Every finding on record at Mission Point Nursing & Physical Rehabilitation Ce

This citation pertains to intake #3073173 & #3071679.Based on observation, interview, and record review, the facility failed to ensure transfers and toileting were completed per the care plan, and ensure staff implement facility policies and procedures for falls in 1 resident (Resident #101) of 4 residents reviewed for accidents/falls, resulting in harm when Resident #101 sustained multiple fractures to her left lower extremity after an unsafe transfer.Findings include:Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: fractures to right fibula (bone on the outside of the lower leg) and left calcaneus (heel bone). Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/16/26 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #101 had moderative cognitive impairment. Review of Resident #101's hospital X-rays dated 6/11/26 at 11:30 PM revealed, Left tibia (inner lower leg bone) and fibula (outer lower leg bone): Findings: No evidence of left tibiofibular (middle portion of lower leg bones) shaft fracture. Avulsed (pulled away from bone) bone fragment adjacent (next to) to the calcaneal (heel) bone.Impression: Avulsed fracture with bone fragment adjacent to the calcaneal bone. Left Ankle: Findings: questionable nondisplaced fracture of the medial (middle) aspect of the lateral malleolus (outer ankle or bony prominence on the bottom of the fibula) . Soft tissue swelling about the ankle joint. Impression: questionable nondisplaced fracture of the medial aspect of the lateral malleolus. Correlate with point tenderness.Review of Resident #101's Hospital Discharge Summary dated 6/16/26 revealed, .Hospital Course: .(x-rays) of right knee showed transverse nondisplaced fracture of proximal fibula.Workup additionally showed avulsed fracture of the left calcaneal bone. Questionable nondisplaced fracture of the left lateral malleolus.Orthopedic consulted and no acute surgical intervention indicated at this time with weight-bearing as tolerated for her bilateral lower extremities.Review of Resident #101's ADL (activities of daily living) Care Plan dated 6/16/26 revealed, the resident had deficits related to fracture of right fibula, multiple falls and obesity. Interventions included: assistance of 2 people with a hoyer lift (a mechanical device used to safely lift and transfer using a sling and lifting system) for transfers, extensive assistance from 2 people for bed mobility, and dependent assistance from 2 people for toileting due to incontinence. It was also noted to offer a bed pan (a receptacle for urine and feces for bedridden people) if resident needs the bathroom urgently.Review Resident #101's Fall Care Plan dated 6/17/26 revealed, Resident #101 was at an increased risk for falls related to history of falls, fibula fracture, weakness, and anemia (not enough healthy red blood cells that can cause weakness). Interventions included: be sure the call light is within reach and encourage to use it for assistance and need for prompt response to all requests for assistance, initiated on 6/19/26; bed pan to be offered if resident is in bed and needs the bathroom urgently, initiated on 6/26/26.Review of Resident #101's Admissions Assessment dated 6/17/26 revealed that the resident was completely dependent on staff for transfers and toileting in the past 7 days and was at risk for falls due to history of falls, fall in the last month, fractures related to a fall, health conditions, and medications.Review of Resident #101's Fall Incident Report dated 6/23/26 at 8:00 AM revealed, .resident call bell was on, went to the room, resident was sliding off the bed and screaming she needs help. Staff was able to get resident back to bed. Resident remain in (sic) the legs on the floor but buttocks on the bed. Resident began to attempt to stand back up to go to the bathroom. Resident was 2 persons to the wheelchair as resident would not allow staff to get hoyer. Resident continued to stand up until she was transferred to the wheelchair. 2 staff members were able to transfer her safely to the toilet. Resident finished with the bathroom, staff was attempting to place hoyer pad under her to hoyer her back to the bed, but resident began to stand up. As the resident was transfer (sic) back to the wheelchair resident legs slide (sic) out from her and she was slowly lowered to the floor. Resident had gait belt on. Following the nurse approving the transfer the hoyer pad was placed under the resident, and she was hoyered back to the bed safely. Resident did not hit her head.Immediate Action Taken: bed pan to be offered if resident is in bed and needs the bathroom urgently. It was noted that the immediate action taken was an intervention in Resident #101's ADL care plan prior to the fall on 6/23/26.Review of Resident #101's facility X-ray of left foot & ankle dated 6/30/26 at 11:07 PM revealed, .Acute (New) distal diaphyseal (the lower shaft of the bone) fracture of fibula with comminution (shattered bone) and mild displacement (not aligned) seen. No joint dislocation. Soft tissue swelling noted .No comparison study. Conclusion: Acute distal diaphyseal fracture of fibula.Review of Resident #101's hospital Emergency Department Course dated 7/1/26 revealed, .7:13 PM Differential diagnosis includes acute fracture of fibula left side. Patient has a known right proximal (upper) fibular fracture. No evidence of cellulitis (skin infection). We will rule out DVT (blood clot) to that left side given the pain and swelling.11:58 PM X-ray does show a medial and lateral malleolar (inside and outside of ankle) fracture along with a diaphyseal fracture of the fibula WHICH IS ALL NEW.Sounds like potentially the injury is from the facility or potentially an accident that happened at that facility.Patient is non weight bearing and will not be able to go home. Patient will be admitted .Review of Resident #101's hospital X-rays dated 7/1/26 at 7:54 PM revealed: Left tibia (bone on inside of lower leg responsible for weight bearing) and fibula (bone on outside of lower leg) Comparison: left lower leg radiographs (x-rays) from 6/11/26. Findings: There is an acute mildly comminuted fracture of the distal fibular diaphysis . There is mild soft tissue swelling in the left lower leg . Left ankle (lower leg where the fibula, tibia and foot bones come together) Comparison: Left ankle radiographs 6/11/26. Findings: The distal fibular diaphysis fracture (noted above) is again seen. There is a questionable fracture line involving the lateral malleolus (outside bone of the ankle) on the frontal projection. There is a bony irregularity involving the medial malleolus (inside bone of the ankle) on the oblique view compatible with a fracture. There is a soft tissue swelling about the ankle circumferentially .The final impressions were: 1. Acute mildly comminuted fracture of the distal fibular diaphysis. 