac arrest or respiratory arrest and the resident does not show obvious clinical signs of irreversible death (rigor mortis, dependent lividity, decapitation, transection, or decompositon) facility staff must provide basic life support, including CPR prior to the arrival of emergency medical services. On [DATE] at 2:34 PM a meeting was held with Nursing Home Administrator A, Director of Nursing B and Regional Nurse Consultant F and were notified of Immediate Jeopardy IJ that was identified as beginning [DATE] and caused a serious adverse outcome of R200 due to failure of staff to provide CPR on a full code resident. R200 had been prounced dead by Physician C on [DATE] at 5:24 AM. The facility submitted a removal plan to remove the Immediate Jeopardy: Documentation of the amount of residents at risk. -On [DATE], the facility identified CPR was not initiated immediately. -On [DATE], the Director of Nursing and/or designee began education of facility staff on initiating CPR immediately to include: checking of code status utilizing the electronic medical record on the laptop or kiosk or utilizing the paper chart; the timeline and steps for assessing pulse and respirations when a resident is found unresponsive and initiating CPR immediately to include placing on floor if needed. Initiating CPR includes checking airway, breathing, circulation and beginning compressions while someone verifies the code status and 911 is called. Identify a team leader to assign duties and scribe. Ensure crash cart is with patient and AED is applied. Compressions will continue until EMS arrives and verbalizes they will take over. -The facility has 26 Licensed Nurses. As of [DATE] at 9:00am, the facility has educated 25 of the 26 Licensed Nurses. -Any staff not educated will not be permitted to work a shift until education has been completed. -The facility Medical Director was notified on [DATE]. -The Director of Nursing and/or designee completed a chart audit on 85 charts and verified the advanced directives to the physician order for accuracy on [DATE]. -On [DATE] an audit was completed of Licensed Nurses to ensure CPR certifications were up to date. The identified nurse was recertified [DATE]. -The QAPI committee has reviewed the Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) policy and has deemed them appropriate on [DATE]. -The facility had an Adhoc QAPI meeting including the Medical Director on [DATE] and deemed this removal plan appropriate. -The Director of Nursing is responsible for continued compliance. The Immediate Jeopardy removal plan was verified and IJ was removed on [DATE] when the facility implemented the approved plan. However, the deficient practice continued at scope and severity of isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that could not be verified by the state agency.

This citation pertains to intake number MI 154. Based on observation, interview, and record review, the facility failed to ensure one out of three residents (Resident #1) had adequate supervision, and appropriate interventions put into place and implemented for fall prevention, resulting in a [CONDITION(S)], and a [CONDITION(S)] that resulted in a decline of activities of daily living (ADLs). Findings Included: Per the facility face sheet Resident #1 (R1) was admitted to the facility on [DATE]. Diagnoses included abnormalities of gait and mobility, dementia, muscle weakness, and anxiety at the time of R1's admission to the facility. In an observation on 6/24/2022, at 8:10 AM, R1 was observed in her bed eating breakfast, alert but confused when spoken too. A Broda chair was observed in her room, along with a sling used on a full mechanical lift (machine used to transfer resident who were totally dependent on staff for transferring). Record review of a *Nursing Admission Evaluation, dated 3/3/2022 revealed R1 had three or more falls within the previous 90 days, had a change in cognitive status in the previous 90 days, had behaviors that included, easily distracted; periods of altered perception or awareness of surroundings; episodes of disorganized speech; periods of restlessness; periods of lethargy; mental function varies over the course of the day; wanders; abusive and resists care, was incontinent of urine, ambulated with problems and with devices (gait is unsteady, slow, lurching), was not steady with balance, but was able to stabilize without physical assistance, and received three or more medications within the previous seven days that had potential adverse drug reactions that included, sedation/fatigue/lethargy, decreased alertness, postural/[CONDITION(S)] (drop in blood pressure with position change as in going from a lying position to a sitting or standing position) dizziness, decreased neuromuscular function/ataxia (an affect the nerves that control voluntary muscles causing muscle spasms and weakness), decreased memory/cognitive impairment, blurred vision, confusion, arrhythmia's (irregular heart beat), [CONDITION(S)] ([CONDITION(S)]) and urinary urgency. The assessment revealed R1 had a fall risk score of 27, which the assessment documentation identified R1 to be at a high risk for falls. The assessment revealed a Fall Risk Care Plan was triggered with the focus of , The resident is at risk for falls related to ., and identified interventions put into place of, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, Bed in low position when not providing care, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Encourage rest periods as needed to avoid overtiring, and use a gait belt for transfers and walking. Record review of a care plan put into place on 3/3/2022 revealed, R1 had a Focus of The resident (R1) is at risk for falls related to: dementia, psyche medications, failure to thrive, poor safety awareness. Resident (R1) attempts to get up from wheelchair without asking for assistance. The interventions put into place on 3/3/2022 were, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, Bed in low position when not providing care, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Encourage rest periods as needed to avoid overtiring, and use a gait belt for transfers and walking. Review of an admission Minimum Data Set (MDS), dated [DATE] revealed R1 was assessed to have a Brief Interview for Mental Status (BIMS) score of five out of 15 which indicated R1 had a severe impairment in cognition. The MDS assessment revealed R1 required extensive assistance with self ability for bed mobility, transferring, walking in room, locomotion on and off the unit, toilet use, however only required limited assistance support from staff. Record review of an incident report, dated 3/11/2022, revealed R1 had an unwitnessed fall. The report revealed R1's roommate was heard hollering for help and upon entering R1's room, R1 was found sitting on the floor soaked in urine. The report also revealed R1 was confused, and had received [MEDICATION(S)] (a sedative/anti-anxiety medication) within 12 hours prior to R1's fall. No investigation report was received at or before time of exit on 6/27/2022. Review of R1's care plan, dated 3/3/2022, that was in place for falls revealed that on 3/11/2022 an intervention of will toilet resident more frequently throughout the night was put into place. Record review of a Pertinent Charting Follow-up, dated 3/11/2022, revealed a notation of resident had mild bruising on forehead from fall, resident has small laceration on top of head from fall. resident was bleeding some from laceration due to her keep touching it, cleaned up with soap and water, and applied [MEDICATION(S)] with 4x4 . laceration not bleeding at this time . no s/s (signs and symptoms) of pain or distress will continue to monitor. Record review of an incident report, dated 4/11/2022, revealed R1 was found, by a Dietary Aid (DA) C on the foot pedals of her Broda chair (chair that offers tilt-in-space postponing) in the dining room. The incident report also revealed R1's fall was unwitnessed. The incident investigation report revealed R1 was in the dining room alone and unattended, and had received an anti-anxiety medication within the previous eight hours of the fall. The report under ROOT CAUSE OF THIS FALL was blank and not filled out. In an interview on 6/24/2022, at 12:53 PM, DA C stated that she heard R1 fall, because she had hear a noise, and upon going out of the kitchen and into the dining room, she observed R1's Broda chair titled forward, and R1 out of the seat and sitting on the foot rest of the Broda chair. her chair was tilted and she was on the foot pedals, DA C said she had to leave the dining room to go get a Certified Nurse Aid (CNA), Review of R1's progress notes revealed that documentation pertaining to R1's fall on 4/11/2022 was not documented until 4/20/2022, which revealed, .New Fall/Follow-Up: on 4/11/2022 @ 1254 resident was observed sitting on the foot pedals of her wheelchair in the dining room Situation (where/when/what/who): She was trying to get out of her chair Injury/No injury: none Factors involved (acute condition/environment, etc.):Resident was in the dining room after lunch and was trying to get out of chair. She has alzheimers and weakness .Analysis of interventions to implement: resident to be removed from dining room after meals. Review of R1's care plan, dated 3/3/2022, that was in place for falls revealed that on 4/11/2022 an intervention was added to R1's care plan, Observe resident on rounds and increase rounds as necessary. Attempt to have resident within close proximity of staff supervision as needed. The care plan revealed that the intervention of R1 to be removed from the dining room after meals was added not to her care plan until 4/20/2022. Review of R1's Electronic Medical Record (EMR) revealed no Pertinent Charting Follow-up' related to R1's fall on 4/11/2022. Review of an incident report, dated 4/25/2022 and timed at 6:30 PM, revealed R1 was in the dining room at 5:00 PM eating dinner, when she was observed by dietary staff sliding out of her Broda chair onto the foot rest of the chair. The incident report revealed R1 had a hematoma/bruise as a result of her fall, however the incident report did not indicate where R1 had the hematoma/bruise on her body. Review of the investigation report revealed R1 was observed by dietary staff climbing out of her Broda chair, and observed R1's Broda chair to fall forward. The investigation report revealed R1 had received ant-anxiety medication with in the previous eight hours of the fall. The ROOT CAUSE OF THIS FALL section was not completed and was blank. Review of a Pertinent Charting Initial - Falls, dated 4/25/2022, revealed R1 was observed by dietary staff sliding out of the Broda chair and onto the foot rest of the chair. The charting revealed R1 sustained a bruise to the left side of her left knee. The charting R1 was wanting to get out of chair. The charting also indicated that the intervention added to R1's care plan was, Increased rounding, however resident was in dining room. Perhaps keep her close to staff when available. Review of R1's care plan, dated 3/3/2022, that was in place for falls revealed that the intervention to Increased rounding, however resident was in dining room. Perhaps keep her close to staff when available. was not added to R1's care plan, and no other new intervention added to R1's care plan related to her fall on 4/25/2022. Review of R1's progress notes, dated 4/25/2022, revealed, Pertinent Charting-Falls Note Text: Date of Fall: 04/25/2022 Situation Details: Observed by dietary staff Assessment: resident is on neuron checks. resident vitals all with in normal limits resident has small bruising on leg side of left knee. Mitigating Factors: wanting to get out of chair. Environmental Factors: NA Interventions: Increased rounding, however resident was in dining room. Perhaps keep her close to staff when available . Record review of an incident report, dated 4/26/2022, revealed R1 had an unwitnessed fall while at the nurses' station. The incident report revealed, Resident was trying to get up and walk., and under Action taken the box checked was Resident Education. The investigation report revealed R1 was attempting to get up, and lost her balance which resulted in her falling. The investigation report revealed R1 had received an anti-anxiety and an anti-psychotic medications with in the previous eight hours prior to her fall. Review of R1's progress notes, dated 4/26/2022, revealed, Pertinent Charting-Falls Note Text: Date of Fall: 04/26/2022 Resident was observed on floor in front of nurses station. No injury noted. No pain or discomfort at this time. Hospice was notified of situation. On call doctor, guardian and DON (Director of Nursing) were notified of situation. Resident has been very agitated all day. PRN (as needed) medication is ineffective. Doctor suggested discontinuing [MEDICATION(S)] order due to adverse reaction to medication. Hospice nurse will be out soon to assess resident and start a pain medication for resident. Review of R1's fall care plan, dated 3/3/2022, that was in place revealed no new interventions were put into place after R1's fall on 4/26/2022. Review of an incident report, dated 5/6/2022, revealed R1 had an unwitnessed fall from her wheelchair while in the dining room. The report revealed R1 was confused, and Action Taken was Care Plan Update. No investigation report was received prior to or at the time of exit on 6/27/2022. Review of R1's progress notes, dated 5/1/2022, revealed, .Resident given a regular wheelchair to help with independence in mobility through the facility . Review of R1's progress notes, dated 5/6/2022, revealed, Pertinent Charting-Falls Note Text: Date of Fall: 05/06/2022 Situation Details: resident was found on flood in dinning room Assessment: resident stated she did not hurt her head. no injury's noted Mitigating Factors: resident had locked [NAME] chair .Comments: care planed resident to not have locked wheelchair except with transfers. Review of R1's care plan for falls, dated 3/3/2022, revealed that on 5/6/2022, an intervention of, do not lock wheel chair except when transferring resident. was added to R1's care plan. The intervention initiated on 4/20/2022 of resident to be removed from dining room after meals. was revised again on 5/6/2022. Review of Physician's progress notes, dated 5/6/2022, revealed, Resident is [AGE] year-old female seen this evening status post fall. Resident fell out of her wheelchair earlier in the evening. There is initially had no complaints at that time and was stable. However when staff went to transfer her from the wheelchair to her bed she started complaining of severe pain in the hip. She was given [MEDICATION(S)] (pain medication) with minimal effectiveness. Nursing reports external rotation of the foot. Resident is crying in pain., and Pain in left hip: 101 yr of old female s/p (slip and fall) fall from wheelchair earlier in the evening now with acute, severe left hip pain. Rotation and shortening (of hip and leg) noted. Will send to hospital for X-rays as concern for hip fracture. Review of the hospital Physician consultation note, dated 5/7/2022, revealed R1 had a fracture of her left hip. The notes also revealed that the Physician informed R1's family that performing a major hip joint surgery for R1 was risky due to her age, and that surgery would not improve R1's ambulatory status. Review of a progress note, dated 5/9/2022, revealed, Writer spoke with resident today about her pain and she states that she seems to be doing ok. After speaking with the CNA and nurse, when care was provided and she was being moved in bed, she was grimacing a bit. The pain seems to intensify in the evening time. Received an order to schedule [MEDICATION(S)] 5/325 Q 6 (every 6) hours for 14 days to keep the residents pain under control. At times she does not know how to express she is in pain. WRiter spoke with the family and they were with her at the ER. They are aware that her left him (hip) is fractured and they state the ER (emergency room ) told them she would probably never walk again. Writer let family know that currently she is a hoyer transfer and she is in her geri chair for comfort . Record review of a significant change MDS assessment, dated 5/20/2022, revealed R1 was now totally dependent for transferring, and locomotion on and off the unit, and for walking R1 did not perform the activity. In an interview on 6/28/2022, at 2:59 PM, DON B stated that R1 was initially using a Broda chair, but stated R1 would pull on the wall to move the chair, so she was given a wheelchair so she could move herself around the facility with her arms and feet, which DON B stated R1 did maneuver herself all over the facility in her wheelchair. Record review of R1's Physician orders from 3/3/2022 through 6/28/2022 revealed R1 had received the following medications that mat cause sedation, drowsiness, and an increased risk for fall: [MEDICATION(S)] 3/24/2022 through 5/20/2022, [MEDICATION(S)] 4/6/2022 through 5/20/2022, [MEDICATION(S)] 3/3/2022 through 5/20/2022, [MEDICATION(S)] 3/4/2022 through 4/26/2022, [MEDICATION(S)] 4/26/2022 which remained an active order, and [MEDICATION(S)] 4/11/2022 through 6/3/2022. Review of a pharmacy recommendation, dated 3/11/2022, revealed the Pharmacist recommenced to R1's Physician that her [MEDICATION(S)] was being administered to her in the morning time, and to consider moving it to bedtime due to [MEDICATION(S)] causing somnolence (drowsiness, sleepiness). R1's Physician agreed with the Pharmacist recommendation, however did not sign it until 6/16/2022. Review of R1's Physician's orders for the month of March 2022 revealed, R1's [MEDICATION(S)] order to change the medication from giving in the morning to giving it at bedtime was not written until 3/22/2022, which was when R1 began to receive her [MEDICATION(S)] at bedtime, which was 11 days after the pharmacy recommendation, and six days after R1's Physician signed the recommendation. Review of R1's EMR revealed no pharmacy medication regimen reviews after R1's falls on 4/25. 4/26 and 5/6/2022. Further interview with DON B on 6/28/2022, at 2:59 PM, DON B stated that fall incident report was filled out after each fall, then an intervention was to be put into place immediately by the resident's nurse. DON B however stated that the interventions put into place for residents regarding fall was not always an appropriate intervention. DON B stated that the next day the Interdisciplinary Team (IDT) would go over the new interventions, and add those to the resident's care plan. Review of a care plan titled, The resident (R1) needs activities of daily living assistance related poor adl (activities of daily living) performance, weakness, deconditioning, recent hospitalization . dated 3/3/2022 for the date the care plan was initiated. Review of the interventions revealed an intervention, that was put into place on 3/16/2022., AMBULATION: Resident is able to ambulate on unit with limited assist x 1 staff., however on 5/9/2022 the intervention was discontinued and changed to, Resident does not ambulate in hallways/corridors, and Resident using a geri chair. Another intervention, dated 3/3/2022, revealed, TRANSFER: The resident (R1) uses 4 wheeled walker with 1 staff assist to maximize independence with transferring., however the intervention was discontinued on 5/9/2022, and changed to TRANSFER: The resident (R1) requires Mechanical Lift Hoyer with 2 or more staff assist for transfers.

