Every finding on record at Medilodge of Traverse City

Based on interviews and record review, the facility failed to act promptly on the grievances and resident concerns voiced in a confidential resident group meeting with eight residents. Findings include:On 7/28/2026 at 1:45 PM, a confidential group meeting took place with eight Residents in attendance. The residents voiced concerns about clothes being lost particularly when sent to the laundry. The residents also agreed their clothes were often being returned with small holes suggestive of chemical burns. They were not certain all the clothes were marked with identification. While all in attendance felt the laundry could do a better job of caring for their belongings, four residents (who wished to remain anonymous) identified specific items that were never found. Each of these residents expressed the staff were aware of the missing items, but they had not been updated on the results of the searches.On 7/28/2026 at 2:51 PM, forms titled Quality Assistance were presented. While some of the items mentioned in the confidential group meeting were noted to be recorded on these forms, the residents expressed they still did not know the outcome of their missing items.One Quality Assistance Form dated 6/4/26 read, Light blue night gown, fleece or flannel long sleeve. The findings on the form stated, I have looked in lost/found and haven't found it yet. Plan/Actions: I will be on the look out for this item and will do a closet search and see if I can locate it. The form indicated the results were reported to the resident and the box was checked satisfied. The resident stated she did not know if they were still looking for this item and had not heard for over a month.Another Quality Assistance Form dated 6/9/26 read, Details: Missing a blanket that says Happy Thanksgiving. A staff member was assigned to review this concern, but no follow-up or further notes were documented on the form.A grievance log was presented for June. There were seven entries for concerns brought up at Resident [NAME]. Five had a check mark completed and two were not marked completed, but all seven did not indicate a date that Results reported to Informant.The Resident Council Minutes were reviewed. While many concerns were raised and documented, there were no follow-up notes the next month on progress or action taken on the concerns raised by the residents. The minutes of the Resident Council May 2026 meeting included the following documentation: (Resident name) Feels like when she tells a staff member about an issue, they do nothing about it. (Resident name) night gown is still missing. (Resident name) stated she is also missing her Pink Jacket.During an interview on 7/28/2026 at 1:37 PM, Activity Staff I stated she does fill out the paperwork Quality Assistance Forms but does not get them back to know the outcome and could not report the results back to the Resident Council.

Based on observation, interview, and record review, the facility failed to securely store topical treatment medications and ocular supplements for two Resident (#79 and #89) of two residents reviewed for medication storage.Findings include:Resident #79 (R79)Review of R79's Electronic Medical Record (EMR) indicated most recent admission to the facility on 7/15/26 with diagnoses including osteoarthritis of the left knee, urinary tract infection (UTI), and chronic obstructive pulmonary disease (COPD).On 7/27/2026 at 2:13 PM, a medication cup filled with green paste was observed on R79's bedside table. R79 stated it was a topical pain gel she intermittently applied to her knees throughout the day.On 7/29/2026 at 12:09 PM, a tube of hydrocortisone topical ointment was observed on R79's bedside table.Review of R79's EMR revealed no care plan, physician orders, or assessment for self-administration of medications. Resident #89 (R89)Review of R89's EMR indicated most recent admission to the facility on 7/23/26 with diagnoses including a left femur fracture, generalized anxiety disorder, and macular degeneration (an eye disease that affects central vision).On 7/27/2026 at 11:02 AM, a bottle of ocular supplements was observed on R89's bedside table. R89 confirmed she takes the daily supplement for her eye health.Review of R89's EMR revealed no care plan, physician orders, or assessment for self-administration of medications.On 7/29/26 at 1:07 PM, an interview was conducted with the Nursing Home Administrator (NHA) who confirmed all medications should be stored in medication carts or room unless a resident has been assessed to self-administer medications.Review of the facility policy titled, Medication - Resident, Self-Administration of, revised 1/30/26, read, in part: .A resident may only self-administer medications after the facility's interdisciplinary team had determined which medications may be self-administered safely. the results of the interdisciplinary team assessment are recorded in the resident's medical record. all nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. the care plan must reflect resident self-administration and storage arrangements for such medications.

Based on observation, interview, and record review, the facility failed to provide appropriate assessments and documentation warranting the use of a physical restraint as a fall prevention aid for one Resident (#37) of one resident reviewed for restraints.Findings include:Resident #37 (R37):Review of R37's Electronic Medical Record (EMR) indicated initial admission to the facility on 6/4/26 with diagnoses including fracture of the right humerus (upper arm), Parkinson's disease, dementia, and difficulty in walking. Review of R37's most recent Minimum Data Set (MDS) assessment, submitted 7/22/2026, revealed a Brief Interview of Mental Status (BIMS) score of 7, indicative of severe cognitive impairment. Further review of MDS Section P did not code the use of physical restraints. On 7/27/26 at 1:15 PM, a geri [geriatric]-chair (a specialized, padded medical recliner equipped with wheels) was observed stationed in the corner R37's personal room.On 7/29/26 9:10 AM, a Geri-chair was again observed stationed in the corner of R37's personal room. R37's Durable Power of Attorney (DPOA) G was present and explained R37 had several falls since her admission. DPOA G indicated he stays with R37 during the day and when he leaves the facility at night, around 7:00 PM, facility staff transfers R37 into the geri-chair and place her at the nurse's station. DPOA G stated the facility has been using this method as a fall prevention technique, as R37 is unable to disengage the leg rest to allow her to rise from the chair. Review of R37's EMR revealed the following progress note written on 7/20/26 at 19:18 [7:18 PM]: CNA [Certified Nursing Assistant] alerted this RN [Registered Nurse] that the resident [R37] had fallen in the room. I immediately went to assist and evaluate the resident. The resident denied any injuries or pain upon evaluation and me and two CNA's assisted the resident into the Geri chair and sat her at the nurse station for better watch.On 7/29/26 at 9:16 AM, a phone interview was conducted with RN H regarding R37's nightly routine. RN H stated R37 is hit or miss when it came to sleeping at night and endorsed, We usually put her in the geri-chair and she'll hang out with us at the nurse's station for half the night. RN H indicated R37's number of falls had decreased because she could no longer independently ambulate if the recliner was engaged.On 7/29/2026 at 9:49 AM, an interview was conducted with R37. When asked if she slept well the previous night, R37 replied, No. When queried as to why she had gotten poor sleep, R37 stated, Because they put me in that thing [R37 pointed to the geri-chair sitting in the corner of the room]. They put me by the circle [nurse's station] out there so they can watch me. On 7/29/26 at 1:07 AM, an interview was conducted with the Director of Nursing (DON) who stated she was unaware R37 was utilizing a geri-chair. When asked if a geri-chair was an appropriate fall prevention intervention or utilized for staff convenience, the DON replied, I will look into the geri-chair. When asked if the geri-chair was considered a physical restraint, the DON replied, I will look into the geri-chair.Review of R37's EMR revealed no assessment, physician order, risk education, medical justification, or care plan for the use of a physical restraint.Review of the facility policy titled, Restraints, revised 10/26/23, read, in part: .Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). An evaluation will be completed to determine the medical symptom requiring the device and to determine the least restrictive device to treat the symptom. care plans which include the use of the physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method.

Based on record review and interviews, the facility failed to notify the legal guardian of a resident's discontinuation of medication in one (Resident #3) of one resident reviewed for notification of change in condition.Findings include:Resident #3 (R3) A review of R3's Electronic Medical Record revealed they had a Power of Attorney-Medical (POA), who was listed as R3's primary emergency contact.During a phone interview on 7/27/2026 at 2:35 PM, POA A stated R3 was not the same as she had been 4-5 months prior and believed the amount of risperidone (an atypical antipsychotic medication used to balance chemicals in the brain) she was receiving was too high. When informed by this surveyor that R3 was no longer receiving risperidone as of 3/15/26, POA A responded, They never notified me of that.During an interview on 7/29/2026 at 10:31 AM, the Social Work Director stated that someone in the facility should have informed the POA when the medications were changed/discontinued.On 7/29/2026 at 12:10 PM, during an interview, Regional Nurse B stated she located the signed consent from the POA, for decreasing the medication risperidone but was unable to find documentation that the POA had been notified of the discontinuation of the medication.The facility provided a policy titled Notification of Changes, last revised on 8/29/24, which stated: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Circumstances requiring notification include. 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition. iii. Exacerbation of a chronic condition .

Based on observation, interview and record review, the facility failed to ensure call lights were within reach for one Resident (R83) of 17 residents reviewed for call light placement and functionality. Findings include: Review of R83's Electronic Medical Record (EMR) revealed admission to the facility on 9/26/25 with a diagnosis of Parkinson's disease. On 7/27/26 at 11:06 AM, a tapping sound was heard coming from R83's room. When this Surveyor entered, R83 was observed laying in her bed. R83 stated that they had a bowel movement, and she wanted to be changed. R83 stated she had been waiting a long time for staff to come assist her. R83's call light was noted to be behind her pillow and above her head, not within visual or physical reach. On 7/28/26 at 10:26 AM, R83 was observed in her room, sitting in her wheelchair, with her bedside table across her lap. R83 had earphones on and was watching television. R83 stated that she would like the aides to know she will not be taking a shower today. During this interview, R83's call light was observed to be draped over the bed side table and not within reach of the resident. Review of R83's Care Plan read, in part, Encourage (R83) to use call light when assistance is needed (Date Initiated: 9/26/25) .Place assistive devices within reach (Date Initiated: 9/26/26) .