2. Acute fracture of the medial malleolus. 3. Suspected acute fracture of the lateral malleolus. 4. Advanced atherosclerotic calcifications (dense calcium deposits). Review of Resident #101's hospital History & Physical dated 7/2/26 at 1:45 AM revealed, .presented to the (hospital name omitted) ED on 07/01/26 from her rehab facility in (city name omitted) with left ankle pain. History is limited given patient doesn't have a clear timeline of events. She was discharged from the hospital 06/16 after being admitted 06/11 for a mechanical fall with a right non-displaced proximal fibular fracture. She was seen by ortho (orthopedic doctor) and plan was to be WBAT (weight bearing as tolerated) .It sounds like at some point, patient had a fall at the SNF. She had resultant L (left) ankle pain. She notes a male worker may have accidentally stepped on her foot during a transfer that led to the fall. (Family Member (FM) L) who is present at bedside notes patient wasn't able to participate well in therapy at rehab due to being out of it from the oxy (narcotic pain medication). When this got better, she wasn't participating well at all because of left ankle pain. It sounds like there was some redness to her ankle so she was placed on an abx (antibiotic) for possible cellulitis (skin infection). She was sent here after an x-ray was done at the facility which showed a bimalleolar (both sides of the ankle) left ankle fracture.L (left) ankle x-ray showed acute mildly comminuted fracture of distal fibular diaphysis, acute fracture of medial malleolus, and suspected acute fracture of the lateral malleolus. Case was discussed with ortho trauma who placed the patient in a short leg splint (immobilizer).was referred for admission.ASSESSMENT AND PLAN: Mechanical fall resulting in left bimalleolar (inside and outside of ankle) fracture, recent non-displaced right proximal (near knee) fibular fracture 06/26, hx (history) of multiple falls, seen by ortho trauma in ED (emergency department); placed in short leg splint (immobilizer), no acute surgical intervention.In an interview on 6/29/26 at 3:30 PM, FM L reported that Resident #101 admitted to the nursing home for rehabilitation for her right leg fracture and then was sent back to the hospital on 7/1/26 due to a left leg fracture. FM L reported that on 6/27/26 Resident #101 had told the family that she had fallen and then an aide stepped on her leg. FM L reported that she visited Resident #101 on 6/30/26 and Physical Assistant (PA) M reported to FM L that Resident #101 was complaining of left leg pain and were going to treat Resident #101 for cellulitis (skin infection). FM L reported that x-rays were ordered later that day and the next day they received results that there was a fracture of the left leg.In an interview on 7/28/26 at 2:57 PM, Certified Nursing Assistant (CNA) J reported that Resident #101 was very difficult to move around in bed and it took at least 2 people to complete care for the resident. CNA J reported on 6/23/26 about 8:00 AM, Resident #101 was in her bed screaming for help and saying she needed to use the toilet. CNA J reported that Resident #101 could not transfer onto the toilet in the bathroom using the hoyer lift, and she did not have a bedside commode. CNA J reported that she didn't have time to wait for assistance from another CNA or nurse because Resident #101 was trying to get out of her bed. CNA J reported that to her knowledge Resident #101 had never tried to get out of bed before that day and transferred only with the hoyer lift, unless therapy was performing the transfer. CNA J reported that she helped Resident #101 sit on the side of the bed, wrapped a gait belt around her waist, lifted her up and pivoted her into the wheelchair next to the bed. CNA J reported that she brought the resident into the bathroom and transferred her again the same way onto the toilet. CNA J reported that at that time, she instructed Resident #101 to press the call light when she was finished using the toilet and CNA J left the room. CNA J reported that approximately 10 minutes later Resident #101 pressed the call light, and CNA J and CNA H attempted to stand and pivot Resident #101 from the toilet and into her wheelchair, but the resident said that she was too tired, so they sat her back down. CNA J reported they attempted to stand Resident #101 to put a hoyer sling under her, but the resident was dead weight and they had to lower her to the floor. CNA J reported that while Resident #101 was on the floor they rolled her, side to side, to place a hoyer sling underneath her, then transferred her back to bed using the hoyer. CNA J reported that she informed Licensed Practical Nurse (LPN) F later that day about the incident. CNA J reported that in the days following the incident Resident #101 had been complaining of pain in her left leg but the nurses thought it was because she wasn't taking the strong pain medication anymore.In an interview on 7/29/26 at 12:00 PM, CNA H reported that CNA J had requested assistance with getting Resident #101 off the toilet and back into bed. CNA H reported that he and CNA J tried to stand Resident #101 up from the toilet, but the resident's legs gave out and she was complaining of pain. CNA H reported that they could not sit her back down on the toilet or get her to the chair, so they slowly lowered Resident #101 to the floor. CNA H reported that he went and got the hoyer lift and they transferred Resident #101 to bed. CNA H reported that he did not notify the nurse about the incident until afterwards, and the nurse was busy; the nurse did not assess Resident #101 until later that day.In an interview on 7/29/26 at 11:13 AM, regarding Resident #101 accident on 6/23/26, LPN F stated, .apparently the aides had to lower (Resident #101) to the floor. LPN F reported that CNA J had informed her sometime after lunch that day about the incident, so she went in to check on Resident #101. LPN F reported that she did not complete a range of motion assessment and Resident #101's pain seemed typical for the resident. LPN F reported that she did not document the incident or report it to management and it was her understanding that if there