This citation pertains to intake MI 319. Based on observation, interview, and record review, the facility failed to provide care to prevent a resident fall, in one of three residents reviewed for falls (Resident #[AGE]), resulting in pain, [MEDICAL CONDITION], hospitalization , and surgery. Findings include: Resident #[AGE] (R[AGE]) On 02/26/2020 at 12:45 PM R[AGE] was observed from the hallway, sitting on the side of his bed in his room, calling out for help. A nursing assistant was observed in another resident's room further down the hall, feeding a resident and did not hear R[AGE] yelling for help. R[AGE]'s quarterly Minimum Data Set (MDS) assessment dated [DATE], introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score of 05 (Scale: 00-07 Severe Impairment), and was admitted to the facility on [DATE]. R[AGE] required limited assistance (staff provide guided maneuvering of limbs or other non-weight bearing support) in transfers (how resident moves between surfaces including to and from bed, chair, wheelchair, stating position) and bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed). R[AGE] required extensive assistance (staff provide weight-bearing support) of one-person physical assist for toilet use (how resident uses the toilet room, commode or urinal; transfers on/off toilet; cleanses self after elimination; adjusts clothes). R[AGE] walked in his room with supervision (oversight, encouragement or cueing) during the 7-day look-back period. The same MDS indicated R[AGE] was occasionally incontinent of urine (less than 7 episodes of incontinence during a 7-day look-back period) and a trial of a toileting program (scheduled toileting, prompted voiding, or bladder training) had not been attempted on admission/entry or reentry or since urinary incontinence was noted in the facility. The same MDS indicated R[AGE] had the [DIAGNOSES REDACTED]. R[AGE]'s urinary tract infection care plan dated 12/14/18 revealed he had a history of [REDACTED]. R[AGE]'s Fall Risk care plan dated 07/13/2018, indicated he was at risk for falls related to poor safety awareness, dementia, and history of falls with a pelvic fracture; his goal was to reduce the risk of serious injury in the event of a fall. The same care plan instructed to anticipate and meet R[AGE]'s needs based on nursing assessments. R[AGE]'s activities of daily living (ADL) care plan dated 07/13/2018, goal was he would maintain current level of function in ADL's related to transfers and toileting. The same care plan with intervention dated 10/12/2018, revealed R[AGE] preferred to lay down between meals. R[AGE]'s bowel incontinence care plan dated 07/13/2018 indicated to offer R[AGE] toileting every two hours and as needed. Fall Risk Evaluation dated 12/02/2019 indicated R[AGE] was at risk for falls and required assistance with toileting. In review of the Fall Protocol dated 06/27/2018, interventions should be developed and implemented based on assessed needs. R[AGE]'s Progress Notes dated 01/04/2020 at 8:30 AM indicated he ate in the dining room for meals and was able to feed himself. R[AGE] was occasionally incontinent of bladder and self-propelled in his wheelchair around the facility. The same note indicated R[AGE] wandered occasionally looking for his wife and he preferred to lay in bed between meals. According to Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.17, October 2019; urinary incontinence increased the risk of falls and injuries resulting from attempts to reach a toilet unassisted. The same reference revealed incontinence could be resolved or minimized by bladder retraining, prompted voiding, or scheduled toileting. The same source revealed a previous fall, especially a recent fall, recurrent falls, and falls with significant injury were the most import predictors of risk for future falls and injurious falls. R[AGE]'s Communication Form and progress note dated 01/13/2020 at 2:28 PM, revealed R[AGE] was observed lying on his right side, with torso under the sink; R[AGE] complained of pain to head and right hip; a large hematoma (collection of blood outside of blood vessels) behind right ear was noted. The same form indicated orders were received to transfer R[AGE] to the hospital for evaluation and treatment. The incident and accident report dated 01/13/2020, indicated R[AGE] fell at 12:30 PM in his bathroom and the fall was not witnessed. The attached investigation indicated that he had just finished eating lunch in the dining room and was self propelling his wheelchair. The attached investigation revealed R[AGE] had stated he was going to the bathroom when he fell . The attached fill-in-the-blank type witness statement, not signed by the witness, verbally with name of nursing assistant was written above the nurse assistant signature line, indicated R[AGE] had last received care was at 11:00 AM, when he was changed prior to lunch. The same report indicated the root cause of R[AGE]'s fall was due to the amount of assistance that was in effect and resident self-toileting. The attached follow-up notes, effective date 01/24/2020, indicated upon return from hospital toileting schedule put into place and is effective at this time. During an interview on 02/27/2020 at 2:12 PM Certified Nursing Assistant (CENA) E stated she had been employed at the facility for [AGE] years and cared for R[AGE] on a regular basis. CENA E stated on the day of R[AGE]'s fall on 01/13/2020, she had come in to work on her day off because of staffing needs, at 10:30 AM. CENA E stated in the same interview that she did not know what time R[AGE] was last toileted prior to his fall, because she did not toilet him or clean him up that day prior to lunch. CENA E stated she remembered that day clearly because she strived to prevent her residents from falling. CENA E stated at the time of R[AGE]'s fall, she was in another residents room; and after she assisted that resident, she walked down the hall and noticed R[AGE]'s door was closed, as she approached the door, she could hear him calling for help. CENA E stated in the same interview, the housekeeper was in the bathroom and had responded just before she did. CENA E stated in the same interview, that she observed R[AGE] lying on the floor in the bathroom, his brief was pulled up and his pant were at his ankles. CENA E stated she observed R[AGE]'s wheelchair brakes were locked. CENA E stated when she normally cared for R[AGE], his routine was to use the toilet before and after lunch; and he lays down between meals. CENA E added, during the same interview, she did not know what his routine was when another CENA cared for him. During an interview on 02/28/2020 at 8:35 AM CENA H stated herself and another CENA had worked as a team on R[AGE]'s hall the morning of his fall 01/13/2020. CENA H stated she did not usually work on R[AGE]'s hall and when CENA E came in at 10:30 AM, she was assigned to work on another hall. CENA H stated in the same interview, she and her hall partner got R[AGE] out of bed and toileted him before breakfast. CENA H stated she didn't think R[AGE] lay down after breakfast that day. CENA H stated in the same interview that maintenance took his chair to be fixed that morning and provided him with a different chair while it was being fixed. CENA H stated R[AGE] had a history of [REDACTED]. R[AGE]'s Bladder Report dated 01/13/2020 revealed he was continent of bladder at 7:46 AM, there was no documentation he was toileted, continent or incontinent at 11:00 AM. On 2/28/2020 at 11:47 AM Director of Nursing (DON) B was interviewed and stated she interviewed CENA E on 01/13/2020 and she had reported R[AGE] was toileted at 11:00 AM before lunch, prior to his fall. DON B did not have an explanation of why she did not have CENA E sign the witness statement nor an explanation as to why R[AGE]'s toileting care was not documented in his medical record at 11:00 AM on 01/13/2020. Progress Note dated 01/13/2020 at 3:56 PM revealed the facility had called the hospital to check on R[AGE] and the emergency room registered nurse reported he had fractured his right hip. Progress Note dated 1/13/2020 4:17 PM R[AGE] indicated hip surgery was scheduled for 01/14/2020. Nursing Quarterly/Significant Change Nursing assessment dated [DATE] revealed R[AGE] used incontinence briefs and preferred to lay down between meals. The same assessment indicated R[AGE] complained of a sore throat and his surgery repair on his right hip; and had experienced frequent moderate pain over the last five days in the right hip, that limited his day to day activities and impacted his mood. The same assessment indicated R[AGE]'s most recent level of pain was an eight, on a scale of zero to ten, with zero being no pain and ten being the worst pain imaginable. R[AGE] was managing his pain with [MEDICATION NAME] (opioid) medication as needed. The same assessment revealed the staples to R[AGE]'s right hip wound were intact, that he complained of pain when he transferred from bed or when toileting and he had a poor appetite. R[AGE]'s significant change of condition MDS dated [DATE], revealed a BIMS score of 03 (Scale: 00-07 Severe Impairment), was re-admitted to the facility on [DATE]. R[AGE]'s same MDS revealed he required extensive assistance of two plus persons physical assist for bed mobility, transfers, and toilet use. The same MDS indicated R[AGE] did not walk in his room over the entire 7-day look-back period and had a fall with a major injury (bone fractures, joint dislocations, closed head injuries with altered consciousness, bleeding under the membrane covering the brain). The same MDS revealed R[AGE] was frequently incontinent of urine (7 or more episodes of urinary incontinence, but at least one episode of continent voiding during a 7-day look-back period) and a trial of a toileting program (scheduled toileting, prompted voiding, or bladder training) had not been attempted on admission/entry or reentry or since urinary incontinence was noted in the facility). The same MDS revealed R[AGE] was frequently incontinent of bowel (2 or more episodes of bowel incontinence, but at least one continent bowel movement during a 7-day look-back period) and no toileting program was being used to manage the R[AGE]'s bowel incontinence. R[AGE]'s ADL care plan dated 07/13/2018, revised 01/21/2020, revealed R[AGE] required assistance due to a history of pelvic and right [MEDICAL CONDITION], unsteady balance and cognitive deficits. Director of Nursing (DON) B was interviewed on 02/28/2020 at 10:40 AM and stated a bowel and bladder patterning assessments were initiated on admission; R[AGE] didn't have a recent bowel and bladder patterning initiated because he was not a new admit. CMS's RAI 3.0, Version 1.17, October 2019, indicated each incontinent or resident found at risk for incontinence should be identified, assessed, and provided with individualized treatment and services to achieve or maintain as normal elimination as possible. The same source advised a toileting trial should include observations of at least 3 days of toileting patterns with prompting to toilet and of recording results in a bladder record or voiding diary. The same source indicated residents should be reevaluated whenever there was a change in cognition, physical ability, or urinary tract function.

This citation is related to intakes MI 997 and MI 008 Based on observation, interview and record review the facility failed to provide care in a timely manner related to pneumonia, bathing/hygiene, bleeding, and pain for 2 of 10 sampled residents (Resident #1 and Resident #4), resulting in pneumonia, sespis, malodorous body odor, vaginal bleeding with clots and severe pain and the potential for worsening of pressure ulcers. Findings Include: Resident #1 (R1) On 11/26/19 at 11:14 AM the Electronic Medical Record (EMR) reflected R1 was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE] to a local hospital related to emergency health concerns. [DIAGNOSES REDACTED]. R1 admission Minimum Data Set (MDS: resident assessment tool) with an Assessment Reference Date (ARD) of 5/21/19 reflected the following for R1: Severely cognitively impaired, required total assistance of 2 persons for bed mobility, transfers, hygiene, toilet use and that she had bilateral upper/lower impaired range of motion. R1's most recent quarterly MDS with an ARD of 8/19/19 reflected the following for R1: Severely cognitively impaired, required total assistance of 2 person for transfers, total assistance of 1 person for eating and bathing, and extensive assistance of 1 person for dressing, toilet use, and hygiene. R1 was unable to be observed during the survey because she had been discharged to a local hospital on [DATE]. On 10/28/19 R1 had an X-ray Chest 2 View performed. The conclusion reflected: Left lower lobe airspace disease can be related to pneumonia or atelectasis. On 11/11/19 R1 had an X-ray Chest 2 View performed. The conclusion reflected: [MEDICAL CONDITION] with [MEDICATION NAME]. The medical visit provided by Nurse Practitioner (NP N) dated 10/31/19 was negative for any documentation referring to R1's Chest X-Ray (CXR) dated 10/28/19. NP N documented R1's lung sounds as coarse. The medical visit provided by Doctor P dated 11/6/19 was negative for any documentation referring to R1's CXR dated 10/28/19. Doctor P documented R1's lung sounds as coarse. The facility's most recent wound consult visit for R1 prior to discharge on 11/15/19, took place on 11/11/19 by Doctor O. The note reflected R1 had a left gluteal, ischial ulceration that probed all the way to the bone. R1 was undergoing negative pressure wound VAC system, the wound was very clean, very moist and hyper-granulated with active bleeding appreciated which indicated angiogensesis formation. The wound measured 6.5 x 4.5 x 2.8 centimeters (cm). R1's right gluetal ischial area was documented as having some black slough material present, which was not undergoing a negative pressure wound VAC system, and Doctor O planned to change R1's treatment to Santyl to clear up the necrotic, black eschar. The wound measured at 3.0 x 3.0 x 0.3 cm. There was no documentation of any other wounds, or odors to the exiting wounds. R1's Activity's of Daily Living (ADL)-shower/bathing Tuesday and Friday days and prn (as needed) record, reflected the most recent shower/tub bath/bed bath provided to R1 before her discharge on 11/15/19, was on 11/12/19 at 1:41 PM. Also, R1's last Bowel Movement (BM) was documented as being on 11/14/19 at 2:35 PM. The EMR reflected only one temperature was taken for R1 on 11/15/19, which was an axillary temperature at 8:48 PM with a reading of 102.8 F (Fahrenheit). The most recent temperature documented prior to 11/15/19 was dated 11/7/19, with a reading of 96.4 F. The SBAR (Situation, Background, Assessment, Recommendation) form for R1 dated 11/15/19 at 1:00 AM reflected R1's vital signs were taken at 12:00 AM and reflected: Temperature 102.8 F (higher than normal), Blood Pressure 140/95 (higher than normal), Pulse 88 and Respiratory Rate 48 (higher than normal). Also, while on 6 liters of oxygen, R1's Sa02 (Oxygen saturation) was at 84% (lower than normal). No other SaO2 readings were noted done in the EMR for 11/14/19 or 11/15/19. Consequently, on the SBAR form the nursing staff failed to check that R1's temperature was >100.4 and that her SaO2 was less than 90%, which (according to the form) were indicators [MEDICAL CONDITION]. The nurse comments reflected: Had lab work with elevated WBC (white blood cells) of 20.1, also C (chest) X-ray indicating pneumonia, which coincide with her symptoms of dyspnea with a drop in sats, and fever. She also exhibited pallor (sic) and sunken eyes. The physician was contacted and ordered R1 to be sent the to ER. R1's guardian was made aware and the also DON (Director Of Nursing: DON B). According to a local hospital's Emergency Documentation, R1 was seen in the Emergency Department (ED) department at 2:12 AM on 11/15/19 by Doctor F, with an 103.9 temperature, pressure ulcers/wounds at her hip and buttock areas. Of note, patient has very poor dental hygiene, oral hygiene, and body hygiene. She arrived quite disheveled, ill kept in appearance, and was generally foul in odor and I suspect in need of a bath or to be cleaned in general. Genital and axillary areas were chronically darkened in appearance and dirty, and dirt wiped off with buttock wipes and cleaning cloths. She has chronic significant buttock/sacral wounds which I suspect is secondary to chronic debility and immobilization, which have purulence with pressure. She appears to require support and care due to her chronic vegetative state. She has a wound vac dressing in place but was sent over by the nursing facility WITHOUT her wound vac supply. I am very concerned given her recurrent episode of hospitalization , [MEDICAL CONDITION], and recurrent infections, general debility, and inability to communicate verbally that the patient is suffering . The History and Physical dated 11/15/19 at 3:25 AM reflected R1 had recently been hospitalized from (MONTH) 25 to (MONTH) 1st 2019 with [DIAGNOSES REDACTED]. In the ED, the patient presented with [MEDICAL CONDITION] without septic shock as evidenced by elevated temperature of 103.9, [MEDICAL CONDITION] a heart rate of 130, tachypnea with respiratory rate of 30, and elevated lactic acid of 3.72 (Normal Value= 0.50-1.0 millimoles per litre). Urinalysis with evidence of possible urinary tract infection. One-view chest x-ray showed persistent right mid-lung hazy infiltrate interpreted as positive for pneumonia by the ER physician .In the ED, the patient was fluid resuscitated and started on [MEDICATION NAME] and [MEDICATION NAME] (antibiotics) . (documented by Doctor E) The 2019 Michigan Medicine University of Michigan on-line medical reference reflected the following related to lactic acid: A lactic acid test is a blood test that measures the level of lactic acid made in the body. Most of it is made by muscle tissue and red blood cells. When the oxygen level in the body is normal, carbohydrate breaks down into water and carbon [MEDICATION NAME]. When the oxygen level is low, carbohydrate breaks down for energy and makes lactic acid. Lactic acid levels get higher when strenuous exercise or other conditions-such as heart failure, a severe infection (sepsis), or shock -lower the flow of blood and oxygen throughout the body. Lactic acid levels can also get higher when the liver is severely damaged or diseased, because the liver normally breaks down lactic acid . The hospital's consulting surgical Doctor G who assessed R1 on 11/15/19 at 11:26 AM note reflected: R1 had a wound VAC on her right ischium where decubiti was present with exposed bone, a deeper left decubiti, with necrotic and foul odor grey colored tissue that with some black skin changes that had not been debrided (the removal of unhealthy tissue from a wound to promote healing) as well as skin shear in the midline gluteal crease, and a draining ostomy wound of some sort in the midline on her abdomen. The plan reflected once R1 was stable from her pneumonia, to arrange for surgical intervention and deridement of her decubiti in the OR (Operating Room). A wound consult was performed by Nurse Practitioner L at the hospital on [DATE] at 4:52 PM, reflected R1 had an osotomy appliance mid upper abdomen with brown/tan liquid drainage, a jejunostomy tube and a Foley catheter. Dressings were removed, and the following was noted: Pressure ulcer on the left ischium measured at 7 x 5.5 x 4.5 cm with necrotic black tissue in the center surrounded by grey and red tissue. Pressure ulcer on the right ischium measured at 8 x 6 x 3.2 cm with mostly red tissue with serosanguinous drainage. The tissue at the coccyx had breakdown of red tissue and measured 4 x 2 x 0.2 cm. Dr. G had evaluated the patient and discussed possible surgical debridement when [MEDICAL CONDITION] and pneumonia were stable. Review of the Nursing Progress Notes reflected, the most recent Nursing Progress Note for R1 was dated on 10/6/19 at 4:21 AM, prior to her discharge to a local hospital on [DATE]. Late entry notes were created by two Nurses 4 days, by Registered Nurse (RN Q) and Licensed Practical Nurse (LPN R) on 11/19/19. RN Q made her late entry note on 11/19/19 at 2:24 AM and Back-Dated it to 11/14/19 at 11:45 PM which reflected, 11/14/2019 23:45 Progress Note-General Late Entry: Note Text: Entered room for medication administration [MEDICAL CONDITION]/suctioning, Resident was having Pallor, change in facial expression, skin felt very warm, RR was elevated, her O2 sat was decreased . VS were as follows T102.8 axillary, Pulse ox .was running between 81-84% on 6 L of oxygen via trach.