Based on observation, interview, and record review, the facility failed to ensure two Residents (R89) were afforded privacy and dignity (When R73 and R25 wandered into R89's room) and for R7 out of two residents reviewed for resident rights.Findings include:Resident #89 (R89)Review of R89's Electronic Medical Record (EMR) indicated initial admission to the facility on 7/23/26 with diagnoses including a left femur fracture, hypertensive and atherosclerotic heart disease, and congestive heart failure. Review of R89's most recent Minimum Data Set (MDS) assessment, submitted after survey exit on 8/6/26, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicative of intact cognition.On 7/28/26 at 8:25 AM, a wheelchair was observed barricaded against the bathroom door in R89's private room. When queried, R89 stated, Didn't you hear about what happened the last two days? R89 stated on the night of 7/26/26, a resident entered her room through the shared bathroom [later identified as Resident #73 (R73)]. R89 stated she was startled and engaged her call light for help. R89 indicated staff were able to re-direct R73 out of her room and stated if she pulled the call light cord out of the wall, they would respond faster in the future. R89 explained she was so shook up from the incident, she had a family member bring in a door security bar (a strong, adjustable metal rod placed between a doorknob and the floor to stop a door from opening) to place under the bathroom doorknob but was told she was unable to do so because of fire code restrictions. R89 stated the next morning, R73 entered her room through the primary entryway without permission. R89 indicated, I started screaming and pulled the [call-light] cord out of the wall. I was terrified. R89 revealed, years before, her mother resided in a nursing home and was smothered by her roommate. R89 indicated because of this traumatic event, she was fearful of unknown people entering her room. R89 stated, They're [facility staff] going to move me two rooms down [the hallway]. I'm not sure how that's going to help. On 7/29/26 at 8:21 AM, a follow-up interview was conducted with R89 regarding the room move. R89 appeared upset and stated she had continued problems with residents entering her room. R89 indicated the previous night, a male resident [later identified as Resident #25 (R25)] entered her room in a wheelchair and approached her bedside. R89 stated she immediately pulled her call light cord out of the wall and tried to direct the resident out of the room without success. R89 shared, It scared me. I didn't sleep well that night. These incidents are not good for somebody with a heart condition. On 7/29/26 at 8:49 AM, a telephone interview was conducted with Registered Nurse (RN) H who verified she had worked the previous night and was responsible for the care of residents residing on R89's hall. RN H confirmed R25 was, all over the facility last night. When queried about R89's reaction to the wandering resident, RN H stated, She told me she was afraid. They [facility staff] actually just moved her [room] due to another resident wandering in her room. Apparently, she is terrified of people with dementia, she thinks they're dangerous.Review of R89's EMR revealed no documentation describing any of the three incidents.Reviews of R73 and R25's EMR revealed no documentation describing any of the incidents and no care-planned interventions for wandering.On 7/29/26 at 1:07 AM, an interview was conducted with the Director of Nursing (DON) regarding the lack of documentation, the lack of meaningful interventions, and the lack of supervision leading to wandering residents entering R89's personal room. The DON confirmed a behavior note should have been made in both R73 and R25's EMR following each event and a progress note should have been entered into R89's EMR to ensure other facility staff were aware of the incidents. The DON stated this was new behavior for both R73 and R25 which explained why they had no care planned interventions for wandering.Review of R25's EMR revealed the following progress notes: 7/8/26 at 3:36 PM: Resident was upset this shift. was exiting seeking. resident reportedly walked across the hall and tried to enter another resident's room.7/9/26 at 8:45 PM: .nursing report that he was naked with only a brief wandering the hallway this am [morning] looking for his clothes.7/28/26 at 10:06 AM: .will often be wandering the hallway without AD [assistive device] or into others' rooms.Review of R73's Behavior Task revealed an episode of wandering on 7/24/26, two days before the initial event.Resident # 7 (R7)Review of R7's EMR indicated initial admission to the facility on [DATE] with diagnoses including Alzheimer's disease, need for assistance with personal care, and weakness. Review of R7's most recent MDS assessment, submitted 7/22/2026, revealed a BIMS score of 5, indicative of severe cognitive impairment. Further review of MDS Section GG, Functional Abilities and Goals, revealed R7 required supervision or touching assistance (a helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for both lower body dressing and toilet transfers.On 7/28/2026 at 7:41 AM, R7 was observed mobilizing her wheelchair past the nurses' station and into the dining room. R7's pants were observed to be positioned at her mid-thighs with an exposed brief. There was no staff intervention to assist R7 with proper pants positioning. On 7/28/2026 at 7:46 AM, Activities Aide/Staff I was observed greeting R7. Staff I assisted R7 getting squared up at the dining room table but did not assist R7 or summon assistance to properly position R7's pants.On 7/28/2026 at 8:30 AM, R7 was again observed at the dining room table, finishing breakfast, with her pants positioned at her mid-thighs revealing an exposed brief.Review of the facility policy titled, Resident Rights, revised 10/30/26, read, in part: .the facility will ensure all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents.

Based on observation, interview and record review, the facility failed to prevent Resident to Resident physical abuse for four Residents (R34, R54, R63, and R68) of four residents reviewed for abuse. Findings include: R63 On 4/29/25 at approximately 2:00 p.m., R63 was observed pacing the hallway of the memory care unit without staff supervision. R63 was attempting to find someone, using derogatory language in her description and getting near residents and visitors faces. R63 then was observed grabbing the hand of R68 and stated, Come on! Come on! while attempting to redirect R68 down the hallway. R68 told R63, No!, when R63 began pinching R68's hand in between her thumb and index finger. R68 began to yell out when R63 closed her right hand to make a fist and hit R68 in the right upper arm, making R68 scream. Two staff members came from the hallway and from another resident room to separate the two residents with one staff member leading R68 into her room. R63 was then left unsupervised in the hallway and took another resident's hand, leading her towards the front door. A request for R63's Incident and Accident reports for the last six months. The following incidents were noted as not reported to the SA (State Agency); 10/28/24 - Resident to Resident Altercation; Resident was asked repeatedly to stop touching other resident (Resident Initials). She first was tapping his shoulder and then starting [sic] his stomach. Resident was unable to be redirected. (Resident Initials) then pushed (R63) into a dining room chair which she fell into. 10/28/24 - Resident to Resident Altercation; (R63) and other resident (Resident Initials) were at the locked exit doors exchanging words that could not be heard when it was observed that (R63) hit (Resident Initials) in the right side of her face. (Resident Initials) then retaliated and hit (R63) in the left side of her face. 11/12/24 - Resident to Resident Altercation; Resident was pushing a napkin with eaten oranges to (Resident Initials). (Resident Initials) asked her to stop and (R63) did not. (Resident initials) then smacked (R63) left hand open palmed with force with her right hand. 11/12/24 - Resident to Resident Altercation; (R63) was near the back door by the med cart attempting to push (R54) in her wheelchair. (R54) asked her to stop and she didn't. (R54) then reached and hit (R63's) left shoulder with her right arm. 3/23/25 - Resident to Resident Altercation; (Resident name) was sitting in her wheelchair in her doorway. (R63) attempted to push into the room. (Resident name) was yelling. (R63) starting [sic] hitting her in the head and pulling her hair. 4/19/25 - Resident to Resident Altercation; (R63) attempted to take a baby doll away from female res. (resident) other female res continued holding on and (R63) made contact with open hand on other female res arm several times. 4/27/25 - Resident to Resident Altercation; Observed resident in hallway making contact with closed hand with another resident who was seated in wheel chair. Observed closed hand contact to side of head and shoulder. R54 A request for R63's Incident and Accident reports for the last six months. The following incidents were noted as not reported to the SA; 11/12/24 - Resident to Resident Altercation; (R63) was near the back door by the med cart attempting to push (R54) in her wheelchair. (R54) asked her to stop and she didn't. (R54) then reached and hit (R63's) left shoulder with her right arm. 11/26/24 - Resident to Resident Altercation; Heard resident (R34) screaming in her room. (R54) found sitting in her wheelchair in front of other resident. Resident stated that (R54) slapped her. 12/15/24 - Resident to Resident Altercation; Resident was sitting at dinning room table when another resident approached on her left. (R54) then turned her wheelchair towards the other resident yelled at her and then hit her with a closed fist on the left side of her face/neck. 4/19/25 - Resident to Resident Altercation; Female Res attempted to take a baby doll away from (R54). (R54) continued holding on and Female Res slapped her several times causing a right forearm skin tear. 4/27/25 - Resident to Resident Altercation; Observed resident seated in wheelchair in hallway receiving closed hand contact from another resident. Other resident was standing and facing (R54). Other resident made closed hand contact to side of (R54's) head and both shoulders. R34 A request for R63's Incident and Accident reports for the last six months. The following incidents were noted as not reported to the SA; 11/26/24 - Resident to Resident Altercation; Heard resident (R34) screaming in her room. (R54) found sitting in her wheelchair in front of other resident. Resident stated that (R54) slapped her. An interview was conducted with the Nursing Home Administrator (NHA) on 5/2/25 at 8:53 a.m. regarding the numerous resident to resident altercations inside the memory care unit. The NHA confirmed all the resident to resident altercations were investigated by staff but continue to happen and believed there was no willful attempt. Review of the facility's Abuse, Neglect and Exploitation Policy reviewed 10/24/22 read, in part, .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .

Based on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the physical, mental, and psychosocial well-being in a locked memory care unit. This deficient practice resulted in the continuation of numerous resident to resident altercations and falls. Findings include: On 4/29/25 at approximately 2:00 p.m., R63 was observed pacing the hallway of the memory care unit without staff supervision. R63 was attempting to find someone, using derogatory language in her description and getting near residents and visitors faces. R63 then was observed grabbing the hand of R68 and stated, Come on! Come on! while attempting to redirect R68 down the hallway. R68 told R63, No! when R63 began pinching R68's hand in between her thumb and index finger. R68 began to yell out when R63 closed her right hand to make a fist and hit R68 in the right upper arm, making R68 scream. Two staff members came from the hallway and from another resident room to separate the two residents with one staff member leading R68 into her room. R63 was then left unsupervised in the hallway and took another resident's hand, leading her towards the front door. On 5/2/25 at approximately 9:30 a.m. an observation was made of the locked Memory Care Unit. 12 residents were located in the dining room of that unit without any staff members present. During this observation, R63 was observed attempting to push R54 in her wheelchair, with R54 becoming visibly upset. Other residents were observed standing up without assistance and furniture surfing around the dining room. R68 was observe down the hallway going into other resident rooms without staff supervision. An interview was conducted with Certified Nurse Aide (CNA) D on 5/2/25 at approximately 9:45 a.m. CNA D stated, the Memory Care Unit usually has 2 CNA's, a nurse and an activity aide, but due to call in's of staff, it doesn't always work out. An interview was conducted with Family Member (FM) E who was visiting in the Memory Care Unit on 5/2/25 at approximately 10:00 a.m FM E stated, she does not feel there are enough staff down in the unit to assist with resident needs and there are often times when residents are left unsupervised. An interview was conducted with the Nursing Home Administrator (NHA) on 5/2/25 at approximately 10:45 a.m. The NHA confirmed that there should be 2 CNA's, a nurse and an activity aide down in the Memory Care Unit. Review of the Facility Assessment reviewed February 2025 read, in part, .22 beds secured dementia unit all long term residents .The unit has an enclosed outdoor space with raised garden beds. The unit includes a dining room/activity area .[Facility Name] has deemed that dementia care has more relative importances as it is a specialty area for the facility .the facility has dementia/memory care is used for marketing purposes to differentiate the facility in the community .