were no injuries then it wasn't considered a fall.In an interview on 7/29/26 at 9:52 AM, Registered Nurse (RN) C reported that she did not typically work with Resident #101 but worked with her on 6/27/26 and 6/28/26. RN C reported that Resident #101 was extremely painful all over and they were administering oral and topical pain medications.In an interview on 7/29/26 at 10:11 AM, Physical Therapist (PT) K reported she worked with Resident #101 while the resident was at the facility. PT K reported Resident #101 needed extensive assistance of 2 staff to sit up in bed and to attempt to stand. PT K reported that Resident #101 had permission to stand and bear weight, but even with assistance, she could not stand or bear weight due to pain in her right leg and was not able to understand cueing to stand. PT K reported that Resident #101 was only able to get into a standing position with therapy staff physically holding her upright but did not put her feet on the ground or bear her own weight. PT K reported nursing and the provider were made aware on 6/25/26 of Resident #101's increase in pain and inability to tolerate therapy; then on 6/26/26 when Resident #101 was reporting left leg pain and talking about something that had happened in the bathroom, nursing staff was asked about a fall, but there was no record of it. PT K reported that on 6/29/26 they placed a CAM boot (a removable hard supportive boot used with fractures) on Resident #101's left foot and she was able to complete pedaling exercises at a very low level. PT K reported that on 6/30/26 Resident #101 was having a hard time following cues and had increased pain in her left leg. PT K reported Resident #101's x-ray on 6/30/26 showed a fracture of the left leg, therefore on 7/1/26 they did not attempt standing exercises. PT K reported that Resident #101's transfer status remained completely dependent on 2 staff and the mechanical hoyer lift from admission on [DATE] until her discharge on [DATE], and Resident #101 was never found safe to stand or pivot for transfers.In an interview on 7/29/26 at 12:35 PM, PA M reported that Resident #101 admitted on [DATE] and was taking narcotic pain medication that was too heavy and caused her to be non-verbal and not able to participate in therapy. PA M reported that she had changed Resident #101's pain regimen and the resident was more alert. PA M reported that on 6/26/26 she had been informed of Resident #101's incident of being lowered to the floor, and PT K had remarked that Resident #101 was having increased pain in her left leg, so a topical pain medication was added. PA M reported that on 6/30/26 Resident #101 was complaining of increased pain in the left lower leg and there was warmth and induration (hardening and thickening of soft tissue, often due to inflammation, infection, or other underlying medical conditions) noted on exam which was treated with an antibiotic and ordered an x-ray. PA K reported that the x-rays showed a fracture and Resident #101 was ordered to wear a CAM boot on the left foot/lower leg, but then later that day was having increased pain and staff requested to have the resident sent to the hospital.In an interview on 7/29/26 at 1:33 PM, LPN G reported that on 6/26/26 staff from the therapy department were asking if Resident #101 had fallen because the resident kept talking about a fall. LPN G reported that after investigating it was found that CNA's had lowered her to the floor during a transfer. LPN G reported Resident #101 had x-rays the next week due to increasing pain in her left leg and the results showed a left leg fracture but did not show the left heel fracture that was listed in Resident #101's hospital records when she admitted to the facility. LPN G reported that the facility thought that the x-ray results may have reversed the left and right, and the fracture on the left was actually the known right leg fracture that Resident #101 admitted with. LPN G reported that Resident #101 was sent to the hospital on 7/1/26 to get clarification of the x-ray results.In an interview on 7/30/26 at 9:34 AM, DON B reported that he was first made aware that Resident #101 had fallen from the therapy director on 6/26/26 at 2:07 PM and determined later that day that the CNA's had attempted to transfer the resident and had to lower the resident to the floor. DON B reported that CNA J should have called for assistance prior to attempting to transfer Resident #101 to the toilet. DON B confirmed that Resident #101 had very brittle bones, was at high risk for fractures, and was not supposed to be physically transferred by the CNA's. DON B reported that Resident #101 was only supposed to be transferred using the mechanical hoyer lift. DON B reported that the x-ray completed in the facility on 6/30/26 and at the hospital on 7/1/26 identified new fractures that were not on the x-rays from the hospital when Resident #101 admitted to the facility on [DATE].In an interview on 7/29/26 at 8:20 AM, Nursing Home Administrator (NHA) A reported that when Resident #101's x-ray on 6/30/26 showed a fracture of the left leg, she thought it was the same fracture that was noted as questionable when she admitted and because the resident did not allege abuse the fracture was not reported. NHA A reported the allegation of abuse was reported on 7/6/26 based on FM L verbalizing that we caused Resident #101's left leg fractures. In a subsequent interview on 7/30/26 at NHA A reported that she was made aware on 6/26/26 that Resident #101 had sustained a fall after being transferred incorrectly by staff.Review of the facility policy Falls-Clinical Protocol dated 11/2/23 revealed, .2. Based on the assessment, an initial plan of care will be developed and implemented to address identified risks. This will be revised as necessary.5. Interventions should be developed and implemented per the assessed needs. Additional items to remember when developing the plan of care include: Resident's abilities and deficits, Balance (sitting/standing), adaptive equipment needs, proper use of mechanical lifts and transfer devices, .bathroom safety.8. For an individual who has fallen, staff should attempt to define possible causes within 24 hours of the fall. Once a fall occurs it is important to gather as much information as possible: observe for evident trauma. provide emergency care and assessment as indicated.The physician and responsible party should be notified as soon as the resident is stabilized. Document findings in the resident's medical record or EHR (electronic health record) per standard protocol. Complete the fall re-evaluation.An accident/incident report will be completed and forwarded to the DON (Director of Nursing).9. Post fall analysis items to be considered: .Review for med changes.Review for other acute clinical changes, Review staff and witness statements.Review of care plan and CNA (Certified Nursing Assistant) assignments/Kardex that were in place at time of fall.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: identification of root cause, assessment of all residents, re-education to all nursing staff, and initiation of weekly audits. The facility was able to demonstrate monitoring of the corrective action and maintained compliance