[MEDICAL CONDITION]. secretions were thick pulse ox did not improve with suctioning. Bed Bath. given to see if temp would come down and for comfort. VS still the same. Oral care provided. Wound care provided as ordered,very strong odor to wounds. no BM at this time. 11/15/19 0015 Physician notified that Resident had a change in condition, elevated WBC and abnormal CXR Order was resident. Dressing dry and intact. resident clean and odor free . 0030 Ambulance notified for transfer to ER. ER notified of resident coming. RN Q's name. LPN R made her late entry note on 11/19/19 at 4:17 AM and back-dated it to 11/15/19 at 00:44 AM which reflected, 11/15/2019 00:44 physician progress notes [REDACTED]. (RN Q's name) made me aware of resident changed of condition having pallor, elevated temperature, pulse ox fluctuating between 81%-84%. Received abnormal chest X-ray. Provider, Dr. P was notified and he ordered to sent resident to ER. Resident guardian was notified and the DON. Resident wound dressing was dry and intact. Wound vac is working when medic showed up. Disconnected wound before transport. During the survey 11/26/19 - 12/3/19 staff were interviewed by phone and in person. Each staff member desired to remain anonymous for fear of reprisal, below are such interviews: The anonymous staff person was asked about R1's hygiene and if R1 had body odor? The staff person replied, She always had diarrhea type stool 9 to 10 times a day. At times she would clinch her mouth for oral care. I would normally give her a bed bath. When asked about R1's wounds, the staff person revealed they had seen R1's wounds. I reported several times to nursing that the treatment she was receiving, did not help them get better. Before her wound vac, they would not do dressing changes and treatment for [REDACTED]. The staff person revealed R1 had an incision at her stomach, where a bag was attached to catch the yellow colored bile, some shifts the facility would have only 3 Certified Nursing Assistants (CAN's) working and at times only 2-3 nurses for the entire building, and the nurses were worried about their licenses. The second anonymous staff person revealed they had taken care of R1 when asked, and that R1 was a double [MEDICAL CONDITION] and a 2 person assist with cares. The staff person was asked to recall R1's appearance and revealed, She had a bag for her bowels and a trach. When asked how was R1's hygiene, the staff person revealed, I went in her room quite a few times. It would be disgusting because dead skin would be at her lips and she would have buildup of mucus, thick and green in color in her mouth. I used foam swabs to clean her lips. I had showed another staff member on the following shift what I had did to clean her mouth. On 11/26/19 at 4:53 PM LPN S was interviewed and asked about R1's hygiene and healthcare status. LPN S revealed she cared for R1, that her wounds were not pretty, when R1 was first admitted she had one wound on the left hip which was healing. She goes in/out of hospital. When she came from the hospital she had a nickel size flat spot that got worse. She went out to the hospital last time came back with a spot deep and thick with a piece of dying tissue. She did start seeing Doctor O and he put her on the wound vac on the left side. LPN S was questioned about R1's oral hygiene and replied, She had dry mouth, because she was on meds to dry secretions. We talked to doctor and we stopped that. Her tongue was dry and getting cracked, put her on prn stuff. When asked if R1 had any perineal area odor LPN S revealed, they tried to cath (place Foley catheter) in her because of the wound and she had some discharge, but had trouble keeping it in place. Also, that R1 had an old jejunostomy tube site that did not work or heal and had drainage coming out of it. On 12/3/19 at 8:17 AM LPN R was interviewed and asked to describe R1 and recall the day of R1's discharge to a local hospital on [DATE]. LPN revealed she worked the day R1 was discharged to the hospital. We had got an X-ray and she was doing okay, I came in at 6:30 PM. On third shift her temp was 100 or something. I gave her Tylenol to get her fever down, checked her pulse oximeter was on the low side 84% . The X-ray came back as pneumonia and I called the doctor who sent her out (which was the 3rd CXR, after the ones dated 10/28/19 and 11/11/19). LPN R was asked how was R1's hygiene and replied, [MEDICAL CONDITION] good. She had a little smell because the wound on her buttock on her left side. On the Left side she had 2 wounds the other one was nice and clean. The only thing I could smell was the wound. She sweats a lot. We put the fan on her. When asked if R1 had a musty smell LPN R replied, Yes. On the left side she had a wound vac. We just disconnected it when she was discharged usually wound vac stays at the facility. When questioned why her Nursing Progress Note entry dated 11/19/19 for 11/15/19 was late LPN R stated, Because I forgot to write a note. My DON told me she did not see a note .DON told me there were some concerns about R1's discharge, and then I was told to write a note. On 12/3/19 at 12:59 PM DON B was interviewed and queried about the missing documentation for R1 on the day of her discharge 11/15/19, and why were there late entries of Nursing Progress Notes made by RN Q and LPN R. DON B stated there were progress notes dated for R1 on 11/15/19. DON B was informed the entries were late and back dated from 11/19/19. DON B revealed, The SBAR is what is covered with a change of condition. I informed the nurses about the progress note being late, and asked them to document R1's care, because I had gotten a call from Adult Protective Services questioning why her (R1) wound vac was not attached and her arm pits were dirty. The procedure is when they get sent to the hospital, we do a dry dressing. DON B was asked to provide the facility's policy related to the wound vac dressing/device. DON B revealed, It was determined she (R1) had a bath, wound care [MEDICAL CONDITION]. The nurse provided a bath prior to leaving. However, there was no documentation prior to R1's discharge of 11/15/19 that R1 left ischial wound VAC dressing had been changed to a dry dressing, as the last dressing change for the area was completed on 11/13/19. The left ischial wound vac dressing order reflected: NPWT (Negative Pressure Wound Therapy) for wound: Change every Monday Wednesday, and Friday . Cleanse wound with normal saline, pat dry, apply skin prep to peri wound, fill dead space with black foam, cover with sealant cover film and apply to NPWT tubing. every day shift every Mon, Wed, Fri for left ischium wound -Start Date- 10/23/2019 0700 -D/C Date-11/15/2019 1029. DON B also revealed the facility did not a have a policy related to the the wound vac dressing prior to exiting the survey. In addition, there was no documentation of a bed bath and or bath prior to 11/15/19, as the last one documented was on 11/12/19. DON B revealed nursing staff are to document about giving a bath and oral care when given. Resident #4 (R4) On 11/26/19 at 10:40 AM R4 was observed to not be in her room, as she had been discharged to a local hospital for a procedure. The EMR reflected she was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. R4's quarterly MDS with an ARD of 11/11/19 reflected R4 was cognitively intact, required limited assistance of 1 person for toilet use and hygiene, and independent with transfers. On 12/3/19 at 8:55 AM R4 was observed in her room sitting up in her bed. R4 was observed to be a [AGE] year old young lady. When asked about the care she received R4 revealed, A nurse got fired because she was mandated and because of her, my care was compromised. When asked in what way she felt her care was compromised R4 explained, I was in a lot of pain, and I was bleeding out and crying. Multiple CNA's (Certified Nursing Assistants) told the nurse I was in pain. The nurse told them she thought it was an anxiety attack. She (the nurse) was sitting and complaining about being mandated. From about 2:00 PM to 5:00 PM at least 3 CNA's went and told her I needed pain medication a total of 7-8 times. I ended up going to the Emergency Department (ED) for pain management. When asked what was the nurse's name R4 revealed, Registered Nurse (RN T) and that it happened earlier in the month. They fired her the next day. She was a floor manager, and they were so short that she had to work the floor. R4 was asked to describe and rate the pain she was in on that day and revealed, That day was really bad. I had them call the ambulance so I could go to the ED. I finally did get a [MEDICATION NAME] and [MEDICATION NAME] but that didn't do anything. At 2:20 PM I had a lot of clotting and bleeding, and the pain was a good 8 to 9 (9 = severe pain on a 1-10 point pain scale). I was on the toilet and clots were coming out. She (the nurse) thought it was a panic attack. She saw the clots and gave me a [MEDICATION NAME]. I was also nauseous and had to vomit a little. R4 revealed CNA's U, V and W were working on her hall and helping her on that day, and that she gave it to the Administrator (ADM A) the next day. R4 was asked how did it make her feel bleeding and in pain, while having to wait to receive pain medication from RN T . R4 stated, I have never felt more horrible in my life. For her to have ignored me especially, when I was hurting that bad. The CNA U suggested I take a shower, that it might make me feel better and that she would stop by the nurses station so RN T could give me my requested pain meds, because she would not come down to give them to me. RN X's Nursing Progress Noted dated 11/7/19 at 7:05 AM reflected, Note Text: Resident had complaint of passing clots continuously from her uterus since 2:30 PM. Resident also has complaint of intractable pain from cramping that grabs and releases. Resident wanted to go to the hospital to see what is going on and to relieve her discomfort. Physician was paged at 7:30 PM. Ambulance was called at 8:20 PM. Resident left for (name of local hospital and city) at 8:47 PM. Doctor P returned page at 9:25 PM. Report was given to (name of nursing staff and hospital) ER at 10:15 PM. Resident was returned to (name of facility) at 5:00 AM without report, but discharge paperwork was sent with resident. The Nursing Progress Notes prior to RN X's, was dated 11/5/19 at 7:05 AM. On 12/3/19 at 10:43 AM CNA U was interviewed and asked to recall the day R4 was having pain and bleeding on 11/6/19. CNA U revealed, She (R4) had her call light on at 2:30 PM. She complained of pain and was heavily bleeding. We told RN T at 2:30 PM, 3:00 PM and 3:15 PM. A total of 5 CNAs told RN T that R4 was bleeding heavily, that she was in a lot of pain and needed something for pain. RN T then said, I'll get to her. At 4:45 PM she (RN T) finally gave R4 pain medication, but because she had waited so long the pain medication did not do her any good and she was shipped off to the hospital. R4 was very tearful, bleeding a lot and saying she was in a lot of pain and needed pain medication. I told R4, that I had told the nurse, other nurses told her (RN T) as well and that is what irritated me. CNA U was asked if she saw R4 bleeding and stated, I viewed the blood in the toilet, with clots and red blood. She was bleeding from the bed to the bathroom. CNA U was asked how did it make her feel, seeing R4 in pain and heavily bleeding? CNA Ureplied, It's the nurse's job to give the patient pain medication. RN T never came down to see the patient until 4:45 PM. She (RN T) was mad she was mandated. On 11/3/19 at 12:05 PM CNA V was interviewed and asked to recall the day R4 was having pain and bleeding on 11/6/19. CNA V revealed, When I had came in to work at 2:30 PM she (R4) told me she was in a lot of pain and had been bleeding. She had big clots and was bleeding heavy. I told RN T that she (R4) was in a lot of pain and was asking for something or pain. RN T said, okay she'd get to it. CNA U told me R4 was in a lot of pain and wanted pain medication and she went up to RN T and told her too. R4 had put her light on again, and said she was in a lot of pain and was given anxiety medication and nothing for pain. I went and told the nurse again she needed something for pain. Then the RN T told me she had just gave R4 anxiety medication and she needed to let it kick in. I told RN T R4 had been bleeding pretty heavy, and that we were out of chucks (absorbent fabric pads used to lie atop of bedding to contain incontinence and/or leakage). Another resident had asked for pain medication and he did not get his pain meds either. I went to the nurse at least 4 different times and asked her to give R4 pain medication. CNA U told me she had requested the nurse give R4 something for pain 4 times as well, so she was asked to give pain medication to R4 at least a total of 8 times. I was really frustrated, so when RN X came in I told him right away, R4 really needs something for pain. R4 was shaky, out of breath, on the verge of crying, leaning forward and clutching her stomach for most of the day. On 12/3/19 at 11:45 AM CNA W was interviewed and asked to recall the day R4 was having pain and bleeding on 11/6/19. CNA W revealed, She (R4) had a lot of bleeding in her bed and on the floor. The blood was probably more bright. I was helping clean it up. There was another nurse and CNA, who told me they saw clots. R4 was in pain that day and had been in pain for a while a few days. She [MEDICAL CONDITION] and complained of pain and she let the nurse know. When I first showed up to my shift at 2:30 PM R4 complained of pain then. CNA W was asked if she informed RN T about R4's pain and replied, Yes, my partner that day was CNA V. Everyone was well aware that she (R4) was in pain and bleeding. On 12/3/19 at 12:19 PM RN T was interviewed and asked to recall the day R4 was having pain and bleeding on 11/6/19. RN T revealed, I was a unit manager and floor nurse, and that was the last day I worked there. I think when I got report she was anxious, and we gave her something for anxiety at 2:30 PM. We offered her something for pain, and she did not want it. I think Nurse Y gave her a [MEDICATION NAME] or [MEDICATION NAME]. A little while later I went down, I went to check on her and asked if the medication worked and she said yes and refused pain medication. The CNA's told me she (R4) wanted something for pain, I think once or twice. I worked from 2:30 PM to 5:45 PM. RN T was asked if she assessed R4's for bleeding and replied, She did not want me to. No one ever complained to me about R4 not getting her pain medication. They fired me. I had worked the floor the majority of the time I worked there, instead of working as unit manager because they were short staffed. RN T did not document that she assessed or attempted to assess R4 for bleeding, nor did she document R4 refused to allow her to assess her (R4), In addition, RN T did not document in the Nursing Progress Notes or the (MONTH) 2019 Medication Administration Record [REDACTED] The (MONTH) 2019 MAR for R4 reflected that on 11/6/19 R4 had as needed (prn) pain medication for pain and between the hours of 2:00 PM and 9:00 PM was administered one dose of [MEDICATION NAME] ([MEDICATION NAME]: anti-anxiety) 0.5 mg 1 tablet on 11/6/19 at 2:44 PM by who appeared to be Nurse Y, and one dose of [MEDICATION NAME] (narcotic [MEDICATION NAME]) 7.5-325 milligrams 1 tablet by mouth on 11/6/19 at 4:40 PM for pain, for a pain level of 9 (severe pain) by RN T. The ED documentation reflected R4 presented with pelvic pain at a 9/10, and had vaginal bleeding secondary [MEDICAL CONDITION], bleeding worsened today, and uterine pain at a 8/10. The urinalysis for R4 collected on 11/6/19 reflected the appearance was turbid, red in color, it had a large amount of blood, and >100 red blood cells which are all indicative of bleeding. R4 was medicated in the ED with: [MEDICATION NAME] (nonsteroidal anti-[MEDICAL CONDITION] drug also used to treat pain) 15 mg intravenous injection at 10:05 PM on 11/6/19. [MEDICATION NAME] (narcotic) 1 mg intravenous injection at 10:05 PM on 11/6/19. [MEDICATION NAME] ([MEDICATION NAME]) 1 tablet 0.625 mg orally at 1:18 AM on 11/7/19. The final [DIAGNOSES REDACTED]. The ED documentation reflected R4 was admitted on [DATE] at 9:36 PM and discharged [DATE] at 4:00 AM. The facility's Abuse Prevention Program policy revised 2/22/18 reflected: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment and involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptom. (Collectively, hereinafter abuse). The policy defined neglect as: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or mental illness. According to the PERFORMANCE IMPROVEMENT FORM (FORM #412) RN T was discharged as an employee from the facility on 11/11/19 for the following reasons: On 11/6/19 employee failed to to follow a directive from her immediate supervisor. Employee was unprofessional in her behavior and disruptive to co-workers on floor complaining about assignment. Employee Conduct: 08. Employee refused a job assignment, directive or being insubordinate to a Facility Supervisor. 17. Leaving work area without prior authorization while on duty. 22. Disruptive or distracting behavior in the work place including insubordination.