Based on observation and interview, the facility failed to ensure exhaust ventilation was functioning in resident bathrooms, on three halls, serving 22 of a total 74 residents. This deficient practice resulted in noxious odors permeating the resident environment, with the potential to cause unpleasant and uncomfortable living conditions. Findings include: On 4/30/25 at 10:45 AM, noxious odors were noted throughout the D hall. On 4/30/25 at 2:15 PM, in response to the presence of continued noxious odors on the D hall, an investigation was initiated into determining the functioning of the exhaust ventilation system for resident bathrooms. The bathrooms serving the following rooms were inspected for functioning exhaust by placing a paper towel over the ceiling mounted duct cover and determining if there was adequate negative pressure to hold the paper in place. The failure to hold the towel in place deemed a failure for that bathroom's exhaust system. This failure was noted in the bathrooms serving the following resident rooms: D Hall; 1, 5, 6 On 4/30/25 at 2:35 PM, an interview was conducted with Maintenance Director (MD) B who conducted a similar test for bathroom exhaust function and confirmed there was not any negative pressure in the duct resulting a failure of exhaust from the bathroom. MD B stated I don't think these have ever worked.

Based on observation, interview and record review, the facility failed to report timely allegations of abuse (resident to resident), within two hours, to the State Agency (SA) for four Residents (R34, R54, R63, and R68) of four residents reviewed for abuse reporting. Findings include: R63 On 4/29/25 at approximately 2:00 p.m., R63 was observed pacing the hallway of the memory care unit without staff supervision. R63 was attempting to find a male, using derogatory language in her description and getting near residents and visitors faces. R63 then was observed grabbing the hand of R68 and stated, Come on! Come on! while attempting to redirect R68 down the hallway. R68 told R63, No! when R63 began pinching R68's hand in between her thumb and index finger. R68 began to yell out when R63 closed her right hand to make a fist and hit R68 in the right upper arm, making R68 scream. Two staff members came from the hallway and from another resident room to separate the two residents with one staff member leading R68 into her room. R63 was then left unsupervised in the hallway and took another resident's hand, leading her towards the front door. A request for R63's Incident and Accident reports for the last six months. The following incidents were noted as not reported to the SA; 10/28/24 - Resident to Resident Altercation 11/12/24 - Resident to Resident Altercation 11/12/24 - Resident to Resident Altercation 3/23/25 - Resident to Resident Altercation 4/19/25 - Resident to Resident Altercation 4/27/25 - Resident to Resident Altercation R54 A request for R63's Incident and Accident reports for the last six months. The following incidents were noted as not reported to the SA; 11/12/24 - Resident to Resident Altercation 11/26/24 - Resident to Resident Altercation 12/15/24 - Resident to Resident Altercation 4/19/25 - Resident to Resident Altercation 4/27/25 - Resident to Resident Altercation R34 A request for R63's Incident and Accident reports for the last six months. The following incidents were noted as not reported to the SA; 11/26/24 - Resident to Resident Altercation An interview was conducted with the Nursing Home Administrator (NHA) on 5/2/25 at 8:53 a.m. regarding the numerous resident to resident altercations inside the memory care unit. The NHA confirmed that the facility did not report any resident-to-resident altercations and was under the assumption that resident to resident altercations were only reportable if there was an injury. Review of the facility's Abuse, Neglect and Exploitation Policy reviewed 10/24/22 read, in part, .Reporting of all alleged violations to the .state agency .immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse .

Based on observation, interview, and record review the facility failed to assess for self administration safety in two residents (#67 & #8) of seven residents reviewed for safety with self medication administration. Findings include: Resident #67 (R67) On 4/30/25 at approximately 8:00 AM, during a medication administration, Registered Nurse A (RN A) was observed handing R67 a medication cup containing multiple medications. R67 then walked away without RN A verifying ingestion or providing supervision. R67 was left alone in their room with the medications. Review of R67's chart indicated that they had not been assessed for self-administration of medications. Resident #8 (R8) During an interview of R8 on 4/30/25 at 8:54 AM, the medication Trelegy, a prescription inhaler used for long term management of chronic obstructive pulmonary disease and asthma (respiratory conditions causing difficulty in breathing) was observed on the bedside table. R8 stated that they had administered the medications earlier in the morning. R8 stated that the nurse had left the medication there and had not come back to get it. Review of R8's chart indicated that they had not been assessed for self-administration of medications. During review of medication storage with the Director of Nursing (DON) on 5/2/25 at 10:31 AM, the DON stated that residents that were self-administering medication, did need to have an assessment. On 5/2/25 the medication administration policy was requested from the Nursing Home Administrator; it was not provided.

Based on interview and record review, the facility failed to ensure staff reviewed residents medical record for code status, ensure code status orders were signed by the physician, and ensure code status was uploaded to the resident chart in a timely manner for two Residents (R72 and R500) of three residents reviewed for advance directives. Findings include: R72 R72 was admitted to the facility on [DATE] with diagnosis of right femur head and neck fracture without operation. R72 was her own responsible party. Review of R72's progress notes revealed the following entry dated [DATE], This nurse entered resident's room to obtain blood glucose reading, Resident was observed in bed laying on right side, not responding to verbal stimulus. This nurse attempted to rouse resident by movement, but resident was still not responding. No pulse was observed when checking radial and carotid arteries. This nurse notified (Nurse Practitioner [NP]) of status. Absence of pulse was confirmed by this nurse and (NP). Family notified by provider, funeral home contacted for release of resident. A DNR (Do Not Resuscitate [Type of Code Status]) physician order was placed in R72's Electronic Medical Record (EMR) on [DATE] but there was no signed Do-Not-Resuscitate (DNR) Order Declarent (Resident) Consent or Advance Directive scanned into R72's EMR. An interview was conducted with Registered Nurse (RN) C on [DATE] at 1:20 p.m. RN C confirmed that she was the nurse on [DATE] who discovered R72 unresponsive, I was the nurse who found her. I called for help but she was a newer admit to me and I didn't know her code status. I had to run back to my computer and saw she was a DNR, and at that time the NP came in to assess (R72). I did not look for a signed advance directive (code status). A request was made for R72's Advance Directive/Code Status. An interview was conducted with the Director of Nursing (DON) on [DATE] at 9:35 a.m. who confirmed the facility could not find R72's signed Advance Directive/Code Status form. R500 R500 was admitted to the facility on [DATE] with diagnosis of orthostatic hypotension. R500 was her own responsible party. Review of R500's progress notes revealed the following entry, dated [DATE], at appx. (approximately) 0445 (4:45 a.m.) CNA (Certified Nurse Aide) answered residents call-light and began to assist resident to bathroom, resident stood from bed and became short of breath then fell back on bed and stopped breathing, CNA called down hall for this nurse and I ran down to residents room and observed resident laying on her back on the bed with face gray and not breathing, called loudly in residents ear and did sternal rub and checked for pulse with none found and no response from resident. Nurse yelled down hall for other nurse to grab crash cart and paged overhead for all staff assist to residents room, this nurse and CNA lifted resident to the floor reapplied her NC (nasal cannula) O2 (oxygen) and started CPR (cardiopulmonary resuscitation [Type of Code Status]) and once crash cart arrived hooked up high flow O2 to bag resident then other nurse ran to check code status in the computer. Other nurse returned and informed this nurse that resident was a DNR and cpr was stopped immediately. Resident then took two agonal breaths (irregular gasps) so this nurse propped up resident in my lap and with assist from CNA positioned resident head to straighten airway and used ambu bag (respiratory support equipment) with O2 to deliver breaths to resident. Other nurse then went to call emergent EMS (Emergency Medical System), and this nurse continued to deliver rescue breaths only, with ambu bad [sic] hooked to O2 until EMS arrived. Resident was taking no breaths once EMS arrived and was hooked to ekg (electrocardiogram) and minimal activity observed so rescue breaths continued until resident vital signs ceased completely. EMS requested code status paper work but was unable to obtain from digital chart so [Hospital Name] called to obtain from previous hospital stay. Once hitting 20 minutes since resident fully down and resident having no further vital signs resident was pronounced by [Hospital] physician as TOD (time of death) of 0515 (5:15 a.m.) on [DATE]. A request was made for R500's Advance Directive/Code Status. An interview was conducted with the Director of Nursing (DON) on [DATE] at 9:35 a.m. who confirmed the facility could not find R500's signed Advance Directive/Code Status form. Review of the facility's Cardiopulmonary Resuscitation (CPR) & Basic Life Support (BLS) policy reviewed/revised on [DATE] read, in part, .Facility staff should verify the presence of advance directives or residents' wishes regarding CPR upon admission. Physician orders to support these choices should be obtained as soon after admission as possible or after a change in preference or condition . During an interview on [DATE] at 9:45 AM, this Surveyor was presented a Past Noncompliance (PNC) document. During the onsite survey, PNC was cited after the facility implemented actions to correct the noncompliance which included: 1. Blanket audit for current residents to assure that advance directives were formulated, orders were correct and physician had signed the DNR order. 2. Education for Licensed Nurses on looking in the chart prior to initiating CPR. 3. IDT (interdisciplinary team) will audit new admissions with AM (morning) clinical M-F (Monday - Friday) to assure all interventions and documentation is completed per policy. 4. DON will review findings and report trends to the QAPI (Quality Assurance and Performance Improvement) committee monthly times 3 months with further monitoring per QAPI committee recommendations The facility successfully demonstrated monitoring of the corrective action and maintained compliance by completing weekly audits of residents identified with Code Status/Advance Directives concerns, to ensure established protocol was followed. The PNC was granted with a Plan of Corrections (POC) date of [DATE].

Based on observation, interview and record review, the facility failed to follow interventions to prevent further falls for one Resident (R54) of three residents reviewed for falls. Findings include: R54 Review of the Electronic Medical Record (EMR) revealed R54 admitted to the facility on [DATE] with diagnoses including Alzheimer's disease. Review of R54's Incident and Accident reports revealed the following incident dated 11/20/24 and read, in part, Resident sitting on dining room chair. She had slid onto the floor. Assessed for injury. No c/o (complaint of) pain .Care plan updated to have Dycem nonslip mat in her wheelchair and dinning room chair . On 5/2/25 at 9:45 a.m. an observation was made of the dining room in the Memory Care Unit which R54 resides. R54 was observed coming out of her room after receiving care from Certified Nurse Aide (CNA) D and was wheeled into the dining room. R54 did not appear to have Dycem underneath her in the wheelchair. An interview was conducted with CNA D who stated that she did not believe she placed Dycem in R54's wheelchair after cares because the Dycem was soiled. R54 was then wheeled back into her bathroom by CNA D who assisted R54 to stand up out of the wheelchair and confirmed there was no Dycem in R54's wheelchair. Review of R54's care plans read, in part, .at risk for falls/injury .interventions: (R54) is to have a dycem nonslip mat in her wheelchair and dining room chair. Date Initiated: 11/22/24.