Based on interview and record review, the facility failed to ensure the proper notifications were made for 4 residents (Resident #101, #102, #104 & #105) of 6 residents reviewed for notifications, resulting in the potential for a delay in care and worsening of medical conditions.Findings include:Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: fractures to right fibula (bone on the outside of the lower leg) and left calcaneus (heel bone). Review of Resident #101's ADL (activities of daily living) Care Plan dated 6/16/26 revealed, the resident had deficits related to fracture of right fibula, multiple falls and obesity. Interventions included: assistance of 2 people with a hoyer lift (a mechanical device used to safely lift and transfer using a sling and lifting system) for transfers, extensive assistance from 2 people for bed mobility, and dependent assistance from 2 people for toileting due to incontinence.Review of Resident #101's Fall Incident Report date of report 6/26/26, date of incident 6/23/26 at 8:00 AM revealed, .resident call bell was on, went to the room, resident was sliding off the bed and screaming she needs help. Staff was able to get resident back to bed. Resident remain in (sic) the legs on the floor but buttocks on the bed. Resident began to attempt to stand back up to go to the bathroom. Resident was 2 persons to the wheelchair as resident would not allow staff to get hoyer. Resident continued to stand up until she was transferred to the wheelchair. 2 staff members were able to transfer her safely to the toilet. Resident finished with the bathroom, staff was attempting to place hoyer pad under her to hoyer her back to the bed, but resident began to stand up. As the resident was transfer (sic) back to the wheelchair resident legs slide (sic) out from her and she was slowly lowered to the floor. Resident had gait belt on. Following the nurse approving the transfer the hoyer pad was placed under the resident, and she was hoyered back to the bed safely. Resident did not hit her head.Immediate Action Taken: bed pan to be offered if resident is in bed and needs the bathroom urgently.Agencies/People Notified: Administrator 6/26/26 at 2:07 PM, Family Member (FM L) 6/26/26 at 2:08 PM, DON (Director of Nursing B) 6/26/26 at 2:07 PM, Physician (Physician Assistant (PA) M) 6/26/26 at 2:07 PM.Review of Resident #101's facility X-ray of left foot & ankle dated 6/30/26 at 11:07 PM revealed, .Acute (New) distal diaphyseal (the lower shaft of the bone) fracture of fibula with comminution (shattered bone) and mild displacement (not aligned) seen. No joint dislocation. Soft tissue swelling noted.Conclusion: Acute distal diaphyseal fracture of fibula.Review of Resident #101's hospital Emergency Department Course dated 7/1/26 revealed, .7:13 PM Differential diagnosis includes acute fracture of fibula left side. Patient has a known right proximal fibular fracture.11:58 PM X-ray does show a medial and lateral malleolar fracture along with a diaphyseal fracture of the fibula WHICH IS ALL NEW.Sounds like potentially the injury is from the facility or potentially an accident that happened at that facility.In an interview on 7/28/26 at 2:57 PM, Certified Nursing Assistant (CNA) J reported that Resident #101 was very difficult to move around in bed and it took at least 2 people to complete care for the resident. CNA J reported on 6/23/26 about 8:00 AM, Resident #101 was in her bed screaming for help and saying she needed to use the toilet. CNA J reported that she helped Resident #101 sit on the side of the bed, wrapped a gait belt around her waist, lifted her up and pivoted her into the wheelchair next to the bed. CNA J reported that she brought the resident into the bathroom and transferred her again the same way onto the toilet. CNA J reported that approximately 10 minutes later Resident #101 pressed the call light, and CNA J and CNA H attempted to stand and pivot Resident #101 from the toilet and into her wheelchair, but the resident said that she was too tired, so they sat her back down. CNA J reported they attempted to stand Resident #101 to put a hoyer sling under her, but the resident was dead weight and they had to lower her to the floor. CNA J reported that while Resident #101 was on the floor they rolled her, side to side, to place a hoyer sling underneath her, then transferred her back to bed using the hoyer. CNA J reported that she informed Licensed Practical Nurse (LPN) F later that day about the incident.In an interview on 7/29/26 at 11:13 AM, regarding Resident #101 accident on 6/23/26, LPN F stated, .apparently the aides had to lower (Resident #101) to the floor. LPN F reported that CNA J had informed her sometime after lunch that day about the incident, so she went in to check on Resident #101. LPN F reported that she did not document the incident or report it to management and/or the physician, and it was her understanding that if there were no injuries then it wasn't considered a fall.In an interview on 7/29/26 at 12:35 PM, PA M reported that on 6/26/26 she had been informed of Resident #101's incident of being lowered to the floor on 6/23/26, and Physical Therapist (PT) K had remarked that Resident #101 was having increased pain in her left leg during therapy.In an interview on 7/30/26 at 9:34 AM, DON B reported that he was first made aware that Resident #101 had fallen from the therapy director on 6/26/26 at 2:07 PM and determined later that day that the CNA's had attempted to transfer the resident and had to lower the resident to the floor.Review of the facility policy Falls-Clinical Protocol dated 11/2/23 revealed, .8. For an individual who has fallen, .The physician and responsible party should be notified as soon as the resident is stabilized.Resident #102Review of an admission Record revealed Resident #102 was originally admitted to the facility on [DATE], with