This citation pertains to intake MI 171. Based on interview, and record review, the facility failed to provide adequate supervision for 1 (Resident #3) of 2 reviewed for falls, resulting in Resident #3 sustaining a fall, and was hospitalized for [REDACTED].). Resident #3 passed away on 5/24/19. Findings include: Review of the Medical Record and Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was a [AGE] year-old male resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #3 had clear speech, sometimes understood, understands, and required extensive assistance of staff for activities of daily living (ADLs). Review of the fall incident documentation dated 4/27/19, and completed by Licensed Practical Nurse (LPN C) revealed at 4:35 p.m., (Resident #3) was observed by a CNA (Certified Nursing Assistant) on the floor in front of his wheelchair .Sent to hospital . Further review revealed that the Care Planned Interventions Prior to Fall included, in view of staff when up. Under the Were Planned Interventions in place? Both Yes and No are checked. Under the If no list reasons section LPN C wrote, Resident wife left (without) informing staff and left resident in his room. Review of the Hospital Transfer Form dated 4/27/19, revealed Resident #3 was transferred to the hospital on [DATE] after sustaining a fall. Review of the Hospital Emergency Department Notes dated 4/27/19 revealed, (Resident #3) with (past medical history of [REDACTED].History provided by EMS (Emergency Medical Services) and family at bedside. I'm told that the patient attempted to stand from his wheelchair and tripped. He fell and hit his head on the ground. He was brought to (name of original hospital) for further evaluation, and CT imaging revealed a new subdural hematoma with 8 mm (millimeter) shift (brain shift). (Resident #3) was transferred to (name of hospital) because (name of original hospital) does not have neurosurgery. (Resident #3) had a previous fall approximately a month ago with head trauma resulting in a subdural hematoma that required neurosurgical intervention, he was just transferred to a rehabilitation facility 3 days ago . Review of the Certificate of Death dated 5/29/19 revealed that Resident #3 had passed away on 5/24/19, cause of death was [MEDICATION NAME] Force Head Trauma & Complications. Manner of Death was Accident. Section 41c, Describe how injury occurred revealed, Fall(s). During a telephone interview on 6/10/19 at 1:20 p.m., Resident #3's wife stated that her husband had passed away since he sustained the fall in the facility. Resident #3's wife went on to further state that Resident #3 was supposed to have a 1:1 sitter with him whenever she was not there visiting. Resident #3's wife stated that she was in the facility on 4/27/19 visiting her husband and had to leave for a little bit. Resident #3's wife stated she told the person that was supposed to be his sitter before she left. Resident #3's wife stated, I was introduced to the person that was sitting with him each day and was told to let that person know when I left so, they could sit with him when I was not there. When asked if she could remember any names of the sitters Resident #3 stated the only name that she could remember was (Certified Nursing Assistant (CNA) M) but said that there were more than just that one. Resident #3's wife further stated that just the day before the fall (4/26/19), she had a meeting with the facility, and they went over his cares. Resident #3's wife stated that during that meeting she had been told that the facility was going to use an extra person to be a sitter for Resident #3 when she was not there. When asked who was a part of that meeting, Resident #3's wife said the only name she could remember was Admissions Coordinator/Patient Advocate L name. Review of the Hospital Discharge Summary dated 4/24/19 revealed that Resident #3 was admitted to the hospital on [DATE] after sustaining multiple falls and was found to have a subdural hematoma which required neurosurgery intervention. Review of the hospital Discharge Summary revealed that Resident #2 required 1:1 supervision (a staff member is always to be with the resident). Review of the facility's Inquiry - Admission Worksheet undated and unsigned revealed, 1:1 Sitter .Craniotomy (surgical removal of part of the bone from the skull to expose the brain) s/p (status [REDACTED]. During an interview on 6/11/19 at 10:37 a.m., when asked about this worksheet, Admissions Coordinator/Patient Advocate L stated he did not know who would have wrote that on the worksheet, That is kind of our reference sheet. When asked about the care meeting that took place on 4/26/19, Admissions Coordinator/Patient Advocate L stated that he did remember being at that meeting. When asked if he remembered a 1:1 sitter being discussed during that care meeting, Admissions Coordinator/Patient Advocate L stated, Not entirely, I do remember that there was a concern with the fall. I know that it was discussed to take extra precautions. I can't say either way that the 1:1 was the plan or not. Review of a provider note dated 4/26/19 revealed, (Resident #3) with pmh (past medical history) significant for Parkinson' .dementia, s/p craniotomy, subdural bleed, multiple falls .Has 1:1 sitter with him d/t (due to) poor judgement, safety concerns, multiple falls .(Resident #3) sitting in wheelchair during assessment. He has tremors and involuntary movements in arms and legs .some questions (Resident #3) able to answer yes or no, but largely confused and disoriented .Care Plan: Continue 1:1 monitoring for safety, continue to monitor for mental status changes . During a telephone interview on 6/11/19 at 11:01 a.m. when asked about being a 1:1 sitter for Resident #3, CNA M stated, Yes, I was not there the time he fell , but I had the opportunity to work with him as his 1:1 a couple of times. When asked if when providing 1:1 care for a resident, do they document that anywhere, CNA M stated, Um, no we don't, I am just there to sit with him. If he had a BM (bowel movement) or something, I would document that, but no nothing about the 1:1. During an interview on 6/10/19 at 4:10 p.m., when asked about Resident #3' fall on 4/27/19, LPN C stated that she was Resident #3's nurse at the time of the fall. LPN C stated, (Resident #3's) wife was there when I came in, she left, and I did not know she left. I sent him out right away. When asked if he was a 1:1 when he fell , LPN C stated, No, just close supervision. When asked why he was not a 1:1, LPN C stated that Management did not make him one. When asked what close supervision means, LPN C stated, Put him close to us, or we are supposed to check on him. When asked about the care plan intervention of Needs to be in view of staff when up, LPN C stated, We could put him by the nurses' station. When asked if Resident #3 was by himself in his room when he fell , LPN C stated, Yes, I did not know the wife left. During an interview on 6/10/19 at 4:00 p.m., when asked about Resident #'s fall on 4/27/19, CNA G stated what she was working when he fell . CNA G stated, He was in his room by the TV by himself. His wife had left and poked her head in to ask if we could sit with him while she was gone. I stayed with him for a while at first when she left. I probably sat with him for about 5 minutes. The wife was pretty upset when she got back and found out he fell . He was pretty relaxed when she left. She was only gone for no more than 30 minutes. When asked if he was supposed to be 1:1 care, CNA G stated, I think he may have been the day before, I wasn't here. When asked if she was aware of the intervention of, in view of staff when up CNA G stated, No, I had to leave him to help other residents. CNA G further stated, I don't remember who else was on the hall, but we would both look in to make sure he was sitting down. During an interview on 6/10/19 at 2:00 p.m., When asked if she took care of Resident #3 on 4/27/19, LPN F stated that she was the day shift nurse that day, The next time I came in they said he fell and hit his head. When asked if Resident #3 was supposed to be a 1:1 that day, LPN F stated, Yes, he was a 1:1 all week. They had the girls sitting in there with him. He was very impulsive. When asked who determines if a resident is a 1:1 LPN F stated, usually the DON (Director of Nursing B) makes that call, (Resident #3) was very high risk (for falls). Review of the work schedule dated 4/26/19 (the day before Resident #3 fell ) handwritten next to CNA M and CNA [NAME] was 1:1. CNA M no longer works at the facility, and CNA [NAME] was not available for interview. Review of Resident #3's Fall Risk assessment dated [DATE] revealed resident was a risk for falls and, Interventions Required. Review of Resident #3's care plan revealed that intervention of, Needs to be in view of staff when up dated 4/26/19. During an interview on 6/10/19 at 3:00 p.m., when asked about Resident #3's fall that took place on 4/27/19, DON B stated, Yes, he went out to the hospital. While looking at the medical record and being asked about any documentation in the chart about the resident falling and going to the hospital, DON B stated, Normally there is a SBAR note that is done and I don't see that. When asked why Resident #3 went to the hospital, DON B stated, He had a fall. When asked if that should be documented in the chart, DON B stated Yes when asked why there were no nurses notes regarding this fall, DON B stated, I can't speak to why that nurse did not document. When asked if she had completed the investigation of Resident #3's fall, DON B stated Yes When asked what the intervention of, In view of staff when up meant, DON B Stated, When he was up in wheelchair, he was supposed to be in view of staff, unless the wife was there. When asked if Resident #3 was in view of staff when he fell , DON B stated, No, his wife had left and did not inform staff she left. When asked how the wife was supposed to know she was to inform staff before leaving, DON B agreed that it was not in the care plan, There is no documentation of that in there (the record), she normally would let staff know when she left. When asked if the surveillance video was reviewed to confirm that the wife do not tell anyone, DON B Stated, I did not look at the video. When asked how she knew that the wife did not tell anyone prior to leaving, DON B stated, I would not know that, (LPN C) told me. When asked if there were any statements from the CNAs that were working that hall the time of the fall, DON B stated, I don't. When asked if Resident #3 had a 1:1 assigned to him at the time of his fall, DON B stated, No, he was not. When asked who determines if a resident requires 1:1 supervision, DON B stated, The IDT (interdisciplinary team) team. When asked if the providers are part of the IDT team, DON B stated, Yes. When asked if CNAs were required to document anywhere when they were providing 1:1 supervision for a resident, DON B stated, Not really, we have a 15-minute check form. When asked how staff would know if a resident was supposed to have 1:1 supervision, DON B stated, Everyone knows, it's an order and on the care plan. When asked about the provider note dated 4/26/19 that indicated Resident #3 had a 1:1 sitter DON B stated, That is our Nurse Practitioner. When asked about the 1:1 sitter DON B stated, I can't speak to that. When asked where the nurse practitioner would have gotten the Has 1:1 sitter with him . DON B stated, I can't speak to her saying that. During an interview on 6/10/19 at 4:40 p.m., while reviewing the 4/16/19 schedule and being asked about the handwritten 1:1 being written next to CNA names, DON B stated, Nurses can use their discretion for a 1:1, they can do this depending on the resident. When asked about the 1:1 written next to CNAs [NAME] and F, DON B stated, That would be the nurse's discretion to do that. When asked which resident this 1:1 would have been for, DON B stated, That would have been for this resident. When asked if the 1:1 would have been for Resident #3, DON B stated, Yes. When asked if the nurse should have documented somewhere that Resident #3 required 1:1 supervision, DON B stated, You would think that the nurse would have documented that. When asked if the CNA would have documented anything regarding 1:1 supervision, DON B stated, You would think that they would have. This surveyor asked DON B to provide the facility's policy, or procedure, or anything regarding 1:1 supervision. At 5:05 p.m., DON B stated to this surveyor that the facility did not have any procedure or policy regarding 1:1 supervision. On 6/11/18 at 11:47 a.m., DON B approached this surveyor to further explain why the 1:1 was written on the schedule next to the two CNAs names. DON B now stated, It doesn't mean 1:1, it just means increased supervision. This surveyor was confused and asked how writing 1:1 next to a staff member could mean that Resident #3 required increased supervision. DON B replied, It just means that the resident required increased supervision. This surveyor then requested clarification and asked, So the 1:1 written next to the staff names on the schedule just mean that a resident required 'increased supervision' and those were the staff members that would be providing the increased supervision, DON B stated, Yes. When asked what Increased Supervision meant DON B stated, It would depend on the individual resident, I can't speak to what that nurse's thoughts. When asked, Could 'increased supervision' mean 1:1 supervision? DON B stated, Yes, if they felt that was what the resident needed. When asked, what were the interventions in place at the time of the fall? DON B stated, Whatever was on his care plan. Again, this surveyor tried to get clarification, asking, But you just said that it could be changed upon nurse's assessment? DON B responded, Yes, if the nurse felt that for a safety concern. yes. This surveyor voiced his confusion stating that the 1:1 written on the schedule did not mean 1:1 supervision but did mean 'need increased supervision' because it was listed 1:1, but you don't know what that meant because there is no documentation, but it could have been for 1:1 supervision for that resident? DON B stated, Yes, based upon nurse's discretion, it could have been, but I am not aware of one. During an interview on 6/11/19 at 12:00 p.m., when asked about Resident #3's fall, Nursing Home Administrator (NHA) A stated, I am just aware that he had the fall and that he did not return to the facility, I was not a part of the fall investigation. When asked about the facility's procedure on providing 1:1 supervision to residents NHA A stated, I think that if they feel they need more supervision they can place that on a resident. When asked to clarify who can place a 1:1 on a resident NHA A stated, the nurse, as far as the procedure they would talk with the director of nursing and I think that could happen anytime. When asked if Resident #3 was supposed to have 1:1 supervision at the time of his fall, NHAA responded, I am not aware if he was or was not. Review of the work schedule for 4/27/19 revealed that CNAs I and J had worked the day that Resident #3 had fallen. During an interview on 6/11/19 at 10:00 a.m. when asked about Resident #3's fall, CNA I stated, I was not on the hall when he fell but he was a code white, and we all rushed to it. I was on that hall earlier in the day and they moved me over to D hall. When asked what a Code White meant, CNA I stated, It means there was a fall, he was supposed to be a 1:1. When asked if there was a 1:1 when he fell CNA I stated, A lot of the time they are not staffed, and we did not have a staff person to work that hall, so the 1:1 had to work the hall until a person came in, We don't always have the staffing for a 1:1 When asked who decides when a resident requires a 1:1 CNA I stated, I think the nurses, I am not really sure. When asked if she remembered what happened with Resident #3's fall, CNA I stated, The wife left and then it happened. I was never the 1:1 (for Resident #3), I know that someone was supposed to be sitting with him when he fell . During an interview on 6/11/19 at 10:00 a.m., when asked about Resident #3's fall, CNA J stated, I know that he was a 1:1, and I think they may have put him on 15 minute checks, I can't remember, and I don't remember the fall. I have never really done a 1:1 before. I know that (CNA K) sat with him, and there was another girl too, but I can't think of her name. During an interview on 6/11/19 at 10:15 a.m., CNA K stated that she worked from 6:30 a.m-2:30 a.m. and then every other weekend. When asked if she was aware that Resident #3 sustained a fall, CNA K stated, I was not aware of his fall. When asked if she was ever a 1:1 for him? CNA K stated, Not that I can recall .I take care of a lot a people, I don't remember him. When asked if it was possible that you don't remember being a 1:1, CNA K stated, Yes, that is possible, that I do not remember, I do so much around here. CNA K was asked to clarify that she had have been a 1:1 before and stated, Yes, I have. When asked if you have to document that anywhere, CNA K stated, No, I just have to make sure that I am with the resident at all times and that if I need to take a break, I would have to find someone to relieve me.

This citation includes Intake MI 551 and Intake MI 933. Based on observation, interview and record review the facility failed to provide adequate supervision, 2 person assistance during a transfer, provide appropriate care assessment and document care provided after a fall, and report a fall to administration for 3 of 9 residents reviewed for falls (Residents #14, #11 and #10) ) from a total of 15 sampled residents, resulting in improper transfer, left ankle fracture (#14), fall with hip fracture (#10), delayed assessment and treatment (#11), severe pain, delayed reporting/investigation of a fall with injury, and the potential for worsening of injury. Findings Include: Resident #14 According to the facility's Electronic Medical Record (EMR) Resident (R) #14 was an [AGE] year old female admitted to the facility on [DATE] and most recently on [DATE] with [DIAGNOSES REDACTED]. A occurrence report dated [DATE] at 11:28 AM reflected, Resident states she fell at her last shower at night. Resident confused on the day. Last shower given [DATE]. R14 was assessed on [DATE], which reflected the fall resulted in pain at the left ankle with bruising and swelling. It was documented no mobility device was used, an X-ray was ordered and staff was re-educated. Resident #14 was observed and interviewed in her room on [DATE] at 10:37 AM. R14, was laying in her bed against the wall, her call light was in reach, and she was dressed in a hospital gown by choice. R14 was asked if she recalled falling, and replied Yes last year, I went to the hospital. The left one was hurt. I fell here (facility) in the bathroom. This girl was supposed to be watching me. The girl was helping me move from the wheelchair to the toilet, I fell before I got on the toilet. R14 was asked if the Nursing Assistant (NA) used a gait-belt during the transfer. R14 denied a gait belt was placed on her or used when she was transferred. R14 could not recall the NA's name. The investigative report related to the fall that occurred on [DATE] was completed by Registered Nurse (RN) Manager (Mgr) X on [DATE]. The report reflected R14 was in the shower room alone with NA (K), and fell at the time she was being transferred. Like the occurrence report, the investigative report reflected R14 reported the fall on [DATE], when the fall actually occurred on [DATE]. The Licensed Practical Nurse (LPN L) and NA K who worked with R14 the day of her fall, were noted to have been interviewed on [DATE] by the post Director of Nursing (DON DD). In the report NA K stated she was transferring R14 to the shower chair, her (R14) legs gave out, and she (NA K) lowered R14 to the floor. There was no documentation available prior to exiting the facility on [DATE] that LPN L had provided a statement, or had been interviewed. Results of the investigation reflected an X-ray was done, and a hairline fracture to the left ankle was the result. Since the fall ([DATE]) progress notes dated [DATE] at 5:44 PM reflected R14 refused a shower and bed bath that evening, Said she was afraid to get up and have a shower. NA K who was with R14 during the fall was interviewed by phone on [DATE] at 11:16 AM. NA K was asked to recall the fall in [DATE] with R14. NA K revealed, We were in the shower room and I went to transfer her after her shower. She buckled, she didn't fall and I lowered her to the floor. NA K was asked what was she transferring R14 from and to. NA K stated, I transferred her from the shower chair to her wheelchair. Also, that at the time R14 was a one person transfer and she used a gait-belt. .She had her clothes on during the transfer, and non-slip socks on her feet. After she was lowered to the floor. I gave her a minute, stood her back up, put her in her wheelchair and took her to her room and placed her in bed. I notified the nurse, I don't remember her name. I