Based on interview and record review, the facility failed to report an injury of unknown origin (right hip fracture) to the State Agency (SA) for one Resident (R1) of three residents reviewed for abuse. Findings include: Review of R1's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with a discharge date of [DATE] to an acute care hospital. R1's diagnoses included Rhabdomyolysis (break down of skeletal muscles, history of falls, and muscle weakness. R1's 8/29/24 Brief Interview for Mental Status (BIMS) score was 15, indicating she was cognitively intact. Review of R1's History and Physical from [Hospital Name] dated 9/8/24 read, in part, .Assessment/Plan: Patient had CT (compute tomography) scan of lumbar spines and pelvis without contrast .there is equivocal nondisplaced fracture line through right femoral neck . An interview was conducted with the Nursing Home Administrator (NHA), Interim Director of Nursing (DON) and Unit Manager/Registered Nurse A on 10/14/24 at 1130 a.m. who stated that R1 was admitted to the facility on [DATE] from the hospital after a fall from home. The hospital had conducted an x-ray and found no fractures, so R1 was admitted to the facility. When the facility was notified of R1 having a right hip fracture on 9/8/24, the hospital notes stated that it could have been from the fall prior to admission, but the facility did not report the injury of unknown origin to the SA. Review of the facility's Abuse, Neglect and Exploitation policy dated 1/10/24 read, in part, .Identification of Abuse, Neglect and Exploitation .Possible indicators of abuse include, but are not limited to: .Physical injury of a resident, of unknown source .Reporting/Response .Reporting of alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes as required by state and federal regulations: Immediately, but not later than 2 hours after the allegation is made, if the vents that cause the allegation involve abuse or result in serious bodily injury .

Based on interview and record review, the facility failed to conduct a thorough investigation for an injury of unknown origin (right hip fracture) for one Resident (R1) of three residents reviewed for abuse. Findings include: Review of R1's History and Physical from [Hospital Name] dated 9/8/24 read, in part, .Assessment/Plan: Patient had CT (compute tomography) scan of lumbar spines and pelvis without contrast .there is equivocal nondisplaced fracture line through right femoral neck . An interview was conducted with the Nursing Home Administrator (NHA), Interim Director of Nursing (DON) and Unit Manager/Registered Nurse A on 10/14/24 at 1130 a.m. who stated that R1 was admitted to the facility on [DATE] from the hospital after a fall from home. The hospital had conducted an x-ray and found no fractures, so R1 was admitted to the facility. When the facility was notified of R1 having a right hip fracture on 9/8/24, the hospital notes stated that it could have been from the fall prior to admission. An internal investigation folder was presented at this time to this Surveyor. The folder contained a handwritten note from the Physical Therapist (PT) G for two sessions on 9/5/24 and 9/26/24, and a Statement of Witness form for R1's roommate dated 9/11/24 with no signature. There was also a Quality Assistance Form dated 9/11/24, written by RN A over concerns the family had on 9/8/24 with R1's care and being transferred to the hospital. On 10/15/24 at 10:00 a.m., The NHA provided additional witness statements from four staff members dated 10/14/24 and 10/15/24 respectively. The NHA acknowledged this was not a complete investigation per the facility abuse policy into an injury of unknown origin. Review of the facility's Abuse, Neglect and Exploitation policy dated 1/10/24 read, in part, .Investigation of alleged abuse, neglect and exploitation: An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include Identifying staff responsible for the investigation, exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence), Investigating different types of alleged violations. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, Focusing the investigation on determining if abuse, neglect, exploitation and/or mistreatment has occurred, the extent, and cause, and providing complete and thorough documentation of the investigation .