pertinent diagnoses which included type 2 diabetes mellitus (chronic high blood sugar levels).Review of Resident #102's Progress Note dated 7/12/26 at 10:10 AM revealed, (Resident #102) was brought up to the front desk before breakfast, (Licensed Practical Nurse (LPN) G) mentioned needing to get a blood sugar before she went to the dining room cause remembered Friday pulling Humalog from backup for a 10 unit give with meals. Checked her blood sugar, which was 338. Checked her MAR (Medication Administration Record) and noted her insulin and blood sugar check had been discontinued. Put her blood sugar reading in, gave patient her medications and stated that it would be looked into today. After AM (morning) meds were finished, checked her orders and observed [NAME] (long-acting) and Humalog (sic) (should say Novolog) in the pending orders tab of the chart and under her orders as pending confirmation. Looked and they had been put in on 7/10/2026 at 9:10 PM by pharmacy. The [NAME] was to start at (9:06 PM) and the Novolog (fast-acting) at (9:09 PM) . Called (Registered Nurse (RN) C) on-call manager at 9:39 AM while trying to confirm the orders.this nurse put in a Humalog 10 unit order.and Gave the insulin to patient. The note did not indicate if the provider had been notified.In an interview on 7/29/26 at 1:08 PM, LPN G reported that when she worked on 7/12/26 she noticed that Resident #102 orders for blood sugar checks and/or insulin had been discontinued. After looking into it, LPN G reported that she found that the pharmacy had switched the name brand of Resident #102's insulin orders shortly after admission on [DATE] which in turn deleted the original orders for insulin and the new orders required confirmation from the nurse to be activated and visible in Resident #102's MAR. LPN G reported Resident #102 had only received insulin and a blood sugar check one time on 7/10/26 until the issue was identified on 7/12/26. LPN G reported she contacted the on-call manager, RN C to get assistance with activating the pending insulin orders; LPN G reported she did not contact the physician.In an interview on 7/30/26 at 10:14 AM, RN D reported that she had tried to pull Resident #102's insulin and other medications from the backup supply at the facility on 7/10/26 and they were not available. RN D reported that she did not notify the physician to report that the medications were not available to administer on 7/10/26 and she did not remember checking the pending confirmation tab on 7/10/26 and/or 7/11/26.In an interview on 7/29/26 at 4:06 PM, RN C reported on 7/12/26 she was made aware Resident #102 had not received her insulin since 7/10/26 due to the pharmacy changing the orders on 7/10/26 and the orders being left in the pending confirmation. RN C did not notify the physician.Review of Resident #102's MAR revealed the following orders for insulin:Humalog insulin to be administered three times a day with meals beginning on 7/10/26 at 4:00 PM and discontinued on 7/10/26 at 9:09 PM. The record indicated LPN G administered one dose in the evening on 7/10/26 and Resident #102's blood sugar was 325.Novolog insulin was ordered on 7/10/26 at 9:09 PM to replace the Humalog, but the order was not confirmed until 7/12/26 at 9:57 AM. Toujeo insulin to be administered daily at bedtime beginning 7/10/26 at 7:00 PM. The order indicated not available on 7/10/26 by RN D and then discontinued on 7/10/26 at 9:06 PM.Lantus insulin was ordered on 7/10/26 at 9:06 PM to replace the Toujeo, but the order was not confirmed until 7/12/26 at 10:00 AM.In an interview on 7/30/26 at 8:50 AM, Director of Nursing (DON) B reported that RN D should have contacted that physician and got a replacement for Resident #102's Toujeo insulin when she identified that it was not available on 7/10/26 during the evening shift.Resident #104 Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: orthostatic (caused by standing up) hypotension (low blood pressure).Review of Resident #104's Care Plan initiated on 7/28/26 revealed, the resident had altered cardiovascular (heart and blood vessels) status related to hypotension with interventions that included: avoid taking blood pressure reading after physical activity or distress but did not indicate that the resident was prescribed medication for hypotension.Review of Resident #104's MAR revealed, Midodrine oral tablet 2.5 mg, give 1 tablet by mouth three times a day (upon rising, afternoon, bedtime) for hypotension. Start date 7/28/26. Resident #104 had received 7 of 7 opportunities for dose of the medication. There were no parameters for blood pressure written in the order. There was no order to check blood pressure.Review of Resident #104's Blood Pressure Results revealed the following:7/30/26 at 12:14 PM: 98/637/30/26 at 4:36 AM 153/867/29/26 at 9:59 PM 99/587/29/26 at 8:08 AM 105/767/29/26 at 5:24 AM 112/617/28/26 at 11:17 AM 101/817/28/26 at 3:53 AM 96/63In an interview on 7/30/26 at 12:30 PM Unit Manager (UM) E reported Midodrine medication was prescribed for low blood pressure (BP) and should always include parameters for BP in the orders, because the medication would only be administered when the resident's BP is low. UM E reported that Resident #104's Midodrine order was not written with parameters. UM E reported that the blood pressure should be checked before every dose is administered (upon rising, afternoon, and bedtime) to ensure it was within the recommended parameters. UM E reported that Resident #104's blood pressure checks do not correlate with when the medication was scheduled to be given, and the blood pressure was not being checked on regular intervals.In an interview on 7/30/26 at 12:26 PM, RN C reported that she had not received any information in report regarding Resident #104's Midodrine; she noticed there were no parameters in the medication order after she had already given the medication.Review of Resident #104's Progress Note dated 12:51 PM by RN C revealed, Nurse contacted PA (Physician Assistant) to request parameters for Midodrine as none provided. (PA M) requested parameters to not give medication if systolic over 120.Resident #105Review of an admission Record revealed Resident #105 was originally admitted to the facility on [DATE], with pertinent diagnoses which included hypotension.Review of Resident #105's Care Plan created on 10/22/24 revealed, the resident had altered cardiovascular (heart and blood vessels) status related to hypotension with interventions that included: vital signs as tasked.Review of Resident #105's MAR