told her that she went down to the floor, but she never complained of any pain or anything. NA K revealed the incident occurred during second shift around 6:00 PM, but she could not recall the day. Also, that she told LPN L right after it happened, but she never had me fill out a statement. I told her after leaving the shower room, and placing (R14's name) in her room. They called me on the phone and asked me about it. I want to say Registered Nurse Manager (RN Mgr X), and I told them the same thing I told you. On [DATE] at 12:15 PM LPN L was interviewed by phone. LPN L was asked if she recalled caring for R14 during a fall, and replied vaguely. The NA said she (R14) had her shower and her ankle or knee gave out, and she lowered her to the floor. LPN L was asked if she assessed the resident in the shower room after she was lowered to the ground. No, I did not because she (NA K) didn't tell me until R14 was already showered and had put the resident back in bed. LPN L was queried if she assessed R14 once she was in bed. LPN L revealed, I looked at her ankle, there was no swelling and bruising. I asked her if she had any pain, and she said no. NA's are to have nurse do a skin assessment after shower. NA K never came and got me. I told RN Mgr X, I asked her what the protocol was. If NA was to come and get me when she dropped her, because R14 was a hoyer, and who helped her (NA K) because 2 people were to be used with the hoyer .R14 was a hoyer transfer. LPN L was asked if she wrote a nursing note related to her assessment of R14, or if she filled out a occurrence report. LPN L replied, RN Mgr X said she did a report for me with my side of the story . I wrote it on a 24 hour report sheet. R14 could move and flex her ankle, and denied pain. RN Mgr X called me at home and talked to me about it over the phone. I came back to work about 2 days later. I did give a statement, she (RN Mgr X) told me it was in the report. Training was not very well and I could not get anyone to help me with anything. LPN L denied being interviewed by post DON DD on [DATE]. RN Mgr X was interviewed the same day at 12:34 PM, and asked if she recalled R14's fall in [DATE]. RN Mgr X revealed, I was working the floor she (R14) said she had a bruise on her ankle, and she said she had fallen the last time she had showered. I called the DON, doctor, and administrator. They ordered an X-ray, and she had a hairline fracture. The doctor came in and put a splint on her ankle. R14 stated they were transferring her into the shower chair and her legs gave out and she was lowered to the floor. RN Mgr X stated she did an incident report and interviewed NA K, but that post DON DD did the investigation. RN Mgr X was asked to provide writer with the nursing 24 hour report for [DATE]. At 2:02 PM the [DATE] hour report was reviewed with RN Mgr X. There was no documentation noted on the 24 hour report related to R14 for [DATE]th, 10th or 11th. The first note related to R14, was documented on [DATE] by LPN (EE), which reflected post fall X-ray 2 view ordered swollen, bruised left ankle. There was no documentation in the Progress/Nursing notes dated [DATE] to [DATE] reflecting that R14 had fallen, that a body part that was injured, or that an assessment took place directly after the fall in the shower room. R14's Activities of Daily Living (ADL) care plan intervention initiated on [DATE] and revised on [DATE] reflected R14 required a Sit To Stand (STS: mechanical transfer device) with 2 person assist to transfer. Then on [DATE] the transfer intervention was changed to: The resident requires mechanical lift (Hoyer) with 2 or more staff assist for transfers. Resident #10 Resident #10 was discharged from the facility on [DATE], and no longer resided at the facility. According to the MDS/Minimum Data Set, dated dated [DATE], Resident #10 was an [AGE] year old admitted to the facility on [DATE], who had severe cognitive impairment, had limited range of motion in one of his legs, and [DIAGNOSES REDACTED]. Resident #10 had been in Hospice since [DATE]. According to an Change of Status MDS dated [DATE], Resident #10 had an additonal [DIAGNOSES REDACTED]. According to an Incident Report, dated [DATE] at 4:45 PM, Resident #10 sustained a fall: Resident was in bathroom and was attempting to clean himself then fell to floor .pain scale (,[DATE]) - 9. The Incident Report revealed Resident #10 was Alone and unattended at the time of the fall, and Action Taken : Staff Re-education . According to the facility's Fall Investigation Report, dated [DATE], Resident #10 had 4 falls since [DATE]. According to physician progress notes [REDACTED].Fall with injury .Resident (#10) was left briefly unattended on the toilet in the bathroom, and was found on the floor, having fallen forward, with an abrasion on his forehead, lying on his left side when he was found. Any movement seemed to cause severe pain to the left leg and left side, therefore he was not removed until EMS personnel arrived. Resident cannot answer questions at this time because he is essentially unresponsive, although awake, but not alert to surroundings. Review of Resident #10's Fall Care Plan, dated [DATE] revealed, The resident is at risk for falls r/t (related to) Contusion, Deconditioning, Incontinence, Unaware of safety needs . The Care Plan did not instruct staff that Resident #10 was not to be left unattended while in the bathroom. Surveyor attempted to reach Nurse Aide P, the Nurse Aide that left Resident #10 unattended, via phone on [DATE] at 11:09am, and left a voice mail message but no return call was received. In an interview, on [DATE] at 11:25 AM, Unit Manager/RN/Registered Nurse X reported, (Resident #10) was unattended (at the time of the fall), and we determined he was not supposed to be unattended (left alone in the bathroom). Unit Manger X said she was responsible to have assessed whether Resident #10 could be left unattended or not and to care plan for that, but she had failed to do so. Unit Manager X said, (Nurse Aide P) should have stayed with him. There should have been others to answer call lights. Resident #11 Resident #11 no longer resided at the facility. Review of Resident #11's Certificate of Death, revealed he expired on [DATE] at the hospital at 8:18 AM, and the causes of death were listed as 1. Sepsis (infection), and 2. Bacterial pneumonia. According to Resident #11's Minimum Data Set, date [DATE], he was a [AGE] year old who was admitted to the facility [DATE], had severe cognitive impairment, needed extensive assistance of 2+ persons physical assist with bed mobility and hygiene, had no range of motion impairments, and [DIAGNOSES REDACTED]. (Resident #11's original admitted to the facility was [DATE].) According to Incident Reports, Resident #11 had 8 falls since [DATE]; 7 of which were due to rolling out of bed. None of the falls in 2017 resulted in apparent injury, except the last fall from bed that occurred on [DATE] at 9:15 PM. According to Emergency Documentation, dated [DATE] at 22:21 (10:30 PM), rolled out of bed deforming left wrist. Pt (Resident #11) c/o (complaint of) pain in wrist. Known schizophrenic with 1:1 d/t (due to) behaviors. C/cervical collar and Left wrist immobilized by EMS (emergency medical team), B/P ,[DATE]. Pt yelling out in pain, swearing as well .admitted to neck pain .Patient has a persistently borderline pulse ox (low oxygen levels) . According to Resident #11's Hospital History and Physical Report, dated [DATE], .X-ray of the left wrist showed fracture of the distal ulna and radius (both bones in the lower arm) .anterior 3rd, 4th, 5th, and possibly 6th right ribs suggesting fractures .evidence of bilateral (both) infiltrates (abnormal fluid), worse in the left lung. There was elevation of the right hemidiaphragm (abnormality of the muscle under the lungs) .His oxygen saturation was labile (unstable) in the ER (emergency room ). It was hovering anywhere between 85% and 95% .He is a DNR (do not resuscitate) . According to a Hospital Progress Notes regarding Resident #11, dated [DATE] at 12:53 PM, .There is some concern about pulmonary contusion (bruising) related to acute rib cage fractures. We do not know if the patient has contusion, pneumonia or scar tissue from previous disease .probable anterior right-sided rib fractures . According to Medscape, 2000, Rib fractures in the elderly .CONCLUSION: Elderly patients who sustain blunt chest trauma with rib fxs (fractures) have twice the mortality and thoracic morbidity of younger patients with similar injuries. For each additional rib fracture in the elderly, mortality increases by 19% and the risk of pneumonia by 27%. As the number of rib fractures increases, there is a significant increase in morbidity and mortality in both groups, but with different patterns for each group . <http://www.medscape.com/> The Incident Report, dated [DATE] at 9:15 PM, revealed Resident (#11) was going to be changed, CNA/Nurse Aide (S) grabbing wipes/brief to change resident, resident observed rolling own self out of bed. Resident found laying on floor left side, wrist swollen, in pain. The Incident Report did not indicate whether a perimeter mattress was in place at the time of the fall, but it indicated the bed was in down position, Resident #11 was on 1:1 supervision at the time of the fall, and the resident was given education and staff were re-educated (content of education not indicated). Page 4 of the 4 page Fall Investigation Report, not dated, revealed, bed lowest position. Review of Resident #11's fall Care Plan revealed, (Revision on: [DATE]) The resident (#11) is at risk for falls r/t (related to) Confusion, Psychoactive drug use, Incontinence, History of falls. He is non-compliant with requesting assistance with transfers and he has no pattern to his falls .([DATE]) Resident lowers self to floor at times .([DATE]) fall mat next to bed .([DATE]) Determine causative factors of fall and resolve or minimize .Educate .caregivers about safety reminders and what to do if a fall occurs .(,[DATE]) parameter mattress to identify bed boundaries . Interventions for this Care Plan did not include instructions on how many staff were required for safety during care, what position the bed should be left at (low or next to the floor), or that Resident #11 was on 1:1 supervision. Review of Resident #11's Progress Notes, revealed Resident #11 had been on 1:1 supervision for over a month. Progress Notes dated, [DATE] at 10:47 AM revealed, resident continues on 1 to 1 at this time . Review of Resident #11's ADL Care Plan revealed, (Revision on: [DATE]) The resident has an ADL self-care performance deficit r/t Limited Mobility .([DATE]) The resident requires extensive assistance by 1 staff with bathing/showering .report PRN (as needed) any changes .self-care deficit .decline in function. Review of another of Resident #11's Care Plans, dated [DATE], revealed, The resident is resistive to care .hygiene, brief changing, and changing clothes . Interventions for this Care Plan did not include instructions on how many staff were required for safety during care, what position the bed should be left at (low or next to the floor), or that Resident #11 was on 1:1 supervision. In an interview, on [DATE] at 10:00 AM, Nurse Aide W reported Resident #11 had been on 1:1 supervision for weeks, and frequently rolled off bed, down to floor. Nurse Aide W said, I was told (Nurse Aide S) had (Resident #11) up in the changing position when he fell on [DATE]. Nurse Aide S said, You really needed 2 people (to change Resident #11's brief). He was a handful. Nurse Aide S said she thought Resident #11's fall was avoidable because, We were educated, you must have bed in low position if leaving a resident, and you should have supplies with you before you start the change. In an interview, on [DATE] at 10:15 AM, Nurse Aide E commented on Resident #11 saying, I always had someone else in there when doing care. He would throw himself out of the bed .I always had everything with me so I didn't have to leave him alone. He shouldn't have been left alone. Nurse Aide E reported there was no staff education about ways to have prevented Resident #11's fall. In a telephone interview, on [DATE] at 10:30 AM, Nurse Aide S reported he smelled something about 20 minutes after Resident #11 was put to bed facing the wall, and saw liquid stool oosing from Resident #11's brief. Nurse Aide S said he checked the bedside stand and there were no wipes or brief, so he went across the room to another dresser to check for those items there. Nurse Aide S said when he turned around Resident #1 was purposely rolling himself off the bed. Nurse Aide S said, I asked him why he did that. When asked if Resident #11 was to be assisted with cares by one or more staff members present, Nurse Aide S said, I don't know for sure .I wouldn't think so for personal hygiene . Nurse Aide S said he knew Resident #11 rolled himself out of bed several times .all the time. When asked about the height of the bed at the time he left Resident #11 to get supplies, Nurse Aide S said the bed was at medium height, not all the way down. Up approximately 1 ,[DATE] feet. Nurse Aide S said he knew something was wrong with Resident #11's left wrist immediately when he fell because, It didn't look right. However, We put a Hoyer (full body mechanical lift) under him, put him in bed, did his vital signs .We asked him (Resident #11) to open and close hand when he got back in bed; he couldn't do it. In an interview, on [DATE] at 10 :57 AM, LPN/Licensed Practical Nurse D said she knew Resident #11 was on 1:1 supervision because, He tended to roll himself out of bed. LPN D said, I went down there .his left arm hurt him really bad .his hand was swollen, I suspected a fracture, called the doctor, and we sent him to the hospital for evaluation. LPN D stated Resident #11 was placed in bed with a Hoyer lift before vital signs or a an assessment were done, and she did not perform range of motion to other extremities or do neuro checks. When queried, LPN D said she had never been told to assess a resident for injury before moving/transferring them after a fall, or to leave them on the floor and allow EMS to transfer to stretcher for transport if injury was found or suspected. In an interview, on [DATE] at 12:08 PM, DON/Director of Nursing B said she found no fault with Nurse Aide S leaving Resident #11's bedside to retrieve supplies because, He didn't go far; he was within the 3 feet parameter when (Resident #11) fell . When queried about post fall procedures in Resident #11's case, DON B said she did not ask about that during her review of the fall. In an interview, on [DATE] at 12:30 PM, Nurse Aide G reported she usually did cares for Resident #11 by herself, but had assistance when Resident #11 was upset. Nurse Aide G said she always gathered supplies before starting cares. Nurse Aide G said, When I did 1:1 with (Resident #11), I sat right by his bed so I didn't worry about him falling. When asked about care after a fall, Nurse Aide G said, We make sure they are ok. Call code white. Get vital signs, then the nurse checks them while they are on the floor, and if ok, we put them to bed. If hurt, we call 911 and have the ambulance come in and they move them. In an interview, on [DATE] at 3:36 PM, Nurse Aide Y reported she placed Resident #11's bed in the lowest possible position; always .He would place himself on the floor. In an interview, on [DATE] at 3:59 PM, Unit Manager/RN/Registered Nurse X reported she was responsible for updating Resident #11's Care Plans, and she knew he put himself on the floor. RN X said Resident #11 was not care planned to have his bed lowered to the floor because he had a history of [REDACTED].#11's bed to the floor, and had never seen it in that position. Unit Manger X also said 2 assist with cares was not necessarily warranted with Resident #11, since his needs varied. In a second interview, on [DATE] at 10:25 AM, in an empty resident room, Nurse Aide S demonstrated the location of Resident #11's bed and then the location of where he went to retrieve supplies; he said, It was across the room, near the door, 12 feet away. Nurse Aide S said he could not remember if a perimeter mattress was on Resident #11's bed at the time of the fall. Review of Resident #11's Kardex/Nurse Aide Care Guide, not dated/printed [DATE], revealed, [DATE] - Resident lowers self to floor at times .parameter (sic) mattress to identify bed boundaries .anticipate and meet needs .Bed against wall to increase floor space for ADLs/Activities of Daily Living .fall mat next to bed . The Kardex did not include instructions on how many staff were required for safety during care, or what position the bed should be left at (low or next to the floor), or that Resident #11 was on 1:1 supervision. According to the facility Falls - Clinical protocol, dated February, 2013, .Interventions should be developed and implemented per the assessed needs .In addition, interventions for direct care givers should be placed on the CNA care card or similar format .The care plan and CNA care card should be updated as interventions change .Provide emergency care assessments as indicated . According to Advanced Healthcare Network for Nurses, 2001, Immediate Post-Fall Evaluation of the Older Patient .In a non-acute care setting such as a psychiatric hospital, nursing home, assisted living or adult day care facility, a nurse is often the first professional to evaluate a potential fall-related injury. A thorough yet quick physical evaluation can reveal conditions requiring immediate attention or interventions to prevent further injury. Appropriate treatment prior to the arrival of a fire/rescue team or contracted ambulance company can positively affect the patient's outcomes . The National Institute of Health: United States National Library of Medicine 2017 advises in the care of broken bones, .Call 911 .Keep the person still and calm .Examine the person closely for other injuries .In most cases, if medical help responds quickly, allow the medical personnel to take further action . <https://medlineplus.gov/ency/article/ 1.htm> However, the facility's Accidents and Incidents - Investigating and Reporting Policy and Procedure, dated February, 2013, gave contrary and/or conflicting instructions to staff regarding moving a resident who has fallen: . Do not move the victim until he/she has been examined for possible injuries .If possible, move the injured to the treatment room .or his or her bed .If necessary, transfer the injured person to the emergency room . The facility documents, did not clearly instruct staff how to thoroughly assess residents post fall, or to allow Emergency personnel to transfer residents with obvious injury to prevent increased pain and injury.