This citation relates to Intake #MI00145188. Based on observation, interview, and record review, the facility failed to ensure dignified care was provided for one Resident (R1) of seven residents reviewed for dignity. This deficient practice resulted in an undignified care interaction for R1. Findings include: Review of the FRI (Facility Reported Incident) received by the State Agency (S.A.) revealed on 6/11/24 at approximately 8:30 p.m., R1 was observed by Registered Nurse (RN) B in the doorway assisting a resident to return to the secured memory care unit. At that time, R1 was attempting to exit the unit through the same door. Another nurse, RN A, told R1 she needed to stay on the unit and she had her hands over her ears. RN B reportedly observed RN A use a door-knocking gesture on R1's forearm to get her attention so she would not leave the unit. R1 did not sustain an injury per the skin assessment after the incident. The report showed an interview after the incident with RN A revealed they moved their hand towards R1's face and made a non-verbal gesture to reduce the volume of her voice, and in doing so, made light contact with R1's right arm with their left hand, which was reportedly non-intentional. No psychosocial decline was found when R1 was interviewed after the incident. The investigation further revealed when R1's family member was interviewed, they revealed R1 had a prior undisclosed history of trauma, which may have contributed to R1's reaction to RN A while she was trying to exit the secured memory unit door. Review of the Minimum Data Set (MDS) assessment revealed R1 was admitted to the facility on [DATE], with diagnoses including kidney disease, urinary tract infection, and dementia. The assessment revealed R1 required maximal assistance with toileting and toileting transfers. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 3/15, which showed R1 had severe cognitive impairment. An interview on 6/25/24 at 2:45 p.m. revealed R1 could answer a few basic yes/no questions. R1 reported she was happy and receiving good care and had no recall of any resident or staff incident. During an interview on 6/25/24 at 4:15 p.m., RN A and RN C were asked about the incident on 6/11/24. RN C confirmed no abuse was substantiated, and RN A described the incident occurred on 6/11/24 at the doorway to the memory unit. RN A explained when the unit door was opened by RN B, R1 attempted to leave the unit unsupervised at the unit doors, while RN B opened the door for another resident to reenter the unit. RN A revealed they stood in front of the secured memory unit door to block R1 from leaving the unit, as she was unsafe to leave the unit unsupervised. R1 clarified the incident occurred around 8:30 p.m. RN A described R1 began yelling at the top of her lungs and in an attempt to try to quiet her I put my hand up towards her mouth .that was a dumb move on my part .I put my hand up to her mouth about 3 inches away. RN A demonstrated to Surveyor while R1 was flapping her arms back and forth with elbows bent they made a shhhhhh sign, with one finger pointed up and moved towards R1's mouth. In doing so, RN A described how his arm accidentally struck the inside of R1's forearm, but there was no intent to do so. RN C was asked if there was a video of the incident, which RN C denied, and clarified they understood R1 struck RN A's arm as her arms were flapping and moving when RN A made the gesture towards R1. RN A reported it was a gesture meant to quiet and calm the resident. When asked if they could have done anything differently, RN A' reported he was acting more like a parent with a child than a resident. RN A clarified if this occurred again they would have just allowed the yelling, however they were concerned about R1 waking up the residents on the unit who were sleeping. During further interview, both RN A and RN C agreed the behavioral interaction and RN A's response was undignified. During an interview with the Nursing Home Administrator (NHA) on 6/25/24 at approximately 5:00 p.m., the NHA was made aware and understood concerns related to the undignified care interaction. A telephone call was attempted to R1's responsible party on 6/26/24 at 9:56 a.m., with no response by the end of the survey time period. Review of RN B's witness statement, dated 6/11/24, revealed RN B described R1 was trying to exit the secured memory unit when they were at the door and R1 let out a loud scream, which was startling. RN B described RN A's reaction was to let out a frustrated noise, and R1 placed her hands over both sides of her ears due to the noise. RN B reported they next observed RN A knock twice on R1's forearm approximately two inches from her wrist, telling her to be quiet. RN B clarified it was not a punch or a slap, and not a hard strike. RN B explained RN A initially put his hands toward the resident to place his hand towards her mouth to shush R1, but R1 did not stop yelling. RN B reported they completed a skin assessment and there were no new skin concerns noted. RN B deemed RN A was trying to tell R1 to be quiet. During an interview on 6/26/24 at approximately 6:00 p.m., RN B confirmed their description in their witness statement was how the incident occurred. Review of the policy, Promoting/Maintaining Resident Dignity, revised 10/26/23, revealed, It is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality . During the onsite survey, past noncompliance was cited after the facility implemented actions to correct the noncompliance which included: A police report was filed, Social Services provided R1 supportive visits, A PTSD diagnosis was added to R1's care plan, The facility initiated an action plan and an had an ad hoc QAPI meeting, Residents on R1's hall including R1 had skin and pain assessments completed (with no concerns found), An all staff education regarding abuse prevention, dementia care, dignified care, behavioral management, and signs of (employee) burnout was completed. Residents were interviewed regarding the potential for abuse; none was found. One to one education was provided by the NHA to RN A, who completed the education on abuse prevention, dementia care, dignified care, behavioral management, and signs of employee burnout as well as additional education on Relias educational training. R1 was referred to a behavioral care provider to evaluate and treat newly diagnosed history of trauma and identify triggers. R1's Care Plan was updated and revised to reflect history of behaviors (which was verified). The facility demonstrated corrective monitoring by completing observations of RN A providing resident care, with no concerns found. The investigation revealed no willfulness was determined or intent to make physical contact of R1 by RN A. The facility determined no functional decline or psychosocial outcome for R1, and no new bruising or skin concerns. The facility was able to demonstrate monitoring of the corrective action and maintained compliance by completing weekly audits of abuse including observations of RN A providing care. The QAPI meeting was initiated to ensure concerns were addressed and sustained compliance with their Plan of Correction.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall with fracture for one Resident (R19) of five residents reviewed for falls. This deficient practice resulted a tibial (lower leg) fracture, with increased pain. Findings include: Review of R19's Minimum Data Set (MDS) assessment, dated 11/15/23, revealed R19 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease and depression. R19 required assistance with toileting and was independent with transfers and walking. R19 was unable to participate in the Brief Interview for Mental Status (BIMS) assessment, showing severe cognitive impairment. The sensory assessment revealed R19 was sometimes understood, and sometimes able to understand. Review of R19's accident and incident report, dated 11/17/23 at 10:14 a.m., revealed R19 was found by a housekeeping staff yelling for help and was observed sitting on the floor at the end of the bed, with her legs out facing her closet. R 19 was holding her left lower leg and said it was painful. R19 stated, I fell . R19 was sent to the Emergency Department (ED). Review of R19's ED report, dated 11/17/23 at 17:36 p.m., showed R19 was diagnosed with a medial tibial fracture. R19 was non-weight bearing on the left lower extremity and provided a knee immobilizer brace. Review of R19's Electronic Medical Record (EMR) showed a fall evaluation report dated 2/18/23, which revealed a score of 16, indicating fall interventions were required. Review of Registered Nurse (RN) J's witness statement, dated 11/17/24, revealed, I was passing meds (medications). Heard [Staff K] call for help. Walked in room. [R19] was by the foot of the bed holding her foot, sitting on the floor .[R19] said her ankle hurt, [from the] knee to ankle .Floor was wet .I saw [Staff K] wiping up the excess liquid on the floor. Review of RN's Gs witness statement, dated 11/17/23, revealed, .Nurse reported a fall in [R19's] room .[R19] was holding left leg and crying out when she tried to move left leg .When asked where it hurt, [R19] stated, 'My leg,' .When I entered the room the floor under and around [R19] was wet. Upon assisting [R19] into bed, her pants were wet on her bottom area, causing wetness of the bed sheet .wetness was r/t [related to] the floor after mopping. Review of Staff K's witness statement, dated 11/17/23, revealed, I entered the room [D-14], to do my routine cleaning .Curtain drapes were closed. I began to mop the floor when I heard [R19], I .found her upright on the floor at the end of her bed .I placed a wet floor sign down before I entered the room I knocked and no one responded. [R19] always has left the curtain closed, so I assumed no one was inside the room . During an interview on 3/19/24 at 12:12 p.m., Housekeeping Staff E reported they would not have mopped R19's floor with R19 in the room, and clarified they only damp mopped the residents' room floors, per facility process. During an interview on 3/19/24 at 4:44 p.m., RN G reported they walked in R19's room after the incident occurred and observed R19 sitting on the floor in a puddle of water. They and staff intervened with considerable assistance as R19's leg was wedged between the back of the bed and against the closet, and she cried out in pain. RN G confirmed this was an avoidable accident due to the wet floor, and R19 was ambulatory at that time. RN G clarified there was a wet floor sign in the doorway, however R19 would not have been able to see it behind the pulled curtain. Review of R19's PAINAD [pain assessment for persons with advanced dementia], dated 11/17/23, after the incident, revealed a score of 5/10, indicative of moderate pain. Review of R19's November 2023 Medication Administration Record (MAR) revealed R19 was on scheduled Acetaminophen, with the dosing increased to 500 mg (from 325 mg), 2 pills by mouth, three times a day, for pain after the incident, from 11/18/23 to 11/30/23. Additionally, on 11/18/24 [upon return from the ED], Tramadol 5 mg [a narcotic pain medication] was prescribed for breakthrough pain, every 4 hours as needed (prn). The Tramadol prn was used 26 times for R19 from 11/18/24 to 11/30/24. R19 was only on Acetaminophen prior to the fall with fracture on 11/17/23. During an interview on 3/20/24 at 12:02 p.m., Surveyor reviewed R19's increased pain per the Medication Administration Record (MAR) with RN G, who confirmed R19 had increased pain after the injury and during her recovery period. During an interview on 3/20/24 at 10:20 a.m., the Rehabilitation Director, Occupational Therapist (OT) F, reported R19 was near their prior level of function (prior to the 11/17/23 fall), and had been on therapy caseload since the fall. OT F reported R19 went from a wheelchair and non-weight bearing at the time of the fall to ambulating without a device. OT F reported they had been informed R19 fell on a wet floor and acknowledged a wet floor left for a cognitively impaired resident in their room would be concerning and dangerous. During an interview on 3/20/24 at 10:50 a.m., Staff I confirmed housekeeper, Staff K, was the staff involved in the incident, and did not follow their policy and process for cleaning the floors in the facility. Staff I reported Staff K received verbal disciplinary action. Staff I stated the typical process would be for staff to knock on the door and receive a response, and said, We are never going to mop if there is a resident in the room . There should have never been a wet floor; you are supposed to wring out the mop. It should be a damp mop . Staff K did wet mop the room . Review of Staff K's, One to One Inservice Record, dated 11/17/23, revealed, Inservice Topic/Title: 5-step cleaning method w/ [with] concentration on floors .The 5-step method is used to clean a resident's room. 'Damp mopping' is required, not wet mopping . The Inservice included a verbal review and return demonstration and was signed by the Environmental Services Director (EVS), Staff I. Review of the policy, Accidents and Supervision, revised 12/27/23, revealed, Each resident will be assessed for accident risk and will receive care and services in accordance with their individualized care plan. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). 4. Monitoring effectiveness and modifying interventions when necessary. Definitions: Accident refers to any unexpected or unintentional incident, which results in injury or illness to a resident .Fall refers to unintentionally coming to rest on the ground, floor, or other lower level .Hazards refers to elements of the resident environment that have the potential to cause injury or harm. Risk refers to any external factor, facility characteristic ( .physical environment) or characteristic of an individual resident that influences the likelihood of an accident .Identification of fall risk .Upon identification of risk for falls, the following interventions may be considered when developing the baseline or comprehensive care plan for the resident: a. Implementing universal environmental interventions that decrease the risk of resident falling, including, but not limited to: .A clear pathway to the bathroom or bedroom doors . During an interview on 3/20/24 at 11:17 a.m., Surveyor reviewed concerns related to R19's fall with fracture, including increased pain and pain medication, and her non-weight bearing status at the time of the incident. The Nursing Home Administrator (NHA) reported they understood the concerns and presented a Past Noncompliance document. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: Housekeeping staff have been reeducated on following the 5-staff (sic) cleaning method with a concentration on cleaning floors. The mop head should be damp and not wet. Floors may not be damp mopped while an independently mobile resident is in the room. CENA's (aides) and nurses were educated housekeeping staff cannot damp mop floors while a resident is in the room. QAPI (quality assurance and performance improvement) committee reviewed policies and procedures related to the incident and deemed them appropriate. The facility was able to demonstrate monitoring of the corrective action and maintained compliance by completing random weekly audits of housekeeping staff to ensure that floors were damp mopped only when a resident was not in the room. Center audits were to be reviewed by the Interdisciplinary team and at QAPI {commitee) to identify any trends and to prompt additional actions where needed.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in a food borne illness among any and all 58 residents. Findings include: On 3/18/24 at approximately 10:30 AM, a bag of food was observed in the upright refrigerator in the kitchen. The bag was from a local fast food restaurant and labeled with a resident's name. An interview with conducted with Kitchen Manager (KM) A at this time and it was learned the bag was brought into the facility by the resident's family member, accepted by kitchen staff and stored in the refrigerator. The bag contained breakfast sandwiches according to KM A. It was further learned this is a common event in which the food is brought into the kitchen then heated in the kitchen microwave oven. KM A acknowledged the food was not supposed to be stored in the kitchen due to the potential contamination brought in from an unknown source. A review of the policy Use and Storage of food brought in by family or Visitors was performed. The policy failed to address the prohibition of food from outside sources from being stored in the facility kitchen and handled by kitchen staff with kitchen equipment. The policy failed to identify where refrigerated food was to be stored and where food requiring heating would be accomplished. The FDA Food Code 2017 states: 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306 On 3/18/24 at approximately 11:28 AM, cook C was observed placing a ground beef patty on a bun on a plate, then using bare hands, put the top of the bun on the sandwich. An interview was conducted with KMA at this time, who stated that she was not able to see Cook C, but affirmed cook C should be wearing gloves or using utensils to handle ready to eat food. The FDA Food Code 2017 states: 2-103.11 Person in Charge. (M) Except when APPROVAL is obtained from the REGULATORY AUTHORITY as specified in 3-301.11(E), EMPLOYEES are preventing cross-contamination of READY-TO-EAT FOOD with bare hands by properly using suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT; 3-301.11 Preventing Contamination from Hands. (A) FOOD EMPLOYEES shall wash their hands as specified under S 2-301.12. (B) Except when washing fruits and vegetables as specified under S3-302.15 or as specified in (D) and (E) of this section, FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT.