revealed, Midodrine oral tablet 2.5 mg, give 1 tablet by mouth three times a day (upon rising, afternoon, bedtime) for hypotension systolic (top number of blood pressure) less than 90. Start date: 7/23/26. There was also a space to record the BP results with each medication administration. Resident #105 received 7 of 21 opportunities for the medication and 5 of the 7 times that the medication was administered, the systolic BP was above 90.Review of Resident #105's Progress Notes related to physician notification and/or orders to administer Midodrine outside of ordered parameters. There was one note in the record on 7/28/26 at 6:52 PM indicating that Resident #105 had requested the medication be administered due to feeling dizzy. There was no documentation that the physician had been notified regarding the other doses of Midodrine that were administered outside of ordered BP parameters.In an interview on 7/30/26 at 12:22 PM, UM E reported that she was not aware Resident #105 was receiving his Midodrine outside of the physician ordered parameters. UM E reported that the nurse should be documenting that a physician had been notified prior to administering the medication. UM E reported that she could not find any documentation and/or secured messaging between the facility and the physician related to the Midodrine. UM E reviewed the MAR and confirmed that there were several times the medication was administered when the BP was outside of the physician ordered parameters.Review of Fundamentals of Nursing ([NAME] and [NAME]) 8th edition revealed, Hypotension is present when the systolic BP falls to 90 mmHg or below .for most people low blood pressure is an abnormal finding associated with illness .record any signs of BP alteration in nurses notes. Report abnormal findings to nurse in charge or health care provider. [NAME], P. A., [NAME], A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 461 and 465.

This citation pertains to intake #3071679Based on interview and record review, the facility failed to release medical records to the resident/resident representative in a timely manner for 1 resident (Resident #101), resulting in delayed access to a resident's medical records. Finding include:Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: fractures to right fibula (bone on the outside of the lower leg) and left calcaneus (heel bone). In an interview on 6/29/26 at 3:30 PM, Family Member (FM) L reported that she had submitted a request for medical records on 7/6/26 on behalf of Resident #101 and the facility had not contacted her regarding the records.Review of Resident #101's Authorization for the Release of Health Information revealed a request for medical records completed by FM L and signed by Resident #101. The document was dated 7/4/26.In an interview on 7/30/26 at 2:00 PM, Nursing Home Administrator (NHA) A reported that she had spoken to FM L today around noon and the records will be released 7/31/26. In a subsequent interview at 3:48 PM, NHA A reported that the records request was received on 7/6/26 but had been held up with the facilities legal team. NHA A reported that she had not been in contacted with Resident #101's family to communicate the delay until 7/30/26.

This citation pertains to intake #3073173.Based on interviews and record review the facility failed to ensure timely reporting of an allegation of neglect for 1 resident (Resident #101) of 4 residents reviewed falls, when staff failed to follow Resident #101's care plan interventions for safe transfers, resulting in acute fractures to the resident's left lower leg and ankle.Findings include: Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: fractures to right fibula (bone on the outside of the lower leg) and left calcaneus (heel bone). Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 6/16/26 revealed a Brief Interview for Mental Status (BIMS) score of 12, out of a total possible score of 15, which indicated Resident #101 had moderative cognitive impairment. Review of Resident #101's ADL (activities of daily living) Care Plan dated 6/16/26 revealed, the resident had deficits related to fracture of right fibula, multiple falls and obesity. Interventions included: assistance of 2 people with a hoyer lift (a mechanical device used to safely lift and transfer using a sling and lifting system) for transfers, extensive assistance from 2 people for bed mobility, and dependent assistance from 2 people for toileting due to incontinence. It was also noted to offer a bed pan (a receptacle for urine and feces for bedridden people) if resident needs the bathroom urgently.Review Resident #101's Fall Care Plan dated 6/17/26 revealed, Resident #101 was at an increased risk for falls related to history of falls, fibula fracture, weakness, and anemia (not enough healthy red blood cells that can cause weakness). Interventions included: be sure the call light is within reach and encourage to use it for assistance and need for prompt response to all requests for assistance, initiated on 6/19/26; bed pan to be offered if resident is in bed and needs the bathroom urgently, initiated on 6/26/26.Review of Resident #101's Admissions Assessment dated 6/17/26 revealed that the resident was completely dependent on staff for transfers and toileting in the past 7 days and was at risk for falls due to history of falls, fall in the last month, fractures related to a fall, health conditions, and medications.Review of Resident #101's Fall Incident Report date of incident 6/23/26 at 8:00 AM revealed, .resident call bell was on, went to the room, resident was sliding off the bed and screaming she needs help. Staff was able to get resident back to bed. Resident remain in (sic) the legs on the floor but buttocks on the bed. Resident began to attempt to stand back up to go to the bathroom. Resident was 2 persons to the wheelchair as resident would not allow staff to get hoyer. Resident continued to stand up until she was transferred to the wheelchair. 