This citation is related to intake MI 936 and MI 915. Based on observation, interview and record review the facility failed to provide supervision, promote safety and prevent the elopement of 1 of 4 residents (Resident #14) reviewed for elopement risk from a total of 15 sampled residents, resulting in the potential for bodily harm and/or death. Immediate Jeopardy was identified on 6-17-16 with the following findings: According to record review the facility completed an incident form dated 6/4/16 at 3:00 PM reflecting Resident #14 was observed outside the building in the vicinity of the exit door A-hall, knocking on the outside of the door. The facility was unaware of how or when Resident #14 exited the building until 3:00 PM. Witness statements dated 6/4/16 reflected the following: Registered Nurse (RN Q) statement at 3:00 PM reflected she last saw Resident #14 at 2:40 PM. Certified Nurse Aid (CNA P) undated/untimed statement reflected she saw Resident #14 last at 2:40 PM. CNA (S) undated/untimed statement reflected she saw Resident #14 last at around 2:45 PM. CNA (R) statement at 3:00 pm reflected she last saw Resident #14 at 2:35 PM. According to the Electronic Medical Record (EMR) Resident #14 had [DIAGNOSES REDACTED]. Her most recent Minimum Data Set (MDS) completed on 4/15/16 reflected Resident #14 had cognitive issues and a Brief Interview for Metal Status (BIMS) test could not be completed, she required supervision of (1) person for locomotion on/off the unit, and recently had a fall. Resident #14's Cognition care plan reflected a focus of: The resident has impaired cognitive function/dementia or impaired thought processes related to short term memory loss, impaired decision making, long term memory loss, Demetria and Alzheimer's (Initialed on 1/14/16). The Elopement care plan reflected a focus of: The resident is an elopement risk relate to resident wanders aimlessly, looking for someone or something familiar. History of attempts to leave facility unattended. (Initiated on 8/17/15). Interventions consisted of: -Distract resident from wandering by offering pleasant diversion, structured activities, food, conversation, television or book. (Initiated 1/5/16) -Provide structured activities: toileting, walking inside and outside, and reorientation strategies. (Initiated 4/18/16) -Wander alert: wander guard on her left ankle (Initiated 8/17/15) The Fall care plan reflected a focus of: The resident is at risk for falls related to poor communication/comprehension, incontinence. 3/7/16 resident sat herself on the floor, and lowered to the floor. (Last revision 3/8/16) The following interviews were completed on 6/16/16: At 5:10 PM CNA S was interviewed and asked to recall the elopement incident of Resident #14. CNA S revealed, I was walking down A hall and looked down hall, and saw Resident #14 standing outside the door trying to get back in. No alarms were going off . CNA S stated she was not aware of Resident #14 wandering off before. She did have a wander guard on. When queried on who checks wander guards for functioning, CNA S stated the nurses and management. Resident #14 seemed nervous upon returning to the building. I told the nurse's she had got out, and they came down the hall and Resident #14 in through the door she exited. I saw her last around 20 minutes prior. I think she came out the front door and came around to the A hall exit door. At 5:39 Pm Registered Nurse (RN K) was called. She was asked to recall the elopement incident of Resident #14. RN K stated, She was going down the hall and someone said a resident was out the door. I turned and looked down the hall and there she was in A or B hall, I can't recall. I went and let her in. I opened the door and let her in, and the alarm to the exit door went off . Prior to activating the A hall alarm to let Resident #14 inside, no exit doors nor the front door was alarming. The weather was warm. Resident #14 smiled while outside the door, and she was not upset or angry. Resident #14 had on pants, shirt and shoes. RN K stated she did not look at or for her wander guard. The A hall exit door locked after opening, after I pulled it shut. She was not on my hall or my patient that day. RN K denied knowledge of Resident #14 eloping before. The exit door alarm had a loud screeching sound. RN K stated, she gave a verbal statement to administration. I don't think Resident #14 was alert and oriented to person, place or time. Lastly she stated, The alarms are checked every shift with a scan device. The scan device screen indicates if device is functioning. They are located at the nurse's station in a basket. At 5:45 PM this writer and CNA S walked out the entry door, around to Hall A exit door. CNA S stated Resident #14 was standing outside, in front of the outside entrance to the A Hall exit door knocking, and requesting entry. This writer walked from the A hall exit door to the facility entrance, which was a total of 240 feet (with a size 10.5 women's shoe). Elapsed time from point to point was approximately 8 minutes. During the walk from the A hall exit door to front entry, rose bushes with thorns, plants, trees, a cement curb approximately 1 foot in height, uneven pavement, and multiple cars were noted in the parking lot. The parking lot had active traffic back and forth. The pathway from the A-hall exit door was a short distance to a busy 2 way street, with high traffic. At 6:00 PM the list provided by the facility with (13) residents listed for elopement risk with wander guards, devices were checked for functioning with a hand held device. 10 residents with wander guards were on-site. At 6:00 PM 5 of 10 were noted to be functioning and at 6:10 PM that last of the 5 wander guards were noted to be functioning at 6:10 PM. The following interviews were completed on 6/17/16: On 6/17/16 at 9:31 AM Licensed Practical Nurse (LPN T) was interviewed by phone. LPN T was asked to recall the elopement incident of Resident #14 on 6/4/16. LPN T stated, I can remember, I was just punching out at the nursing station and talking. I heard an aid say, Hey look, its Resident #14 she's outside the door. I looked down A hall and I could see Resident #14 standing outside the glass door. Several of us rushed down the hall to bring her back in. LPN T was asked if alarms were sounding prior to letting Resident #14 back inside. LPN S replied, The A hall door was not opened or sounding. It sounded when we opened the door. I told the CNA to get her inside. The front door was not sounding that I could recall . She had a shirt, jogging pants, and shoes on. Her wander guard was on. After we brought her in I checked her wander guard to make sure it worked, and it worked through the remote. I then walked by her the front door and it activated the door lock and sounded. I don't recall her location, before she left the building. She was alert and oriented to herself. In my opinion, she had pushed the door opened, but not sure she knows she was pushing the door. It was warm outside the day of the incident. Her demeanor was fine somewhat anxious, but with interaction she became less anxious. Prior to her exiting she was walking around the nursing station 15-20 minutes prior. LPN T stated no other resident's had eloped. On 6/1717 9:57 AM LPN Q was interviewed by phone. LPN Q was asked to recall the elopement incident for Resident #14 on 6/4/16. LPN Q stated, It was about 2:40 PM, she set the front door alarm off. I got her away from the door and shut the alarm off. She was at the nursing station. She had a wander guard on her ankle, I believe the left. She had pants, tennis shoes and I think a purple shirt on. I went to a resident ' s room and did a treatment that took about 15 minutes and then I came out to the nursing station, and the first shift nurse stated Resident #14 just got outside and was knocking on the A hall door trying to get in. LPN Q stated, I did not hear anything. I was in a resident's room. They already had her in. When a resident with a wander guard goes near front door the alarm goes off, the door does not lock. It would go off, if a Resident tried to exit independently or with a group of people. It should go off . When queried about Resident #14's cognition, LPN Q stated, She was alert, but did not talk. She had dementia. She required supervision. The temperature was pretty warm I think, and it was not raining when she was outside. When I interacted with her, she was just walking around. She does that every summer, she wants to go outside. The activity lady takes her out back, but that's not enough for her, she wants to go outside. The Risk Of Elopement/Wandering Review sheet (most recently performed before the elopement of 6/4/16) dated 5/8/16 reflected, Resident #14 had a history of [REDACTED]. Nurse's Notes dated 4/27/16 reflected Resident #14 was monitored for exit seeking. Nurse's Notes dated 5/8/16 reflected Resident #14 was observed exit seeking. At 12:28 PM this writer walked from the main entrance of the facility to the edge of the street, which took approximately 8 minutes. The distance was 338 feet (wearing a size 10.5 women ' s shoe). Again, traffic was flowing fluently and fast with automobiles and semi-trucks. Resident #14 walked out of the building, into the parking lot (with uneven pavement, cement curbs, thorny bushes, and cars and with moving traffic at times), around to the A Hall exit door, and had the potential to walk from the parking lot out into the street with moving traffic. The previous noted actions, had the potential to cause bodily harm and/or death. ( ) On 6-17-16 the facility provided an immediate jeopardy past non-compliance packet which was accepted on 6-17-16, upon verification by the surveyor onsite with the following interventions: · On 6/4/2016 Resident #14 was assessed for injury and negative outcomes by staff LPN and 6/8/2016 by staff LPN none were identified. · On 6/4/2016 an audit to assure exit door alarms were in working order was completed by Maintainence Supervisor and daily thereafter and reviewed by the administrator. All were found to be functional. · On 6/4/2016 and continuing until discharge 6/13/2016 Resident #14 was placed on 1:1 to monitor for exit seeking behaviors, and promote safety. · On 6/4/2016 POA, was informed of and agrees with the Plan of Care. · On 6/4/2016 an audit of current residents 68 of 68 residing in the facility was completed by staff RN and Nursing Home Administrator to ensure current residents were safe and accounted for. · On 6/4/2016 an audit of residents 13 of 68 current resident, with wander guards in place has been completed to check placement, function, and expiration date was conducted by the Director of Nursing and nursing staff. · On 6/4/2016 a sign was verified to be in place on the front door by Nursing Home Administrator alerting persons that exit the facility to not allow residents out without checking with the nurse. · On 6/4/2016 Elopement Prevention and management Program was reviewed by the Director of Nursing and Nursing Home Administrator and deemed appropriate. · On 6/4/2016 Resident #14 Elopement risk assessment was updated, Care Plan reviewed, Care delivery guide reviewed to ensure appropriate assessment and interventions were in place. · On 6/4/2016 - 6/5/2016 at various times to include each shift. Elopement drills were conducted by the Nursing Home Administrator, facility Educator, and Director of Nursin, each shift and recorded on the record of in-service form. · On 6/4/2016 the process for daily alarm checks was changed to include utilizing a facility map, for all checks, with alarmed doors identified by number which requires a signature attesting to functionality. These reports are reviewed by the Administrator or designee on the next business day. · On 6/4/2016 Residents at risk for elopement 13 of 68, were reviewed by Director of Nursing, and staff nurses to review/revise elopement risk, care plan, care delivery guides to ensure appropriate assessment and intervention in place. · On 6/4/2016 an audit was completed, by Director of Nursing and staff nurses, of the elopement book to verify that all residents at risk for elopement 13 of 68 had an elopement photo sheet in place. · Beginning on 6/4/2016 Facility staff, including nursing, maintenance, dietary, activities, social services, billing, staffing, payroll, and medical records in addition to contracted housekeeping, laundry, and therapy staff, were re-educated by the Facility Educator, Administrator, and Director of Nursing on the elopement policy including, prevention, reporting responsibilities, management, maintaining door alarms and wander control systems, responding to alarms and ensure doors are secured when passing through. The education that was initiated on 6/4/2016 and continued until 6/15/16 at which time 98 of 98 staff members were educated. With the onset of the education, uneducated staff member were not allowed to work until they received the education. · Beginning 6/6/16 employees newly hired to the facility will receive the elopement training by the completion of classroom training. · On 6/6/2016 the Front door code alert system was changed to a new code by Frank Grajewski, Maintenance Director. · On 6/6/2016 an IDT meeting regarding resident #14 was held to review elopement risk, care plan, care delivery guides to ensure appropriate assessment and intervention in place. · On 6/6/2016 an Elopement Prevention Care audit tool was completed by Director of Nursing. · On 6/6/2016 the front door sign was placed on both sides of the front door to be viewable upon entrance and exit, by Nursing Home Administrator, alerting persons that exit the facility to not allow residents out without checking with the nurse. · On 6/6/2016 an Ad Hoc QAPI meeting was held to review the event as well as the plan. · On 6/6/2016 the plan was reviewed with the the facility Medical Director by phone by the Administrator. · Beginning 6/4/2016 weekly the Administrator/designee is reviewing alarm checks which include the front exit door to ensure they are completed. · Beginning 6/4/2016 weekly the Director of Nursing/designee will complete an audit to verify documentation on wander guard checks daily are being documented in the Treatment Administration record. · Beginning 6/6/2016 and monthly the Director of Nursing/designee and IDT will complete the Elopement prevention Care Audit for residents at risk for elopement. · Beginning 6/4/2016 an Elopement drill will be completed weekly for one month then monthly thereafter. ( )

This citation pertains to MI 821. Based on interview and record review the facility failed to provide adequate and appropriate care while inserting a Foley catheter (tube inserted into bladder for urine drainage) for 1 resident (#1) from a total sample of 3 residents reviewed for Foley catheters, resulting in Resident #1 being hospitalized for [REDACTED]. Findings include: Review of the Face Sheet dated 8/24/14 and the current Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS is a resident assessment tool) revealed Resident #1 was cognitively intact and required extensive assistance with most activities of daily living (ADLs). Review of the Nursing Home to Hospital Transfer Form dated 10/3/14, revealed Resident #1 was transferred to the hospital on [DATE] for the reason, "gross hematuria". Review of the hospital patient discharge instructions dated 10/3/14 at 6:41 p.m. revealed, "Discharge Diagnosis: [REDACTED]." Trauma to the urethra can cause significant problems. Injury can cause leakage of urine into surrounding tissues and result in swelling, inflammation, infection and abdominal pain. Urethral trauma can also cause the inability to urinate, retention of urine in the bladder and blood in the urine (hematuria). (http://www.urologyhealth.org/urology/index.cfm?article=44). Review of the facility nursing note dated 10/3/14 at 2:00 p.m. revealed, that the Director of Nursing (DON) "B" changed Resident #1's Foley catheter prior to the residents transfer to the hospital. Review of nursing notes just prior to the 10/3/14 at 2:00 p.m. note failed to reveal any issues with Resident #1's Foley catheter, to include no mention of blood in the Foley collection bag. Review of the SBAR Communication Form dated 10/3/14 revealed, "CENA (Certified Nursing Assistant) alerted this nurse (RN "I") to blood in resident (#1's) Foley collection bag. 300 cc (cubic centimeters) of hematuria noted in bag (with) blood in drainage tube...Foley balloon deflated and 5 cc of NS (normal saline, it should have been 10 cc) extracted from balloon. Foley was found to be inserted approximately 2 inches into penis. Upon removal, blood and clots flowed from penis...MD (medical doctor) notified and (received) order to (transfer) resident to ER (emergency room )... During an interview on 10/29/14 at 2:09 p.m., RN "I" stated, on 10/03/14 at round 3:30-4:00 (p.m.) a CENA told RN "I" that there appeared to be blood in Resident #1's Foley. RN "I" stated she went to Resident #1's room to assess the Foley bag, and found there to be about 300 cc of bloody urine in the Foley bag. RN "I" further stated that she told the night supervisor, RN "N" of her findings, and together they assessed Resident #1 before receiving the physician order [REDACTED]. During an interview on 10/29/14 at 3:55 p.m., Night Shift Supervisor, RN "N" stated that during the assessment of Resident #1, it was found that the balloon that holds the Foley catheter in place was palpated to be in the middle of the shaft Resident #1's penis, not in the bladder where it was supposed to be. Review of the facility's Indwelling Urinary Catheters Procedure revised July 2012, failed to reveal instructions for proper insertion of a Foley catheter. During an interview on 10/29/14 at 12:15 p.m., the facilities District Education and Training Director, RN "H" stated that there was no facility policy and/or procedure containing step by step instructions for inserting a Foley catheter. RN "H" stated, the facility has access to and is encouraged to use Lippincott's (a leading provider of trusted content for [MEDICATION NAME] nurses) Online Procedures site for nursing procedures. RN "H" further stated that nurses are not required to complete any type of training or skills competency for Foley catheter insertion. During an interview on 10/29/14 at 12:15 p.m., DON "B" stated, "I changed the catheter (for Resident #1 on 10/3/14), there was some trauma going in...He (Resident #1) didn't present with any signs or symptoms of a UTI, I think that the blood was not from the UTI, but rather from the catheter change". During the same interview, this surveyor asked DON "B" if prior to inserting Resident #1's Foley catheter, if DON "B" reviewed the Lippincott's Procedure, DON "B" stated "no". DON "B" was asked about the procedure she used when inserting Resident #1's Foley catheter. DON "B" stated that she washed her hands and then applied gloves, deflated the balloon from the old Foley and then removed the old Foley. DON "B" further stated, that she then washed her hands, put on clean gloves. This surveyor asked DON "B" if this procedure was a "clean" or "sterile" procedure. DON "B" stated it was a "clean" procedure, this surveyor then clarified with DON "B" if the procedure was a "clean" or "sterile" procedure. DON "B" stated, "clean". DON "B" further stated that she started to insert the catheter into Resident #1's penis, this surveyor asked DON "B" to clarify at what angle the penis was being held while inserting the catheter, DON "B" stated, "I don't remember at what angle I held the penis". DON "B" further stated, "I felt some resistance, pulled back a little bit and then was able to to go back in". Review of the online Lippincott Procedures - Indwelling urinary catheter (Foley) insertion, male, revised 10/4/13, revealed, "Use sterile technique when inserting...Hold the patient's penis with your nondominant hand...Then gently lift and stretch the penis to a 60-90 degree angle. Hold the penis this way throughout the procedure to straighten the urethra and maintain a sterile field". ( )

This citation pertains to MI 121 This citation contains two deficient practice statements (A and B). DPS A. Based on observation, interview and record review, the facility failed to implement timely and effective interventions to prevent a stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) coccyx pressure ulcer for 1 (Resident #1) of 9 reviewed for pressure ulcers from a total sample of 9, resulting in the facility being placed in Immediate Jeopardy on 8/26/14 when Resident #1 had foul odor and gray drainage from her pressure ulcer and was not seen at the wound clinic until 9/4/14. There were no additional interventions implemented during that 10 day period. On 9/5/14, Resident #1 was hospitalized for [REDACTED]. This deficient practice placed 6 residents identified with pressure ulcers (Resident #3, #4, #5, #6, #7, #8) from a total sample of 9, at risk for serious harm, injury, and/or death. The facility was placed in Immediate Jeopardy as a result of the facility's failure to implement timely and effective pressure ulcer interventions for 1 (Resident #1) who developed a stage 4 pressure ulcer. On 8/26/14, Resident #1 had foul odor and gray drainage from her pressure ulcer, the physician was notified, a wound clinic evaluation was recommended, and no other interventions were implemented for the following 10 days. On 9/4/14, Resident #1 was assessed at the wound clinic and noted to have a stage 4 pressure ulcer measuring 4.7 cm in length x 2.6 cm in width x 2.8 cm in depth, orders were received to start 2 IV (intravenous) antibiotics ([MEDICATION NAME] and [MEDICATION NAME],) an IV antifungal ([MEDICATION NAME]) and a wound VAC. Resident #1 did not receive any ordered IV medications while in the facility and on 9/5/14, Resident #1 was transferred to the hospital for a [DIAGNOSES REDACTED]. On 9/19/14 at 4:13 pm, the Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy that began on 8/26/14, and identified on 9/19/14, due to the facility's failure to protect Resident #1 from a stage 4 pressure ulcer and the potential for 6 sampled residents (Resident #3, #4, #5, #6, #7, #8) with pressure ulcers to remain at increased risk for worsening pressure ulcers. A request for a written plan of removal was requested at that time. On 9/24/14 at 9:00 am, the surveyor verified that the facility had done the following to remove the Immediate Jeopardy: - On 9/19/14 residents with identified pressure ulcers were reassessed. Residents' medical records were also reviewed to validate timely implementation of current physician orders [REDACTED]. Records were reviewed to ensure care plans reflected current status as well as consult recommendations has been implemented as deemed appropriate by primary physician and Interdisciplinary Team (IDT). - On 9/19/14 a one time skin assessment was completed on remaining in-house residents to ensure any areas of skin impairment were identified appropriately and had timely, effective interventions in place per physician order [REDACTED]. On 9/19/14 the facility began re-educating Unit Managers, the District Education and Training Director, and the Director of Nursing in regards to physician notification, implementation of timely and effective interventions, and the wound program. - On 9/19/14 the facility began re-educating all licensed nurses on physician notification, implementation of timely and effective interventions, and the wound program. As of 9/21/14, 24 of 25 licensed nurses received the education. 