Based on observation, interview and record review, the facility failed ensure the right to privacy for four Residents (R10, R11, R34, and R37) related to intrusive wandering behaviors of one Resident (R14), of five residents reviewed for privacy. This deficient practice resulted in feelings of frustration from violations of privacy and ongoing, intrusive wandering behaviors for R14. Findings include: Review of R14's MDS assessment, dated 11/8/23, revealed R14 admitted to the facility on [DATE], with diagnoses including dementia and depression. R14 was independent with transfers and walking and required moderate assistance with toileting. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 0/15, indicating R14 had severe cognitive impairment. The behavioral assessment showed R14 had verbal behaviors directed at others and wandering behaviors daily. During an observation on 3/18/24 at 2:03 p.m., R14 was observed exiting a male resident's room on the unit with another female resident, unsupervised by staff. The male resident was not in his room. R14 then entered another unoccupied female resident's room, closed the door, and then exited again. R14 next entered another unoccupied male resident's room on the unit and exited without staff awareness. During an observation on 3/19/24 at 12:29 p.m., R14 was observed in R37's room [a male resident] for a few minutes, looking out the window. There were two staff in the hallway when this occurred who did not intervene. During an interview on 3/19/24 at approximately 12:40 p.m., Licensed Practical Nurse (LPN) P stated, We [staff] can't stop her. [R14] wanders. She used to take things from people's rooms .she sleeps better in other people's beds than when we put her in her own bed . During interview on 3/19/24 at 12:42 p.m., Certified Nurse Aide (CNA) Q was asked about R14 entering other residents' rooms and taking items from other residents' rooms. CNA Q responded, Yes, she does .if they [the items] make it back, it's on accident. We know whose things are whose and they are labeled. Surveyor asked if this bothered any residents. CNA Q clarified it bothered some of the residents when R14 was in their beds, so they retrieved her only from these rooms, but if it did not bother a resident, they would allow R14 to lay in their bed. During an interview on 3/19/24 at 2:28 p.m., R34 was in her room and was asked about privacy in her room. R34 reported R14 frequently wandered into her room, and it bothered her when R14 took items off her nightstand, like her water and other personal items. It initially appeared R34's roommate was sleeping in her bed during the interview; however, it was soon after observed R14 was laying in R34's roommates' bed, sleeping. R34 observed R14, and commented, Different people are in this bed ., motioning to her roommate's bed. Staff did not retrieve R14 from R34's room during the interview. Two aides were in the hallway upon exiting. During an interview on 3/19/24 at 2:41 p.m., R37 was interviewed about privacy in his room; he did not have a roommate. R37 said, I don't like it. I have lost more stuff .clothes. They [unnamed resident] get in the drawer and take things out of it . and described missing toothbrushes. R37 stated, I have said too much .I have told them [staff] .They [resident] watch you, when I go to get some food, when I'm gone . and stated he often watched this occurring in his room from the hallway. R37 showed Surveyor his blue wheeled walker and said, They take it, and I spend half a day or more trying to get it back . R37 stated he did not like it when other residents entered his room. R37 explained [R14] is one of them. [R14] is the worst one; she'll climb right into bed with you. When asked if this happened recently, day or night, R37 responded, Anytime. I don't like it when she's [R14] in here. [R14] has taken my shoes. I didn't get them back but I notified the people here [staff] and they got them back. It bothers me, as I should not have to deal with that. I'm glad to find somebody I can trust to talk to. I can live with it but it shouldn't be happening. R37 expressed he felt frustrated as he had told staff many times and R14 continued to wander into his room. R37 showed Surveyor how his door latch did not fasten completely, and reported the wandering residents pushed his door open as it did not close, which Surveyor observed. During an interview on 3/19/24 at approximately 3:30 p.m., CNA Q confirmed it bothered R34 when R14 took items from her room, and stated, [R14] is a shoe thief . During an observation on 3/19/24 at approximately 3:38 p.m., R14 was observed entering R37's room, and looking around, while R37 was not in his room. Review of R14's progress notes revealed: 3/10/24 at 9:19 a.m.: [R14] wanders facility in and out of [resident] rooms and lays in other residents' beds and grabs things out of there [their] rooms . 3/8/24 at 8:15 p.m.: [R14] wandering into the rooms of others . 3/2/24 at 9:36 a.m : [R14] wandering into residents' rooms and takes stuff . 2/15/24 at 8:32 p.m.: [R14] pacing; in and out of [residents'] rooms . 2/11/24 at 6:13 p.m.: [R14] is getting in other residents' belongings; they respond madly or pull their things away and she will continue to reach. [R14] gets mad and starts punching staff when they intervene between residents. 2/10/24 at 6:11 p.m. [R14] wanders in and out of every single room up and down the hall. 2/9/24 at 6:06 a.m ., [R14] in other resident personal space and taking items from other resident rooms and off their person .[R14] appears sad and tense. 1/25/24 at 3:52 p.m., [R14] continues to wander the halls and in and out of other resident's rooms and attempts to take other resident's belongings . 1/21/24 at 9:17 a.m., [R14] wandering into [residents'] rooms and taking items . 1/12/24 at 3:20 p.m., [R14] wandering in and out of every resident's person [sic] space . 1/5/24 at 11:04 a.m., [R14] wanders the hall in and out of rooms, taking other residents' possessions . 1/1/24 at 1:37 p.m., [R14] .frequently goes into other residents' rooms and takes their belongings . 12/23/24 at 9:52 a.m., [R14] .has been intrusive with other residents and trying to walk off with pillows and blankets and stuffed animals. 12/15/23 at 1:20 p.m., [R14] walking off with other people's belongings . 12/3/23 at 8:54 a.m., [R14] .wandering into other residents' rooms, removing items . 11/17/23 at 10:56 a.m., [R14] was found standing at bedside, swinging at [R11] in bed . 11/12/24 at 7:24 p.m., [R14] .would lay in [residents'] beds, take bedding and others' belongings . 11/8/24 at 19:21 p.m., [R14] in and out of rooms, taking others' belongings. Being very aggressive about this. Threatening gestures. 11/7/24 at 8:09 p.m., [R14] in and out of rooms. Taking others' belongings. Crawling into bed with others. 11/6/24 at 2:47 p.m., [R14] continues to wander in and out of other resident's rooms, take items out of the garbage and take other resident's belonging [sic] out of their rooms. Review of an Accident and Incident report for R14, dated 2/1/24 at 19:42 [7:42 p.m.] revealed, [R14] has been in and out of others [residents] rooms all day and taking their personal items. [R14] continues to go into rooms that she has been asked to stay out of by the resident. Tonight, [R14] went into a residents' room [R10] and sat in the recliner in room. [R10] .grabbed [R14's] arm and pulled her out of the recliner in her w/c [wheelchair] .[R10] description: I don't want [R14] in here and I was trying to protect my roommate .Other information: [R14] has wandering behavior, can be intrusive to other residents, causing agitation. [R14] will grab an object from other residents' rooms, carry it around and set it down in different places .[R10] does not like [R14] because of her behaviors of wandering in her room, taking her and roommates belongings . During an interview on 3/20/24 at 1:09 a.m., with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), Surveyor shared the concerns regarding R14's wandering behaviors and subsequent violations of privacy affecting other residents on the unit. The NHA and the DON reported they understood the concerns. Review of the document, [State] Know your rights - Your Medicaid Care and Coverage in a Long-Term Care facility, edition DCH 0731 (10-13), revealed, Basic rights: As a resident of a Medicaid nursing home, you have the same rights about your life, medical care, and personal treatment as others who live in the community. These rights are protected by rules made by both the State and Federal government .you have the right to the same quality of resident care as other nursing home residents .you have the right to personal privacy .This includes your accommodations .

Based on observation, interview, and record review, the facility failed to ensure expired medications and loose pills were disposed of properly in two of four medication storage carts reviewed for medication storage. Findings include: On 3/18/24 at 4:27 PM, an inspection of the medication cart for A-hall was conducted for medication storage and was found to have the following expired medications: a.) nystatin topical power 30 grams with lot number 402336 and expiration date of 06/2023, and lacked an open date was dispensed on 1/17/2022 b.) cyclosporine ophthalmic emulsion single use eye drops solution 0.05% with lot number 393113 and expiration date of December 2023 On 3/18/24 at 4:35 PM, an interview was conducted with Registered Nurse (RN) L and confirmed that expired medications should not be left in the cart. On 3/18/24 at 4:40 PM, an inspection of the medication cart for C-hall was conducted for medication storage and was found to have the following loose medications: The third drawer had 7 loose pills, of which two were identified as baclofen 5 mg and sucralfate 1 gm. The second drawer had 9 loose pills of which 7 were identified as metoprolol tartrate 50 mg and 25 mg, norvasc 5 mg (x2), mirtazapine 15 mg, memantine hydrochloride 5 mg, and metoprolol succinate 25 mg. The first drawer had one unidentifiable loose pill. The bottom drawer had a name brand container of sani-wipes with a purple top laying on its top with clear liquid escaping from the top and spilling onto 6 individually wrapped needles. The liquid was pentrating the paper portion of the needle packaging. There was also an expired 25 guage needle. On 3/18/24 at 5:00 PM, an interview was conducted with RN N regarding the observations during the review of the C-Hall medication cart. RN N confirmed expired and loose medications or biologicals should not be in the cart and carts are cleaned regularly but was unable to provide a schedule or documentation showing this was completed regularly. In addition to the expired and loose pills the second and third drawers had visible debris from medication blister packs and medication powder residues in various colors. There were three inhalers without open dates. RN N confirmed all inhalers should have an opened date written on the box and inhaler. On 3/19/24 at 8:30 AM, the Director of Nursing (DON) was asked about the expired medications, medication storage, and loose pills and replied, The nurses are responsible for keeping medication carts clean, free from loose pills, and expired medications. Review of facility policy titled, Medication Storage, dated 1/30/2024, read in part, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored according to the manufacture's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines .7. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.