2 staff members were able to transfer her safely to the toilet. Resident finished with the bathroom, staff was attempting to place hoyer pad under her to hoyer her back to the bed, but resident began to stand up. As the resident was transfer (sic) back to the wheelchair resident legs slide (sic) out from her and she was slowly lowered to the floor. Resident had gait belt on. Following the nurse approving the transfer the hoyer pad was placed under the resident, and she was hoyered back to the bed safely. Resident did not hit her head.Immediate Action Taken: bed pan to be offered if resident is in bed and needs the bathroom urgently. Review of Resident #101's facility X-ray of left foot & ankle dated 6/30/26 at 11:07 PM revealed, .Acute (New) distal diaphyseal (the lower shaft of the bone) fracture of fibula with comminution (shattered bone) and mild displacement (not aligned) seen. No joint dislocation. Soft tissue swelling noted .No comparison study. Conclusion: Acute distal diaphyseal fracture of fibula.Review of Resident #101's hospital Emergency Department Course dated 7/1/26 revealed, .7:13 PM Differential diagnosis includes acute fracture of fibula left side. Patient has a known right proximal (upper) fibular fracture. No evidence of cellulitis (skin infection). We will rule out DVT (blood clot) to that left side given the pain and swelling.11:58 PM X-ray does show a medial and lateral malleolar (inside and outside of ankle) fracture along with a diaphyseal fracture of the fibula WHICH IS ALL NEW.Sounds like potentially the injury is from the facility or potentially an accident that happened at that facility.Patient is non weight bearing and will not be able to go home. Patient will be admitted .In an interview on 6/29/26 at 3:30 PM, Family Member (FM) L reported that Resident #101 admitted to the nursing home for rehabilitation for her right leg fracture and then was sent back to the hospital on 7/1/26 due to a left leg fracture. FM L reported that on 6/27/26 Resident #101 had told the family that she had fallen and then an aide stepped on her leg.In an interview on 7/28/26 at 2:57 PM, Certified Nursing Assistant (CNA) J reported that Resident #101 was very difficult to move around in bed and it took at least 2 people to complete care for the resident. CNA J reported on 6/23/26 about 8:00 AM, Resident #101 was in her bed screaming for help and saying she needed to use the toilet. CNA J reported that Resident #101 could not transfer onto the toilet in the bathroom using the hoyer lift, and she did not have a bedside commode. CNA J reported that she didn't have time to wait for assistance from another CNA or nurse because Resident #101 was trying to get out of her bed. CNA J reported that to her knowledge Resident #101 had never tried to get out of bed before that day and transferred only with the hoyer lift, unless therapy was performing the transfer. CNA J reported that she helped Resident #101 sit on the side of the bed, wrapped a gait belt around her waist, lifted her up and pivoted her into the wheelchair next to the bed. CNA J reported that she brought the resident into the bathroom and transferred her again the same way onto the toilet. CNA J reported that at that time, she instructed Resident #101 to press the call light when she was finished using the toilet and CNA J left the room. CNA J reported that approximately 10 minutes later Resident #101 pressed the call light, and CNA J and CNA H attempted to stand and pivot Resident #101 from the toilet and into her wheelchair, but the resident said that she was too tired, so they sat her back down. CNA J reported they attempted to stand Resident #101 to put a hoyer sling under her, but the resident was dead weight and they had to lower her to the floor. CNA J reported that while Resident #101 was on the floor they rolled her, side to side, to place a hoyer sling underneath her, then transferred her back to bed using the hoyer. CNA J reported that she informed Licensed Practical Nurse (LPN) F later that day about the incident. CNA J reported that in the days following the incident Resident #101 had been complaining of pain in her left leg but the nurses thought it was because she wasn't taking the strong pain medication anymore.In an interview on 7/29/26 at 12:00 PM, CNA H reported that CNA J had requested assistance with getting Resident #101 off the toilet and back into bed. CNA H reported that he and CNA J tried to stand Resident #101 up from the toilet, but the resident's legs gave out and she was complaining of pain. CNA H reported that they could not sit her back down on the toilet or get her to the chair, so they slowly lowered Resident #101 to the floor. CNA H reported that he went and got the hoyer lift and they transferred Resident #101 to bed. CNA H reported that he did not notify the nurse about the incident until afterwards, and the nurse was busy; the nurse did not assess Resident #101 until later that day.In an interview on 7/29/26 at 11:13 AM, regarding Resident #101 accident on 6/23/26, LPN F stated, .apparently the aides had to lower (Resident #101) to the floor. LPN F reported that CNA J had informed her sometime after lunch that day about the incident, so she went in to check on Resident #101. LPN F reported that she did not complete a range of motion assessment and Resident #101's pain seemed typical for the resident. LPN F reported that she did not document the incident or report it to management and it was her understanding that if there were no injuries then it wasn't considered a fall.In an interview on 7/30/26 at 9:34 AM, DON B reported that he was first made aware that Resident #101 had fallen from the therapy director on 6/26/26 at 2:07 PM and determined later that day that the CNA's had attempted to transfer the resident and had to lower the resident to the floor. DON B reported that CNA J should have called for assistance prior to attempting to transfer Resident #101 to the toilet. DON B confirmed that Resident #101 had very brittle bones, was at high risk for fractures, and was not supposed to be physically transferred by the CNA's. DON B reported that Resident #101 was only supposed to be transferred using the mechanical hoyer lift. DON B reported that the x-ray completed in the facility on 6/30/26 and at the hospital on 7/1/26, identified new fractures that were not on the x-rays from the hospital when Resident #101 admitted to the facility on [DATE].In an interview on 7/29/26 at 8:20 AM, Nursing Home Administrator (NHA) A reported that when Resident #101's x-ray on 6/30/26 showed a fracture of the left leg, she thought it was the same fracture that was noted as questionable when she admitted and because the resident did not allege abuse the fracture was not reported. NHA A reported the allegation of abuse was reported on 7/6/26 based on FM L verbalizing that we caused Resident #101's left leg fractures. In a subsequent interview on 7/30/26 at NHA A reported that she was made aware on 6/26/26 that Resident #101 had sustained a fall after being transferred incorrectly by staff and did not report the incident to the State Agency.