1 nurse was issued a certified letter of termination. - On 9/19/14 at 6:45 pm, an ad hoc QAPI meeting was held with the Medical Director via telephone, the Nursing Home Administrator (NHA) "A", and the Regional Director of Clinical Operations (RDCO) "J". - On 9/19/14, Unit Managers began reviewing physician orders [REDACTED]. Although the Immediate Jeopardy was removed on 9/19/14, the facility remained out of compliance with a scope of isolated and severity of "No actual harm with a potential for more than minimal harm that is not immediate jeopardy" due to sustained compliance having not been verified by the State Agency. Findings include: Resident #1 Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE], revealed Resident #1 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #1 had severe cognitive impairment, required extensive assistance of 2 staff for bed mobility, was always incontinent of bladder, and had 1 stage 2 pressure ulcer with an onset date of 6/26/14. Resident #1 was not in the facility during the survey. Review of Resident #1's Braden Risk Assessment Scales, dated 5/20/14 and 8/10/14, revealed a score of 12 (high risk) Review of Resident #1's IDT (interdisciplinary team) notes, dated 6/26/14, revealed Resident #1 had an "area to coccyx stage 2". The IDT note revealed Resident #1 would be turned and repositioned every hour. There were no measurements of Resident #1's pressure ulcer. Review of Resident #1's skin grid, revealed on 7/2/14, her coccyx pressure ulcer measured 3.1 cm in length x 2.3 cm in width x 0.2 cm in depth. There was no staging of the pressure ulcer. The skin grid revealed the following measurements for Resident #1's coccyx ulcer: 7/22/14 (20 days later) stage 2 measuring 3.5 cm x 2.3 cm x 0.1 cm 7/31/14 (9 days later) stage 2 measuring 1 cm x 0.4 cm, 0.1 cm 8/4/14 stage 2 measuring 0.5 cm x 0.4 cm x 0.1 cm 8/12/14 unstageable (full thickness tissue loss in which the base of the ulcer is covered in slough or eschar) measuring 1.4 cm x 1.7 cm x 0.2 cm 8/18/14 unstageable measuring 2 cm x 1.6 cm 8/25/14 unstageable measuring 5 cm x 2 cm 9/2/14 unstageable measuring 5.7 cm x 2.6 cm x 0.4 cm with foul odor and purulent drainage Review of Resident #1's Skin Integrity Assessment: Prevention and Treatment Care Plan dated 5/12/14, revealed Resident #1 was on the "yellow dot turning program" as of 5/12/14. The care plan revealed that on 8/9/14, Resident #1 was marked as "high risk" and "increase frequency of turning" was checked. There were no new interventions after 8/9/14, despite documentation on the care plan that on 8/13/14, Resident #1's coccyx ulcer was restaged as unstageable. Review of the facility's Turning and Repositioning Program policy and procedure revised 4/09, revealed "1. Place a yellow dot on the nameplate of the resident's door and/or wheelchair/gerichair whenever a resident is: unable to turn self, unable to reposition self. 2. Turn and reposition residents ever 1-2 hours when; in bed, in wheelchair/gerichair...5. Place a black line thru the Yellow Dot for residents who...require more frequent turning and repositioning. An observation on 9/19/14 revealed Resident #1's name was still on the nameplate outside her room. There was a yellow dot beside her name. There was not a black line through the yellow dot (indicating more frequent turning and repositioning) despite Resident #1's care plan stating as of 8/9/14, she required more frequent turning and repositioning. Review of Resident #1's Medication Administration Record [REDACTED]. Review of the Nutrition Risk Data Collection and assessment dated [DATE], revealed Resident #1 had her quarterly nutrition assessment performed. The assessment revealed Resident #1 had a coccyx and heel ulcer and "following nutrition intervention to be added to improve nutritional status and heel wound. Add Prostat AWC 30 cc (cubic centimeter) BID (twice a day) to aid (with) wound healing will (change) IC (ice cream) to fortified ice cream (magic cup) BID for added calories..." Review of the Physician Nutrition Recommendation Form dated 8/14/14, revealed a recommendation for Prostat AWC (Prostat Advanced Wound Care/high calorie, protein supplement) 30 cc twice a day. The form was signed by the physician on 8/18/14 (4 days later) and marked as "noted" on 8/19/14 (5 days later). Review of Resident #1's Medication Administration Record [REDACTED]. Review of Resident #1's lab results dated 8/20/14 revealed total protein was 6.4 (normal 6.6-8.2) and [MEDICATION NAME] (main protein of the blood) was 3.4 (normal 3.5-5.2). Review of Resident #1's progress notes dated 8/26/14, revealed "drainage dark gray, foul odor noted. (physician) called. Rec (recommend) new order send to (wound clinic). Appt 9/4/14 at 0815 (8:15 am). There was no documentation of increased monitoring or new interventions between the time the physician was notified and the scheduled wound clinic appointment. Review of Resident #1's Actual/Potential for Infection Care Plan dated 7/3/14, revealed interventions dated 7/3/14 which included: treatment of [REDACTED]. The care plan was not updated. Review of Resident #1's Vital Signs-Individual Resident Flowsheet, revealed vital signs were performed on 8/1/14 at 9/1/14. Review of the Progress Notes revealed the next documented vital signs were on 9/5/14. Review of the physician's progress notes dated 8/9/14, revealed no mention of Resident #1's pressure ulcer and no documentation that Resident #1's wound was assessed by the physician. On 9/19/14 at 3:25 pm, this surveyor requested documentation from the last time a physician visualized Resident #1's pressure ulcer. Unit Manager (UM) "C" stated the only documentation was from when Resident #1 was evaluated at the wound clinic on 9/4/14. In an interview on 9/19/14 at 11:32 am, Licensed Practical Nurse (LPN) "D" reported the she called Physician "E" after noticing that Resident #1's coccyx ulcer had a foul odor and gray drainage. LPN "D" reported that Physician "E" ordered a wound clinic consultation. LPN "D" reported she told Physician "E" to hold on because she wanted to see if any other interventions should be put in place for Resident #1, but Physician "E" hung up and transferred the call to the wound clinic. When queried if Physician "E" was made aware that Resident #1's wound clinic appointment was scheduled for 10 days later, LPN "D" stated "I'm not sure. I don't know what conversation he had with them". In a second interview on 9/19/14 at approximately 12:00 pm, LPN "D" reported that she notified Unit Manager (UM) "F" and the response was to let UM "F" know when Resident #1's appointment was scheduled. In a third interview on 9/19/14 at 1:30 pm, LPN "D" stated that she contacted the physician on 8/26/14 "because it had odor...she needed a new treatment...I was thinking infection". When queried if anything was done differently for Resident #1 during the following 10 days, LPN "D" stated "No, still doing the same treatment". In a telephone interview on 9/19/14 at 10:25 am, Director of Nursing (DON) "B" was queried if Resident #1 was on any different repositioning schedule/program than every 2 hours. DON "B" stated that she did not recall anything other than reposition every 2 hours and that she did not remember the increased frequency of turning that was placed on the care plan on 8/9/14. When queried about what interventions were implemented during the 10 days following the recommendation for the wound clinic and Resident #1's actual appointment, DON "B" stated "we had spoke with the physician. He had no new orders for her treatment at that time. He just wanted the consult". When queried how many times the physician had assessed Resident #1's wound, DON "B" reported that she was not sure. DON "B" reported that Resident #1 did not receive a dose of IV antibiotics after her wound clinic appointment because the PICC line nurse did not come to the facility on [DATE] to place a PICC line. DON "B" reported Resident #1 was sent to the hospital the following day, 9/5/14. When queried if side to side only positioning was ever considered for Resident #1, DON "B" stated "If so, that would be in the care plan. I don't specifically recall that as an intervention. It would be on her care plan if it was." In a second telephone interview on 9/19/14 at 12:57 pm, DON "B" stated the physician was contacted on 8/26/14 because Resident #1's "wound was getting worse". When queried if there was any follow up with the physician regarding the foul odor and gray drainage from Resident #1's wound. DON "B" stated "I know he was in the facility after that, but I don't know if he made a note". In an interview on 9/24/14 at 2:00 pm, Physician "E" reported that he was Resident #1's physician while she was in the facility and also the wound physician who assessed her at the wound clinic on 9/4/14. Physician "E" reported that he could not recall seeing Resident #1's wound prior to 9/4/14. Physician "E" stated "when I saw the wound in the wound care center, it was necrotic and showed signs of infection..." and reported that he wrote orders for a PICC line and IV antibiotics. Physician "E" reported that he called the facility the following day (9/5/14) to notify the facility of the lab results and osteo[DIAGNOSES REDACTED]. At that time, facility staff informed him the PICC line had not been placed and therefore Resident #1 had not received any of the ordered IV antibiotics. Physician "E" stated "So 24 hours had gone by and I ordered IV antibiotics and I would have expected the patient to get them. I was told that they couldn't get out to put the PICC line in...My major concern was a nurse did not use her nursing knowledge and start a peripheral IV to start the antibiotics..." Review of the Wound Clinic report dated 9/4/14 and electronically signed by Physician "E", revealed "consultation for sacral decubitus ulceration...there was a pressure ulcer that had developed...the sacral decubitus foul smelling ulcer with tissue breakdown that is present...the wound probes all the way to the bone and the material was extremely foul smelling..." The assessment and plan section revealed "sacral decubitus pressure ulceration that appears to be osteo[DIAGNOSES REDACTED] and I wrote orders for the patient (Resident #1) to be transferred back to (the facility). Start IV PICC line, IV [MEDICATION NAME] 1 g (gram) IV q (every ) 12 hours...IV [MEDICATION NAME] 3.375 g IV q 6h (hours) along with [MEDICATION NAME] 200 mg (milligrams) IV daily. Review of Resident #1's physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. DPS B. Based observation, interview, and record review, the facility failed to implement care planned interventions for 1 (Resident #3) of 9 reviewed for pressure ulcers, from a total sample of 9, resulting in the potential for a worsening pressure ulcer. Findings include: Review of the Face Sheet and MDS dated . 6/21/14, revealed Resident #3 was an [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #3 weighed 81 pounds. Review of Resident #3's Braden Risk Assessment Scale dated 8/15/14, revealed a score of 15 (minimal risk). Review of the Skin Grid dated 8/1/14, revealed Resident #3 had a stage 2 pressure ulcer on her right upper buttock measuring 0.5 cm in length x 0.7 cm in width. The Skin Grid also revealed that on 9/16/14, Resident #3 continued to have a stage 2 pressure ulcer measuring 1 cm in length x 0.8 cm in width x 0.1 cm in depth. Review of Resident #3's Skin Integrity Assessment care plan dated 12/18/13, revealed an intervention dated 8/12/14 to turn the air mattress setting down from firm related to decreased weight. Observations on 9/18/14 at 11:25 am, 12:00 pm, 1:15 pm, 2:55 pm, 9/19/14 at 9:45 am and 11:15 am, revealed Resident #3's mattress was set at "9" which was the firmest setting and labeled for 350 pounds. ( )

This citation pertains to intake number MI 351 Based on observation, interview and record review the facility failed to prevent a fall for 1 (#11) resident from a total sample of 4 assessed for falls resulting in a fall with compression fractures. Findings include: According to the facility face sheet, dated 1/23/14, Resident #11 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #11 was readmitted on [DATE] after hospitalization resulting from a fall on 1/3/14 which caused compression fracture of 2 lumbar ( low back) vertebrae and a [DIAGNOSES REDACTED]. According to the Minimum Data Set, dated dated [DATE], Resident #11 had minimal cognitive impairment, required assist of 2 staff for bed mobility and transfers, required assist of 1 staff to push his wheelchair, dress, hygiene, bathing and toileting. He was never incontinent of bladder and occasionally incontinent of bowel. According to Resident #11's mobility plan of care, dated 12/5/13, he was a stand-by assist with gait belt for ambulation and, on 12/13/13, he was a stand-by for transfer. The risk factors for mobility, check-marked under "problem", were chronic back pain, falls, atrial fibrillation, diabetes, antidepressant and generalized weakness. Not mentioned were the history of respiratory failure resulting in ventilator support, multiple surgeries prior to admission, blood pressure (BP), water and pain pills Resident #11 was taking and low BPs, nor were sweating with activity, shortness of breath, or staring spells noted. According to the admission history and physical, dated 12/9/13, Resident #11 sustained a fall from a standing position and hit head prior to his hospitalization that led to admission to the facility. According to Medication Administration Records for December 2013 and January 2014, Resident #11 was prescribed the following medications that could lower blood pressures: Furosemide (water pill) 20 milligrams (mgs) once daily, Norco (narcotic for pain) as needed, Tramadol (non-narcotic pain med) 40 mg as needed, lisinopril with Hydrochlorothiazide (combination BP-water pill) 20/25 mgs daily and Metoprolol (BP) 25 mg twice daily. Both the Lisinopril and Metoprolol were to be held 24 if the systolic BP (top number) was below 110. Resident #11's Lisinopril was documented as held 16 of 44 opportunities, and Metoprolol 43 of 91 opportunities. There was no evidence that the physician was notified of the number of low BP readings, and Administrator "A" was unable to locate any orthostatic BP (series of BP checks to determine if pressure drops from lying to sitting and sitting to standing) documentation for Resident #11. Administrator "A" also verified that Resident #11's physician had not visited since 12/9/13, and was unsure how this was missed. According to occupational therapy treatment notes, dated 12/31/13, Resident #11. "has progressively become 'shakier' with transient confusion during treatments often just having a blank stare. He also appears to have SOB (shortness of breath) with activity. Notified nursing". According to the occupational therapy assistant progress notes indicated that between 12/25/13 and 1/1/14, Resident #11 seems to be acting confused during tx (treatment)", and "showing little to none (sic) progress this period due to progressively getting 'shakier' and SOB". A review of resident #11's Nurse's Progress Notes reflected the following: On 12/12/13 at 3:30 a.m. he refused Norco because he felt dizzy after taking it. On 12/12/13 at 9:15 a.m. he reported that the Norco made him feel sick. On 12/14/13, he requested his blood sugars be checked more often as he was worried about them being too high. No symptoms are documented. On 12/18/13, he refused supper because he was not hungry. On 12/31/13, he refused Tramadol because it upset his stomach. According to the facility Progress Note dated 1/3/14, at 8:00 p.m., Resident #11 was found sitting against the bathroom door in his room. His walker was with him. Resident #11 reported that he hit his head and had hip pain. The note reflected that Resident #11's facial expressions indicated that he was having pain. The recorded BP was 90/56 which is low, even for him. Resident #11 was sent to the hospital, and the progress note reflected that the physician was notified. On 1/27/14 at 11:30 a.m., Resident #11 was interviewed. He was seated in his wheelchair and wearing his brace which resembled armor and covered him front and back from armpit to groin. When asked, Resident #11 said that he hated the brace he had to wear whenever out of bed because he couldn't urinate properly into the toilet or the urinal, and it was clumsy. Resident #11 said that the nurses were always yelling at him for sitting on the edge of his bed without the brace, and when he removed the brace after up in his wheelchair. He said that he wasn't currently walking, but hoped that would change soon. On 1/27/14 at 1:30 p.m., Therapy Director "E" was interviewed. When asked, she said that staff in the therapy department did check the BP, orthostatic BP, pulse, respirations and pulse oximetry (oxygen in the blood) for residents. Therapy Director "E" stated no orthostatic BPs were checked for Resident #11. On 1/27/14 at 2:00 p.m., Registered Nurse (RN) "K" was interviewed. When asked if she recalled staff from therapy advising her of Resident #11 having symptoms of transient confusion, shaking or sweating. After consulting Resident #11's medical record, she recalled that it was on 1/3/14, and said, "I believe I let the doctor know". Concurrently, Resident #11's lab for managing his Warfarin (blood thinner) dose was critically high, and that was documented as called to the physician. There was no documentation of symptoms, as described by therapy staff, being reported to the physician. On 1/27/14 at 2:15 p.m., Certified Nurse Assistant (CNA) "N" was interviewed. When asked, CNA "N" said that Resident #11 did get up to use the bathroom without calling for assistance, and had done so since he was admitted . When asked if Resident #11 seemed ill or not himself prior to his fall on 1/4/13, CNA "N" said that he was "off", seemed more confused before the fall. When asked, CNA "N" looked at the calendar and said that she worked December 23, 27 and 30 and did care for Resident #11 on those days. On 1/278/14 at 2:25 p.m., RN "O" was interviewed. When asked, RN "O" said he had never done orthostatic BP measurements on Resident #11. When asked, RN "O" said that he had been Resident #11's nurse often. RN "O" said that other nurses reported Resident #11 typically only answered in yes's and no's, but he (RN "O") felt Resident #11 would engage in conversation with him. When asked, RN "O" conveyed that Resident #11 did became gradually more withdrawn since admission. On 1/29/14 at 11:40 a.m., Occupational Therapy Staff "J" returned this surveyor's phone call. When asked, Staff "J" felt that Resident #11 was less attentive when greeted in the facility. During therapy, Staff "J" would be talking with Resident #11, and he would stop answering or moving, and stare off. The last week of December 2013, Staff "J" observed this behavior more frequently, up to 4-5 times per therapy session. Resident #11 would also get shaky and sweaty during therapy, which was new for him. Staff "J" stated that her therapy aide reported similar observations nearly every day that week. When asked, Staff "J" could not recall which nurse she reported the symptoms to. Staff "J" also said that Resident #11 would say, "Something is not right with me" on a few occasions during the week before the fall. On 1/29/14 at 12:10 p.m., Therapy Assistant Staff "L" called this surveyor. When asked, Staff "L" said that Resident #11 reported not feeling well and complaining of increased back pain during the last week of December 2013. When asked, Staff "L" could not remember which nurse she reported this information to. The facility failed to notify the physician and follow up on multiple instances of low BP, and Resident #11's complaints of not feeling in the week prior to the fall on 1/3/14. ( )