Based on interview and record review, the facility failed to ensure adequate monitoring of a high risk resident (Resident #66) for inadequate intake of foods and fluids during a COVID infection. This deficient practice resulted in Resident #66 having an acute change in condition requiring hospitalization where she was found with acute dehydration and septic shock and expired seven days after readmission to the facility. Finding include: Resident #66 (R66): A review of R66's medical record revealed she admitted to the facility on [DATE] with diagnoses including quadriplegic cerebral palsy, dysphagia, hx (history) of sepsis, and dementia. A review of R66's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed she scored ,d+[DATE] on the Brief Interview for Mental Status (BIMS) assessment, indicating moderately impaired cognition. This assessment also showed she required limited assistance of one staff for eating. A review of a [DATE] Dietary Progress note by former Registered Dietitian (RD) H revealed, Weight Warning. Value: 118.8 (pounds) . -5.0% change . -7.5% change . -10.0% change (13.3%, 18.2 (pounds)) . records show wt (weight) has fluctuated ,d+[DATE]# (pounds) x 1 month Eating (about) ,d+[DATE]% of meals, refused 7 meals x 1 week . continue to monitor nutrition intake and wt. There were no nutrition notes after this in R66's record. Further review of R66's progress note revealed the following: [DATE] Site of infection: COVID+ . During outbreak testing resident tested COVID+ on POC (point of care) test. R/T (related to) dementia diagnoses resident will quarantine in own room . [DATE] . Res (resident) presents as fatigued and possibly a decreased appetite but is otherwise asymptomatic at this time . [DATE] . COVID+. FATIGUE. [DATE] Resident has had multiple episodes of emesis this shift. Afebrile, no other symptoms . [DATE] Sent to (name of emergency room ) . Emesis x 3 on [DATE] evening. Current s/s (signs and symptoms), BP (blood pressure) ,d+[DATE], resp (respirations) 14, lethargic, confused, diaphoretic, cool to touch . A review of R66's hospital records revealed the following: A review of the [DATE] emergency room notes revealed, . Reexamination/Reevaluation: The patient was noted to be persistently hypotensive despite having multiple boluses of fluids. She received 30 mL/kg bolus and an additional liter on top of this. Her pressures were not improved . she has a acidosis noted, likely secondary to lactic acidosis. Patient has end organ injury including mental status changes, acute kidney injury. She does appear dehydrated this is possibly compounding her clinical picture . A review of the [DATE] Hospital History and Physical revealed, . coming from (name of facility); woke up unusually difficult and diaphoretic this am. Hypotensive for ems . pt (patient) c/o (complaints of) abd (abdominal) pain w (with) palpation . per nursing home report, patient had not been complaint of anything prior to this morning, with no unusual coughing . patient had been positive for COVID-19 on ,d+[DATE] . husband also reports that patient had been her usual cheerful self this past week . A [DATE] progress note stating, . pt (patient) had some bloody mucosy stool, I sent labs and HGB (hemoglobin) was 10.5 and HCT (hematocrit) was 33.1 . A review of a [DATE] hospital progress note revealed, . Assessment/Plan: Acute Dehydration. Acute Kidney Injury. Altered Mental Status. Chronic Anemia. Lactic Acidosis. Septic shock . last stool prior to admission . Alk phos (alkaline phosphate) elevation . suspect in setting of dehydration/shock . A review of the hospital orthopedic notes revealed: [DATE] . Brought from (name of facility) this am (morning) due to change in health status and difficulty arousing. Has a UTI (urinary tract infection), but with shoulder history, will have shoulder aspirated to ass (assess) for recurrent infection. Can begin antibiotics after aspiration and will discuss . [DATE] . didn't have enough fluid for aspiration earlier in admission . A review of R66's [DATE] Dietary Progress note revealed, . Malnutrition screen score 2 or greater . Pt has been losing weight over the past 6 months, only accepting of sweet such as pudding, ice cream, ensure . RN at (name of facility) reports unintended, progressive weight loss over the past ,d+[DATE] months that had stabilized recently . EMR weight . [DATE]XXX,d+[DATE].4 kg . ,d+[DATE]% weight loss since [DATE] (9 months) . nutrition diagnosis: Unintended weight loss related to decreased ability to consume sufficient energy (dementia) as evidenced by Weight loss of ,d+[DATE]% since [DATE] (9 months), decreased oral intake per SNF (skilled nursing facility) staff . A review of the Intensivist Hospital notes revealed: [DATE] . regarding sepsis/shock, patient also appears to be dehydrated, possible with poor pre-hospitalization oral intake at (name of facility). Urinalysis consistent with UTI but culture negative . cardio/hemodynamics: . likely component of hypovolemia (low blood volume). Resolved after 7 L (liters of fluids) and 5 kg (kilogram) net gain since admit .Infectious disease: . source unclear; urine culture negative . CXR (chest xray) negative, renal US (ultrasound) negative, shoulder joint without significant fluid on US . vanco (antibiotic) stopped today; will continue empiric Zosyn until blood cultures final tomorrow . A review of R66's Intake and Output (I and O's) from [DATE] - [DATE] revealed she received over 9000 mL of a variety of IV fluids (0.9% sodium chloride, Dextrose 5% in water, and lactated ringers). A review of the blood cultures on [DATE] revealed no growth found even after five days (no source of infection). A review of the urine cultures taken on [DATE] revealed no growth found. A review of the microbiology results revealed no evidence of viral, bacterial, or parasitic infection. A review of R66's facility progress notes revealed she readmitted to the facility on [DATE] and was admitted to hospice the same day. No progress notes were documented from [DATE] through [DATE]. The last progress note for R66 on [DATE] at 1:03 a.m. revealed, (Name of R66) deceased ,d+[DATE] time of death 2350 (11:50 p.m.) . A review of R66's Food acceptance records prior to her hospitalization on [DATE] revealed the following average intakes: [DATE]: accepted only 15% at one meal, refused the other two meals [DATE]: 25% at all three meals [DATE] 38% average across three meals [DATE]: 13% average of three meals [DATE]: Refused all three meals [DATE] 18% average intake among three meals [DATE] 0% (no intake at any meals) [DATE] Accepted 25% of two meals only. [DATE] Refused every meal. In the one week prior to her hospital transfer, R66 refused or ate 0% at meals 11 meals (11 refusals out of 3 meals per day for 7 days = refusal rate of 52%), which was a marked increase from her normal refusal rate of 18% (11 refusals in 60 meals between [DATE] and [DATE]). A review of R66's fluids in the seven days prior to her hospitalization on [DATE] revealed an average of 601 mL of fluids per day as follows: [DATE]: 1280 milliners (ml) fluid intake [DATE]: 910 mL [DATE]: 240 mL [DATE]: 500 mL [DATE]: 340 mL [DATE] 700 mL [DATE]: 240 mL A review of R66's average intake of fluids calculated for [DATE] - [DATE] was 876 mL per day. A review of R66's weights in the vitals section of her medical record revealed the following: [DATE] 120.1 pounds [DATE] 120.5 pounds [DATE] 118.6 pounds [DATE] 119.4 pounds [DATE] 115.7 pounds. A review of R66's Medication Administration Record (MAR) for [DATE] showed two additional weights: [DATE] 115.7 pounds and [DATE] 115.7 pounds. A review of R66's bowel log revealed in the 7 days prior to her hospital transfer on [DATE], R66 only had two medium sized bowel movements. A review of R66's care plan for hydration revealed, The resident has potential for fluid deficient r/t decreased intake, modified diet/thickened liquids, cognitive impairment developed on [DATE]. The interventions included, Encourage resident to drink fluids of choice: (Chocolate milk, water) dated [DATE] and Monitor/document/report nurse/MD PRN an s/sx dehydration: decreased or no urine output, concentrated urine . new onset confusion . fatigue/weakness . recent/sudden weight loss . initiated [DATE]. The intervention of Offer/encourage fluid intake with meals, med pass, with cares, during activities was also added to the care plan on [DATE]. A review of R66's care plan for COVID-19 infection initiated on [DATE] revealed, The resident has or is suspected to have COVID-19 . Monitor for anorexia or lack of appetite ([DATE]) . A review of R66's care plan for nutrition initiated [DATE] revealed, Resident is at risk for nutritional declines related to nutritionally pertinent diagnosis of dementia, B 12 deficiency . non-detrimental wt loss. Hx (of) poor PO (oral) intake d/t (due to) dementia . Monitor FAR (Food Acceptance Record) and fluid intake and offer alternative choices for refused food and fluids PRN (as needed) ([DATE]) . A review of R66's provider notes dated [DATE] and [DATE] revealed no mention that R66 had been diagnosed with the primary diagnosis of acute dehydration. NP I had only discussed the history of R66's shoulder surgeries and that R66's family was choosing palliative care. On [DATE] at 3:03 p.m., an interview was conducted with the Director of Nursing (DON). The DON was asked about R66's noted decline in weight and intake of fluids and food prior to her hospitalization on [DATE]. The DON reported that they had found she was having issues with her shoulder so they got an appointment for orthopedics. The DON reported that R66 had multiple episodes of emesis and was found to have infection in her shoulder prostheses. The DON was asked why the hospital documentation was stating the hospital had noted that they could not find a source of infection. The DON reported that something must have been brewing. When asked why NP I had not even noted the hospitals diagnosis of acute dehydration and concern for inadequate intake prior to admit, the DON provided no answer. A review of a handwritten paper scanned into R66's electronic medical record revealed, [DATE] . Admit to (Name of Hospice) Dx (Diagnosis): Sepsis . This was signed as a verbal order from the hospice physician. No other hospice documentation was found in R66's record. A review of R66's death certificate revealed her cause of death as End Organ Failure and Septic Shock, with the approximate interval between onset and death listed as 2 weeks. A review of the facility policy titled, Nutritional Assessment revised on [DATE] revealed, . 1. The Dietitian or Registered Dietetic Technician (as allowed by state regulations), in conjunction with the nursing staff and healthcare practitioners, will complete a nutritional assessment for each resident upon admission, annually, and as indicated by a Significant change in condition . 6. Once risk factors for impaired nutrition are identified, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences . A review of the facility policy titled, Weight Monitoring revised on [DATE] revealed, . the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrates that this is not possible . 7. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions . e. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes .

This citation pertains to intake MI00132096 Based on observation, interview and record review, the facility failed to prevent a fall with major injury for one Resident (#308) of four residents reviewed for falls. This deficient practice resulted in a laceration to the right forehead above the eyebrow requiring sutures, surgical intervention for a fracture of the left tibia, and a subsequent required hospital stay. Findings include: A review of the Electronic Medical Record for Resident #308 revealed an initial admitted to the facility on [DATE] with diagnoses including repeated falls, cognitive social or emotional deficit following cerebral infarction, weakness, cerebral infarction (Stroke 8/24/22), Dysphagia (difficulty swallowing 8/24/22), muscle weakness, abnormalities of gait and mobility, cerebral infarction due to occlusion or stenosis of right anterior cerebral artery, and fracture of shaft of left tibia (10/15/22). On 3/14/23 at approximately 1:35 p.m., Resident #308 was observed working in therapy. Two therapy staff were observed on both sides of Resident #308 during the observed therapy session. Therapy staff had to actively assist Resident #308 to stay upright in the sitting position while performing removal of plastic pegs and placing them into a container. Resident #308 had observable difficulty with trunk control and was leaning/falling to her right during the therapeutic exercise. Resident #308 would have fallen on the floor to her right side if staff were not in attendance. During an interview on 3/14/23 at 2:57 p.m., Family Member (FM) A stated she had received a call from the facility indicating Resident #308 had fallen out of a wheelchair and hit her head and was sent to the hospital to be checked out. FM A stated she had a conversation with Registered Nurse (RN) B regarding the details of what happened. FM A stated RN B told her Resident #308 had fallen out of a wheelchair and not the chair she was supposed to be in which was a cardiac chair. When asked why she was in a wheelchair, FM A stated she was in attendance, at a doctor's appointment, for a follow-up with FM A, and recalled Resident #308 was in a regular wheelchair during the appointment. When asked who had made the notification to the family, FM A stated someone named (RN C) called her and told her she had fallen out of a wheelchair and had hit her head and sustained a laceration to her forehead. FM A stated the laceration had to be sutured at the hospital and the doctor at the hospital informed FMA that Resident #308 had also sustained a Left Tibia Fracture. FM A stated she asked RN B to pass along that she wanted to know what exactly happened, and why Resident #308 was left in a wheelchair unattended. FM A stated RN B told her this would not have happened if she was on duty, and said she would pass her request on to administration, but never heard back from the facility. A review of the EMR progress notes for Resident #308 revealed the following: 9/29/2022 (5:05 p.m.) Nurses' Notes . Resident (#308) was sitting in wheelchair and reached for bag of popcorn that fell on the floor and fell out of the chair face first. Resident (#308) cut above her right eye and complains of left ankle pain. (Author: RN D) A review of unwitnessed incident report dated 9/29/23 at 4:53 p.m., revealed Resident #308 had fallen on the floor face first, sustaining a cut above the right eye, and was complaining of left ankle pain. Resident #308 was sent to the hospital. The mental status section of the incident report was left blank. Predisposing Environmental Factors were marked as having none. Predisposing Physiological Factors was marked as Confused. Predisposing Situational Factors was marked as Other and described as Resident (#308) was in wheelchair and fell forward out of the chair [NAME] leaning forward. No further investigation into the fall was completed by facility leadership. No new intervention was identified following the fall. A review of the hospital records for Resident #308 revealed the following: Face sheet dated 9/29/22: Admission to the emergency room (ER) on 9/29/22 with an admitting diagnosis of FALL ON THINNERS EMS (emergency medical services) STS (states) Informed Consent for Procedure dated 9/30/22: Left tibia intramedullary nailing and revision open reduction internal fixation left fibula which was signed by Resident #308's Power of Attorney (POA). Discharge Documents dated 10/3/22: All Diagnoses This Visit: . Facial Laceration Fracture of left tibia and fibula . Hospital Course: 75 y/o (year old) with history of stroke, was residing at (the Facility), wheelchair-bound. (Resident #308) fell out of a wheelchair with resultant left leg fractures. 1. Fracture of left tibia and fibula -fell out of wheelchair at (the facility) -Has proximal left tibia and fibular nondisplaced fractures; history of left ankle ORIF (open reduction internal fixation) in May s/p (status post) 9/30 Intramedullary nailing left tibia with removal of hardware left fibula and extension of fibular plating L (left) leg is paralyzed 2nd (secondary) to CVA (stroke) . History and Physical dated 9/29/22: Chief Complaint: c/c (chief complaint) pt (Resident #308) arrives via EMS post slip out of wheel chair, pt hit head, lac (laceration) to right eye, denies LOC (loss of consciousness), on Lovenox (anticoagulant), pt includes right knee pain and left ankle pain . . 2. Fracture of left tibia and fibula --fell out of wheelchair at (the facility) --Has proximal left tibia and fibular nondisplaced fractures; history of left ankle ORIF in May --Orthotech (orthopedic technician) called in for splinting --Ortho (Orthopedic Physician) contacted by ED (emergency department) --Patient made NPO (nothing by mouth) after midnight; 1 L (liter) NS (normal saline) ordered total --Keep bed rest until seen by ortho --Planning to continue home prophylactic Lovenox . . Diagnostic Results TIBIA/FIBULA Xray: Oblique (slanted) fracture of the proximal (near center of the body) left fibula, minimally displaced. There is a transverse fracture of the distal tibial diaphysis (midsection) just above a fixation plate with multiple screws fixating the distal aspect of the fibula. There is minimal posterior apex (highest part) angulation of this fracture. A fixation screw is demonstrated fixating the medial malleolus (inner ankle bone). There is an oblique fracture of the mid to distal left tibial diaphysis with 1/2 shaft with displacement of the distal fracture fragment medially with posterior apex angulation . A review of a orthopedic progress note for Resident #308, dated 12/8/22 read in part: Date of Surgery: 9/30/22 Procedure Performed: Intramedullary nailing LEFT tibia with removal of hardware left fibula and extension of fibular plating . Surgical History: . Open reduction internal fixation left trimalleolar ankle fracture: 5-24-2022 . During an interview on 3/15/23 at 10:07 a.m., RN C stated he recalled the incident and had recalled assisting RN D with the filling out an assessment to send Resident #308 to the hospital for an evaluation. RN C acknowledged Resident #308 was highly impulsive and stated she used a geri-chair when she was out of bed. RN C acknowledged Resident #308 would have been unsafe to be left in a regular wheelchair. During an interview on 3/15/23 at approximately 11:30 a.m., Certified Nurse Aide (CNA) F stated she was assigned to the B-hall by herself on the day of the fall incident with Resident #308. CNA F stated she knew she was out on an appointment because she was told in report by CNA G. CNA G also indicated to CNA F, Resident #308 was not supposed to remain in the wheelchair when she came back, without direct supervision because of Resident #308's impulsiveness and risk of tipping out of the wheelchair. CNA F stated she asked CNA H who had transported Resident #308 to a doctor's appointment, what had happened. CNA F indicated CNA H stated he had told someone Resident #308 was back in her room in a wheelchair, but could not remember who. CNA F stated CNA I, CNA J, and CNA K were all working that afternoon, and they all said they were unaware Resident #308 was back in her room in a wheelchair. During an interview on 3/15/23 at approximately 11:53 a.m., CNA H stated he did take her to an appointment the day of the incident. CNA H stated he came back with Resident #308, took Resident #308 to her room, and stated he gave her a call light. CNA H stated he told a female CNA, whom he could not identify, Resident #308 was back and in her room. CNA H stated he also indicated to the unknown female CNA, Resident #308 was very tired and she should get Resident #308 back to bed in short order. CNA H confirmed no staff were in the room when he left Resident #308 in the wheelchair with a call light. CNA H denied being informed Resident #308 could not be left alone in a wheelchair by anyone from therapy. During an interview on 3/15/23 at approximately 12:23 p.m., CNA G confirmed a regular wheelchair was supposed to be used for appointments and therapy only. CNA G confirmed she could be left alone in her geri-chair with her call light, but if she was in a wheelchair, she had to have eyes on her at all times due to behaviors and leaning forward. During an interview on 3/15/23 at approximately 12:25 p.m., OTR L, stated the biggest problem Resident #308 had hypertonicity, which affected her entire left side with left sided neglect. OTR L indicated Resident #308's cognition was very impaired and she was highly impulsive. OTR L indicated the therapy staff made it very clear to the facility staff, Resident #308 was not to be left in a wheelchair, including a tilt-back chair without supervision. OTR L confirmed this was communicated to CNA H on the day of the transport to a medical appointment by OTR M. OTR L stated she was aware Resident #308 was left alone in a wheelchair and confirmed the fall and subsequent major injury was a direct result of being left unsupervised in the wheelchair. OTR L stated Resident #308 was not safe to be left in an upright position without constant supervision due to her impulsivity and poor safety awareness from her stroke. OTR L reiterated everyone in the facility was aware Resident #308 could not be left alone, unsupervised, in a wheelchair. During an interview on 3/15/23 at 2:38 p.m., OTR M confirmed CNA H had asked for a wheelchair with a reclining back for Resident #308 to be transported to a medical appointment on the day of the incident. OTR M stated he provided such a wheelchair and indicated he had communicated to CNA H, Resident #308 was under no circumstances to be left in the wheelchair alone and unsupervised when returning to the facility. OTR M stated the facility was using a geri-chair prior to the incident for Resident #308 to be up in when out of bed because she was not safe in a wheelchair due to impulsivity and poor safety awareness. A review of the Occupational Therapy notes for Resident #308 revealed the following: 9/29/22 at 11:38 a.m. - Precautions: (Resident #308) is a fall risk and has poor safety awareness and judgement . (Resident #308) required max assist to sit up on the edge of the bed and max assist to maintain sitting balance at the edge of the bed. (Resident #308) required max assist with a stand pivot from the bed to the W/C . W/C (wheelchair) Mngmt (management): analysis of patient's body alignment and functional skills in new or existing W/C and assessment of current seating system for appropriate modifications . (Author: OTR M) 9/22/22 at 4:51 p.m. - Precautions: (Resident #308) is a fall risk and has poor safety awareness and judgement . Facilitation of sitting at the edge of bed to increase strength, balance, safety awareness, and functional activity tolerance for increased function with ADLs. (Resident #308) required minimal to maximal assistance for balance sitting at the edge of bed with RUE (right upper extremity support of bed. Increased assistance required with movement of LE (lower extremity) . (Author: OTR N) 9/8/22 at 3:44 p.m. - Precautions: (Resident #308) is a fall risk and has poor safety awareness and judgement . Transfer training from w/c to standing completed 2 times with (Resident #308) requiring Max A (maximal assistance) with mod (moderate) vc's (verbal cues) for carry over with toilet transfers . (Author: OTR L) 9/7/22 at 3:00 p.m. - Precautions: (Resident #308) is a fall risk and has poor safety awareness and judgement . Mod (moderate) assist provided to improve (Resident #308) positioning while eating a meal. (Resident #308) was able to complete self-feeding with MOD I (modified independence) assist when sitting upright in her gerry (sic) chair . (Author: OTR M) A review of the Physical Therapy notes for Resident #308 revealed the following: 9/27/22 at 4:09 p.m. - . Sitting balance at edge of bed with mod/max assist, verbal and tactile cues for anterior weight shifting in order to prevent posterior LOB (loss of balance). Bed to Broda (reclining type chair, similar to geri chair) transfer with [NAME] lift, verbal cues for posture, max assist for set up . (Author: Physical Therapy Assistant (PTA) O, co-signed by Registered Physical Therapist (RPT) P) 9/26/22 at 1:27 p.m. - . completed bed mob (mobility) with P mod (partial moderate assist) to roll L (left) S Max (substantial maximal assistance) to roll R (right) and S Max for lying to sitting from R side, stand pivot transfer with 2 person S Max assist bed to cardiac chair (geri chair) . (Author: RPT P) 9/15/22 at 3:30 p.m. - . Static sitting at edge of bed with min (minimal) -max (maximal) assist, verbal cues for posture and anterior lateral weight shifting in order to prevent LOB. Patient sits at edge of bed ~ 10 mintues (sic) with progressively increased physical assist . (Author: PTA O, co-signed by RPT P) 8/30/22 at 4:41 p.m. - . training in supine/side lying to/from sitting edge of bed and training in safe sit to stand mobility using (sit-to-stand) lift to cardiac chair (geri-chair) Dependent transfer . (Author: RPT P) Upon request for all falls sustained by Resident #308, the facility provided an additional incident report dated 7/15/22. Resident #308 slid out of her wheelchair and was found sitting on her foot pedals. The incident report indicated Resident #308 had other instances of . events of placing herself on fall mat next to the bed on the floor . However, there were no additional incident reports provided for those incidents. The immediate action was as follows: Speak with resident (#308). Offer to place in wheelchair. We have ordered a geri chair for resident . The geri chair was not noted anywhere on the care plan review located below. A complete care plan review for Resident #308 from the initial admitted [DATE] revealed the following: The . limited physical mobility . care plan for Resident #308 . related to CVA with significant left sided deficit, left ankle fracture with ORIF ., with a date initiated of 7/11/22 revealed the following: Locomotion interventions indicating Resident #308 required the use of a wheelchair, despite multiple staff acknowledging she should have been in bed or a geri-chair, unless directly supervised by staff in a wheelchair. The . at risk for falls . care plan reflected Resident #308 . related to: CVA with significant left sided deficit, left ankle fracture with ORIF . revealed the following interventions: Goal: To reduce the risk of serious injury in the event of a fall through the review date (date initiated 7/7/22) . The care plan failed to address supervision needs when in a wheelchair as several staff identified in interviews and failed to address the need for a geri-chair. There were no other interventions to address Resident #308's need for direct supervision when sitting in a wheelchair. Three RN's, two OTR's, and two CNA's indicated Resident #308 required direct supervision when sitting in a wheelchair and the use of a geri-chair for any unsupervised periods out of bed. The RN's and CNA's stated they were made aware of this need by therapy. The care plan failed to address Resident #308's use of a geri-chair for safety. There was no indication Resident #308 had poor trunk control and what safety measures should be in place to prevent falls contained in the care plan. There were no new interventions evident/applied to the fall care plan after the first fall on 7/15/22. A review of the facility policy, Fall Prevention Program, with a revised date of 1/1/22, read in part: . 6. When any resident experiences a fall, the facility will: . e. Review the resident's care plan and update as indicated . . g. Obtain witness statements in case of injury .