THIS CITATION PERTAINS TO MI 173 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE THE NECESSARY CARE AND SERVICES TO ATTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL-BEING ( IMMEDIATELY PERFORM CARDIOPULMONARY RESUSCITATION (CPR) AND INITIATE EMERGENCY MEDICAL SERVICES (EMS) ON A FULL CODE RESIDENT) IN 1 OF 7 SAMPLED RESIDENTS (RESIDENT #505) WHO HAD ADVANCED DIRECTIVES IN PLACE, FROM A TOTAL SAMPLE OF 7 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY WHEN RESIDENT #505, WHO WAS A FULL CODE, WAS FOUND UNRESPONSIVE ON [DATE] AT 6:45 AM AND CPR AND EMS RESPONSE WAS NOT INITIATED FOR 13 MINUTES BY FACILITY STAFF. THIS DEFICIENT PRACTICE PLACED ALL 31 RESIDENTS, IDENTIFIED AS BEING FULL CODE, AT RISK FOR SERIOUS HARM, INJURY, AND/OR DEATH. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET IN THE MEDICAL RECORD (UNDATED) REVEALED RESIDENT #505 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE]. REVIEW OF THE [DIAGNOSES REDACTED]. REVIEW OF THE MINIMUM DATA SET (MDS), dated [DATE], REVEALED RESIDENT #505 HAD NO COGNITIVE IMPAIRMENTS AND REQUIRED STAFF ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADL'S). REVIEW OF A CARDIOPULMONARY RESUSCITATION (CPR) CONSENT FORM, DATED [DATE], REVEALED RESIDENT #505 WANTED CPR PERFORMED IN THE EVENT OF AN OBSERVED OR UNOBSERVED [MEDICAL CONDITION] (HEART STOPPAGE) AND FOR NURSING STAFF TO INITIATE CPR, USE OF THE AUTOMATIC EXTERNAL DEFIBRILLATOR (AED - A DEVICE USED TO RESTART THE HEART), AND EMERGENCY MEDICAL SERVICES (EMS) PERSONNEL WOULD BE CALLED. IN AN INTERVIEW ON [DATE] AT 12:50 PM, REGISTERED NURSE (RN) #1 REPORTED ON [DATE] AT 6:00 AM, RESIDENT #505'S MEDICATION WERE HELD DUE TO SOMNOLENCE (SLEEPINESS). RN #3 REPORTED RESIDENT #505'S RESPIRATIONS WERE REGULAR AND UNLABORED AND SHE DID NOT APPEAR TO BE IN DISTRESS AT THAT TIME. IN AN INTERVIEW ON [DATE] AT 1:45 PM, CERTIFIED NURSING ASSISTANT (CNA) #4 REPORTED ON [DATE] AT 6:45 AM, SHE WENT INTO RESIDENT #505'S ROOM TO GIVE HER FRESH WATER FOR THE DAY AND FOUND RESIDENT #505 IN BED, WITH HER SKIN PALE IN COLOR, AND NOT BREATHING. CNA #2 STATED THAT SHE IMMEDIATELY NOTIFIED LICENSED PRACTICAL NURSE (LPN) #5. IN AN INTERVIEW ON [DATE] AT 3:20 PM, LPN #5 REPORTED ON [DATE] AT APPROXIMATELY 6:50 AM, SHE ASKED RN #3 FOR ASSISTANCE AND THEY BOTH WENT INTO RESIDENT #505'S ROOM. LPN #5 REPORTED SHE CHECKED RADIAL AND CAROTID PULSES ON RESIDENT #505 AND NONE WERE PALPATED. LPN #5 REPORTED SHE THEN CHECKED APICAL PULSE AND LUNG SOUNDS WITH A STETHOSCOPE AND NONE WERE AUSCULTATED. LPN #5 REPORTED RESIDENT #505 WAS PALE IN COLOR AND HER SKIN WAS COLD TO THE TOUCH. LPN #5 REPORTED SHE INSTRUCTED RN #3 TO CALL THE DIRECTOR OF NURSING (DON) #2. PER THE AMERICAN RED CROSS FIRST AID AND SAFETY HANDBOOK (2011), "A PERSON IN [MEDICAL CONDITION] IS UNCONSCIOUS, NOT BREATHING AND HAS NO HEARTBEAT." THE HANDBOOK REVEALED THAT A PERSON IN [MEDICAL CONDITION] WILL HAVE THE GREATEST CHANCE OF SURVIVAL IF THERE IS 1) EARLY ACCESS TO THE EMERGENCY MEDICAL SERVICES (EMS) SYSTEM, 2) EARLY CPR, 3) EARLY DEFIBRILLATION, AND 4) EARLY ADVANCED MEDICAL CARE. THE HANDBOOK ALSO REVEALED THAT "WITHOUT EARLY CPR AND DEFIBRILLATION, THE CHANCE FOR SURVIVAL IS GREATLY REDUCED." THE HANDBOOK MENTIONED THAT "ONCE YOU BEGIN CPR, DO NOT STOP EXCEPT IN ONE OF THESE SITUATIONS....ANOTHER TRAINED RESPONDER OR EMS PERSONNEL TAKE OVER." IN AN INTERVIEW ON [DATE] AT 12:50 PM, RN #3 REPORTED SHE CALLED DON #2 AT 6:58 AM TO INFORM HER OF RESIDENT #505'S DEATH AND DON #2 ASKED WHAT RESIDENT #505'S CODE STATUS WAS. RN #1 STATED SHE INFORMED DON #2 RESIDENT #505 WAS A FULL CODE. RN #3 REPORTED DON #2 INSTRUCTED HER TO INITIATE "CODE BLUE." REVIEW OF THE FACILITY "CARDIO [MEDICAL CONDITION] RESUSCITATION (CPR) BASIC LIFE SUPPORT (BLS)" PROCEDURE, DATED AS BEING LAST REVISED ,[DATE], REVEALED: "UNLESS A DECISION NOT TO INITIATE CPR HAS PREVIOUSLY BEEN MADE BY THE RESIDENT...CPR WILL BE INITIATED ON ANY RESIDENT THAT EXPERIENCES A WITNESSED OR UNWITNESSED CARDIOPULMONARY ARREST WHILE IN THE CENTER." REVIEW OF THE AMBULANCE REPORT, DATED [DATE], REVEALED EMS RECEIVED A CALL FROM THE FACILITY AT 7:03 AM AND ARRIVED AT THE SCENE AT 7:07 AM. THE REPORT REVEALED RESIDENT #505 WAS PRONOUNCED DEAD AT 7:28 AM BY THE EMS PERSONNEL. ON [DATE] AT 1:10 PM, THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT BEGAN ON [DATE], AND WAS IDENTIFIED ON [DATE], WHEN THE FACILITY FAILED TO PROVIDE CARE AND SERVICES TO ATTAIN THE HIGHEST PRACTICABLE PHYSICAL WELL-BEING (PERFORM CARDIOPULMONARY RESUSCITATION (CPR) AND INITIATE EMERGENCY MEDICAL SERVICES (EMS) ON A FULL CODE RESIDENT) IN 1 (RESIDENT #505) OF 10 SAMPLED RESIDENTS WHO HAD ADVANCED DIRECTIVES FOR CPR IN PLACE, FROM A TOTAL SAMPLE OF 10 RESIDENTS, RESULTING IN AN IMMEDIATE JEOPARDY WHEN RESIDENT #505 WAS FOUND UNRESPONSIVE ON [DATE] AT 6:45 AM. ON [DATE], THIS SURVEYOR CONFIRMED THAT THE FACILITY IMPLEMENTED THE FOLLOWING TO REMOVE THE IMMEDIATE JEOPARDY: 1. ON [DATE], IMMEDIATE INITIATION OF EDUCATION FOR LICENSED NURSES BEGAN, INCLUDING CPR POLICY, INITIATION OF CODE BLUE, AND PROPER RESPONSE TO UNCONSCIOUS RESIDENT INCLUDING CHECKING THE RESIDENT'S CHART FOR CODE STATUS AND CONTACTING LOCAL EMS. NO NURSE WAS ALLOWED TO WORK AFTER 8:30 AM PRIOR TO RECEIVING EDUCATION AND BEING ABLE TO VERBALIZE POLICY AND PROCEDURE. 22 OF THE 23 NURSES HAVE BEEN EDUCATED AND THE ONE REMAINING WAS CASUAL AND WOULD NOT BE SCHEDULED OR ALLOWED TO WORK UNTIL EDUCATION WAS RECEIVED. ANY NURSE HIRED AFTER [DATE] WOULD RECEIVE THE ABOVE EDUCATION WITH ORIENTATION. 2. ON [DATE], RECORDS OF ALL 86 RESIDENT'S ADVANCE DIRECTIVES/CODE STATUS WERE REVIEWED, 31 RESIDENTS HAD A FULL CODE STATUS. 3. ON [DATE], INITIATION OF THE FACILITY'S QUALITY ASSURANCE PROCESS OCCURRED WITH THE FACILITY TEAM AND EXTENDICARE'S REGIONAL AND AREA DIRECTOR'S OF CLINICAL SERVICES. MOCK CODES WERE INITIATED ON [DATE] AND CONTINUING TO BE DONE WEEKLY TIMES FOUR, MONTHLY FOR 3 MONTHS, AND QUARTERLY THEREAFTER. MOCK CODES WERE CONDUCTED ACROSS ALL SHIFTS. RESULTS WOULD BE SUBMITTED TO THE ADMINISTRATOR, DON, AND QPI MONTHLY TO DETERMINE PROPER INITIATION OF THE POLICY. IDENTIFIED NONCOMPLIANCE WOULD RESULT IN 1:1 RE-EDUCATION. REPEAT NONCOMPLIANCE OF POLICY WOULD RESULT IN PROGRESSIVE DISCIPLINARY ACTION PER POLICY. ALTHOUGH IMMEDIATE JEOPARDY WAS REMOVED ON [DATE], THE FACILITY REMAINED OUT OF COMPLIANCE AT A SCOPE OF PATTERN AND A SEVERITY OF NO ACTUAL HARM WITH POTENTIAL FOR MORE THAN MINIMAL HARM THAT IS NOT IMMEDIATE JEOPARDY DUE TO ALL EDUCATION HAD NOT YET BEEN COMPLETED AND SUSTAINED COMPLIANCE HAD NOT BEEN VERIFIED BY THE STATE AGENCY. ( )

This citation pertains to intake number MI 428. Based on observation, interview, and record review the facility failed to prevent falls with injury in 2 of 2 sampled residents (Resident #500 & #504), from a total sample of 5 residents, resulting in: 1) Resident #500 having 2 falls, 1 causing a fractured humerus (upper arm), and 2) Resident #504, who fell , sustained a laceration (cut) to the forehead, and was transferred to the emergency room for sutures to the laceration. Findings include: Resident #500 Resident #500 no longer resided at the facility at the time of the investigation. Per the facility face sheet Resident #500 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of the "Minimum Date Set" ((MDS) dated [DATE] revealed Resident #500 was not able to recall information told to her when asked to repeat the information at a later time. An MDS dated [DATE] revealed Resident #500 required extensive assistance with bed mobility, transfers, and ambulation and was occasionally incontinent of urine. Record review of a facility "Accident/Incident Report" dated 9/5/2011 revealed that at 10:45 PM Resident #500 was observed lying on her back on the floor in her room, which resulted in a skin abrasion to her left leg and right upper arm. The report revealed Resident #500 stated she had attempted to get up to go to the bathroom and she was, "tired of taking the Lasix" (water pill). The intervention/action taken, as noted on the incident report, was to remind Resident #500 to wait for staff for assistance before transferring. Review of the "Accident/Incident Report" dated 9/17/2011 revealed Resident #500 was observed at 10:30 PM in her room, lying on her right side, with her head in the doorway. The report revealed Resident #500's right arm was twisted and under Resident #500's head. The report also revealed Resident #500 had an episode of incontinence. The report revealed Resident #500 stated she was, "Trying to get to the bathroom". The report revealed Resident #500 was transferred to the hospital for evaluation and treatment. Record review of hospital physician emergency room notes dated 9/17/2011 revealed Resident #500 had a fracture to her right humerus. Record review of nursing "Progress Notes" dated 9/18/2011 revealed Resident #500 was transferred back to the facility on [DATE] at 3:15 AM, after treatment in the emergency room . Record review of a care plan titled "Fall/Injury Assessment: Preventions and Management Plan of Care" dated 4/21/2011 revealed no updated interventions on 9/5/2011 after Resident #500's first fall, but dated 9/6 & 9/7/2011 interventions of placing an non-skid adhesive to the floor and Resident #500 was to wear an incontinent product at bedtime. Further review of the care plan revealed that after Resident #500's fall on 9/17/2011 no update or changes were made to the preventive interventions on 9/17/2011. The care plan revealed that on 9/20/2011 a bed and chair alarm were added to the interventions, three days after Resident #500 returned from the emergency room with a fracture of her right arm. Record review of a care plan titled "Alteration in Urinary Continence Plan of Care" dated 5/2 and 7/14/2011 revealed no interventions related to Resident #500's prescribed Lasix, urinary urgency, and attempts to self ambulate related to having to get to the bathroom. Review of a care plan titled "ADL (activities of daily living)/Mobility: Plan of Care" dated 4/21/2011 revealed Resident #500 required assistance for ambulation. Documented interventions was noted that there were two methods of safe transferring for Resident #500, "one person assist with gait belt" and "sit to stand" (mechanical lift). The one person assist was dated for 4/21/2011 and the sit to stand was not dated, both interventions were written on the care plan twice with the one person assist intervention dated 4/21/2011 being the only interventions with a date, and did not clearly identify how Resident #500 was to be safely assisted with transferring from bed to chair or chair to bed. Licensed Practical Nurse (LPN) #1 was interviewed on 11/3/2011 at 9:55 AM. LPN #1 said she was Resident #500's primary nurse at the time of her fall on 9/17/2011. LPN #1 said Resident #500 told her that she (Resident #500) had put on her call light but her light was not answered in a timely manner, so she attempt to get herself to the bathroom and fell . LPN #1 said Resident #500 did not have any fall alarms in place at the time of her fall on 9/17/2011. LPN #1 said Resident #500 had both of her legs wrapped due to edema and also had 2 toes on her right foot that had been amputated. LPN #1 said Resident #500 would get up on her own prior to her fall on 9/17/2011. LPN #1 said she placed a fall alarm on Resident #500 after her 9/17/2011 fall. Registered Nurse (RN #2) (the Assistant Director of Nursing, reviewed incident reports and determined appropriate intervention changes) was interviewed on 11/3/2011 at 2:50 PM. RN #2 said after Resident #500's fall on 9/5/2011 she thought the intervention of educating Resident #500 to wait for staff assistance was appropriate and made no other changes. RN #2 stated that Resident #500 had her own agenda and would get up all the time on her own to go to the bathroom. RN #2 said after Resident #500's fall on 9/5/2011, and the re-education to wait for staff assistance, Resident #500 continued to get up on her own and not wait for staff assistance. RN #2 said after Resident #500's fall on 9/5/2011 she (RN #2) changed the time Resident #500 received her Lasix in the PM. RN #2 said after Resident #500's second fall on 9/17/2011, a fall alarm was added. RN #2 said at the time of Resident #500's fall on 9/17/2011 Resident #500 got up on her own without waiting for staff, and stated even if Resident #500 had her call light on she still would not wait for staff to assist her and got up on her own anyhow. RN #2 said Resident #500 was on a toileting plan, but after RN #2 reviewed Resident #500's medical record (care plan, documentation of toileting plan) RN #2 stated Resident #500 was not on a toileting plan, as RN #2 was not able to find documentation of a toileting schedule or plan. Record review of the "Medication Administration Record" (MAR) dated September 2011 revealed that Resident #500's Lasix time for the evening dose was not changed from 8:00 PM to 4:00 PM until 9/19/2011. Resident #500 returned to the facility after her hospital visit on 9/17/2011 and transferred back to the hospital again on 9/20/2011 for issues not related to the fall. Resident #504 Per the facility face sheet Resident #504 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of an MDS dated [DATE] revealed Resident #504 required extensive assistance with transfers and ambulation. The MDS also revealed Resident #504 had an impaired cognitive status. Review of the "Order Regarding Appointment of Guardian of Incapacitated Individual" dated 11/19/2011 revealed Resident #504 had a legally court appointed guardian. Record review of the "Accident Incident Report" dated 9/24/2011 revealed Resident #504 was found on floor in hall with a laceration on her forehead. The report revealed Resident #504 had exhibited behaviors of standing up in her wheelchair prior to her fall. Immediate action taken to prevent further incident was, "send to ER (emergency room ) and therapy referral." The report also revealed Resident #504 had attempted to get up out of her wheelchair and tripped over the foot pedals. The report revealed, "Resident continuously attempts to stand up from the w/c (wheelchair), and is hard to redirect. Resident had no complaints when attempting to stand, and cannot tell staff what she needs or wants." Record review of an emergency room physician report dated 9/24/2011 revealed Resident #504 was, "Apparently found next to her wheelchair. She apparently was left there sitting in the chair and when they (staff) checked on her she was lying next to it (w/c) with a laceration on her forehead." The report revealed Resident #504 had a 3 centimeter laceration the upper forehead near the hairline. The report revealed that Resident #504 received 7 sutures to close the laceration. Record review of a care plan "Fall/Injury Assessment: Prevention and Management Plan of Care" dated 9/3/2011 revealed, under "Interventions" a notation that Resident #504 was a stand with assist for transfers with a gait belt, no date was documented with the interventions. On 9/24/2011 an intervention was added that indicated Resident #504 was a total (mechanical) lift with two person assist. The stand by assist transfer intervention was not removed or crossed off the care plan. The care plan included interventions of a chair and bed fall alarm dated 9/4/2011 and a bed parameter mattress dated 9/3/2011. RN (Registered Nurse) #5 was interviewed on 11/4/2011 at 9:50 AM. RN #5 said she was at lunch at the time Resident #504 fell face first from her wheelchair. RN #5 said Resident #504 had been up out of her wheelchair several times and had to be reminded to not get up without assistance. RN #5 said Certified Nurse Aide (CNA) #6 had been dealing with Resident #504 getting up without assistance from her wheelchair all day long. RN #5 said Resident #504 was re-educated on not getting up without assistance but stated that Resident #504 was not able to understand instruction. RN #5 said CNA #6 had gone into another resident's room to provide care and all the other CNA's were at lunch break. RN #5 said that she tried to keep Resident #504 close for supervision, but Resident #504 was left alone while in the hall just prior to her fall on 9/24/11. RN #5 said usually re-directing Resident #504 was effective but on 9/24/2011 it was not. RN #5 said she did not direct any staff member to increase supervision, such as a 1 on 1 supervision, for Resident #504 on 9/24/2011. RN #5 said the laceration to Resident #504's forehead was about 1.5 inches long. CNA #6 was interviewed on 11/4/2011 at 10:05 AM. CNA #6 said Resident #504 had been up and down all day long from her wheelchair. CNA #6 said she tried different interventions with Resident #504 but every time she stopped Resident #504 would attempt to get up. CNA #6 said she was in another resident's room with the door closed providing personal care at the time Resident #504 fell . CNA #6 said she still could hear Resident #504's fall alarm while she was in the other resident's room, and stated that she had to leave the room where she was providing care a couple of times to check on Resident #504 because her fall alarm had sounded. CNA #6 stated that neither RN #5 nor anyone else ever directed her to place Resident #504 on increased supervision such as a 1 on 1 supervision. Record review of additional facility "Accident/Incident Report" revealed Resident #504 had falls on the following dates with noted interventions as follows: ? 9/4/2011, a fall out of bed without injury, intervention added to place fall alarms on Resident #504. ? 9/5/2011 at 4:00 PM, a fall out of bed without injury, intervention added to place Resident #504 on 15 minute safety checks. ? 9/5/2011 at 9:00 PM, a fall out of bed without injury, intervention added to placed bed against the wall. ? 9/9/2011, a fall out of bed without injury, intervention added to place bolsters (soft wedge placed along side the mattress to create a concave type of mattress) on Resident #504's bed. ? 9/15/2011 at 5:10 PM, a fall out of bed without injury, intervention added to place a mattress on the floor next to Resident #504's bed. ? 9/15/2011 at 8:25 PM, a fall out of bed without injury, no added interventions. ? 9/20/2011, a fall out of bed, no added interventions. ? 9/24/2011, a fall out of wheelchair with laceration to forehead that required sutures, added interventions were to refer to therapy and complete a medication review. ? 9/26/2011, a fall out of bed, interventions added to place on a one hour toileting plan. ? 9/27/2011 at 7:30 AM, a fall out of bed, no interventions added. ? 9/27/2011 at 9:00 PM, a fall out of bed, interventions to continue with 15 minute safety checks, trial run of Resident #504's use of a "Merri Walker" (an enclosed chair with wheels that allows a resident to walk around). ? 10/21/2011 a fall out of the "Merri Walker", no new interventions added. ? 10/26/2011 at fall out of bed, interventions added to place on a restorative program and offer a snack at 10:00 AM. ? 10/28/2011 at fall out of the "Merri Walker", interventions added to place a magnetic stop sign in Resident #504's room door and direct to activities when Resident #504 wandered. ? 11/3/2011, a fall out of the "Merri Walker", interventions added to lay Resident #504 down and place on a lay down schedule. (This intervention was not documented on any of Resident #504's care plans). RN #3 the Unit Manager was interviewed on 11/3/2011 at 1:40 PM. RN #3 said the "Merri Walker" was initiated for Resident #504 about 3 weeks ago. RN #3 said Resident #504 was never had increased supervision, such as a 1 on 1 supervision, in spite of all her falls and rolling out of bed. RN #3 said that she did not make those decisions and that RN #2 (ADON) usually made those decisions (interventions for safety). CNA #4 was interviewed on 11/4/2011 at 9:30 AM. CNA #4 said on 9/24/2011 when Resident #504 fell and received the laceration, Resident #504 was in the hallway in her wheelchair. CNA #4 said she heard the fall alarm and looked up just in time to see Resident #504 stand up and fall face forward onto the floor. CNA #4 said no staff was in the hall where Resident #504 was sitting. CNA #4 said when the "Merri Walker" was put in place as an intervention it was effective at first but stated that Resident #504 learned how to place her legs over the strap that went between her legs and learned how to release the bar in the front of the "Merri Walker". CNA #4 also stated that Resident #504 knew how to remove her tab (fall) alarm. RN #2 (ADON) was interviewed on 11/3/2011 at 2:50 PM. RN #2 said that after Resident #504's fall on 9/27/2011 she implemented a "Merri Walker" for Resident #504. RN #2 said Resident #504 did not have any falls, after the "Merri Walker" was implemented, until 10/21/2011 when Resident #504 climbed out of the "Merri Walker". RN #2 said Resident #504 had gotten her foot caught up in the strap on the "Merri Walker" upon her attempt to climb out and fell on to the mattress on the floor that was next to her bed. RN #2 said Resident #504 was attempting to get into bed. RN #2 said that 2 medications reviews were conducted at one point as a result of Resident #504's falls, but stated that no changes were made to medications. RN #2 said that on 10/28/2011, Resident #504 climbed out of the "Merri Walker" again and fell on to the mattress on the floor next to her bed. RN #2 said she placed a magnetic stop sign on Resident #504's room door so she would not enter alone and attempt to get out of her "Merri Walker". RN #2 said Resident #504 had been on 15 minute safety checks since her admission to the facility. RN #2 said that she was aware Resident #504 had a history of [REDACTED].#504 had a sitter (1 on 1 constant supervision) while she was at the hospital due to her attempts to get up unassisted and her fall history. RN #2 said Resident #504 was a very busy person. RN #2 said that she did not initiate closer supervision such as a 1 on 1 supervision for Resident #504 to keep her safe due to all of her falls, and while assessing if interventions put into place would be effective. Observation of Resident #504 was conducted on 11/4/2011 at 9:10 AM. Resident #504 was observed up in her "Merri Walker" attempting to remove the magnetic stop sign in front of her door. When approached by RN #5, Resident #504 requested to lie down in her bed. ( )