This citation pertains to intake #3073173 & #3071679.Based on interview and record review, the facility failed to implement care planned interventions for transfers and toileting in 1 resident (Resident #101) of 4 residents reviewed for falls, resulting in Resident #101's fall with multiple fractures to her lower leg following an unsafe transfer.Findings include:Review of the facility policy Falls-Clinical Protocol dated 11/2/23 revealed, .2. Based on the assessment, an initial plan of care will be developed and implemented to address identified risks. This will be revised as necessary.5. Interventions should be developed and implemented per the assessed needs.Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: fractures to right fibula (bone on the outside of the lower leg) and left calcaneus (heel bone). Review of Resident #101's ADL (activities of daily living) Care Plan dated 6/16/26 revealed, the resident had deficits related to fracture of right fibula, multiple falls and obesity. Interventions included: assistance of 2 people with a hoyer lift (a mechanical device used to safely lift and transfer using a sling and lifting system) for transfers, extensive assistance from 2 people for bed mobility, and dependent assistance from 2 people for toileting due to incontinence. It was also noted to offer a bed pan (a receptacle for urine and feces for bedridden people) if resident needs the bathroom urgently.Review Resident #101's Fall Care Plan dated 6/17/26 revealed, Resident #101 was at an increased risk for falls related to history of falls, fibula fracture, weakness, and anemia (not enough healthy red blood cells that can cause weakness). Interventions included: be sure the call light is within reach and encourage to use it for assistance and need for prompt response to all requests for assistance, initiated on 6/19/26; bed pan to be offered if resident is in bed and needs the bathroom urgently, initiated on 6/26/26.Review of Resident #101's Admissions Assessment dated 6/17/26 revealed that the resident was completely dependent on staff for transfers and toileting in the past 7 days and was at risk for falls due to history of falls, fall in the last month, fractures related to a fall, health conditions, and medications.Review of Resident #101's Fall Incident Report dated 6/23/26 at 8:00 AM revealed, .resident call bell was on, went to the room, resident was sliding off the bed and screaming she needs help. Staff was able to get resident back to bed. Resident remain in (sic) the legs on the floor but buttocks on the bed. Resident began to attempt to stand back up to go to the bathroom. Resident was 2 persons to the wheelchair as resident would not allow staff to get hoyer. Resident continued to stand up until she was transferred to the wheelchair. 2 staff members were able to transfer her safely to the toilet. Resident finished with the bathroom, staff was attempting to place hoyer pad under her to hoyer her back to the bed, but resident began to stand up. As the resident was transfer (sic) back to the wheelchair resident legs slide (sic) out from her and she was slowly lowered to the floor. Resident had gait belt on. Following the nurse approving the transfer the hoyer pad was placed under the resident, and she was hoyered back to the bed safely. Resident did not hit her head.Immediate Action Taken: bed pan to be offered if resident is in bed and needs the bathroom urgently.Review of Resident #101's facility X-ray of left foot & ankle dated 6/30/26 at 11:07 PM revealed, The bones appear diffusely demineralized. Acute (New) distal diaphyseal (the lower shaft of the bone) fracture of fibula with comminution (shattered bone) and mild displacement (not aligned) seen. No joint dislocation. Soft tissue swelling noted. Plantar (bottom of) and posterior (back side of) calcaneal bone spurs noted. No comparison study. Conclusion: Acute distal diaphyseal fracture of fibula.Review of Resident #101's hospital Emergency Department Course dated 7/1/26 revealed, .7:13 PM Differential diagnosis includes acute fracture of fibula left side. Patient has a known right proximal fibular fracture. No evidence of cellulitis. We will rule out DVT (blood clot) to that left side given the pain and swelling.11:58 PM X-ray does show a medial and lateral malleolar fracture along with a diaphyseal fracture of the fibula WHICH IS ALL NEW.Sounds like potentially the injury is from the facility or potentially an accident that happened at that facility.Patient is non weight bearing and will not be able to go home. Patient will be admitted .In an interview on 7/28/26 at 2:57 PM, Certified Nursing Assistant (CNA) J reported that Resident #101 was very difficult to move around in bed and it took at least 2 people to complete care for the resident. CNA J reported on 6/23/26 about 8:00 AM, Resident #101 was in her bed screaming for help and saying she needed to use the toilet. CNA J reported that Resident #101 could not transfer onto the toilet in the bathroom using the hoyer lift, and she did not have a bedside commode. CNA J reported that she didn't have time to wait for assistance from another CNA or nurse because Resident #101 was trying to get out of her bed. CNA J reported that to her knowledge Resident #101 had never tried to get out of bed before that day and transferred only with the hoyer lift, unless therapy was performing the transfer. CNA J reported that she helped Resident #101 sit on the side of the bed, wrapped a gait belt around her waist, lifted her up and pivoted her into the wheelchair next to the bed. CNA J reported that she brought the resident into the bathroom and transferred her again the same way onto the toilet. CNA J reported that at that time, she instructed Resident #101 to press the call light when she was finished using the toilet and CNA J left the room. CNA J reported that approximately 10 minutes later Resident #101 pressed the call light, and CNA J and CNA H attempted to stand and pivot Resident #101 from the toilet and into her wheelchair, but the resident said that she was too tired, so they sat her back down. CNA J reported they attempted to stand Resident #101 to put a hoyer sling under her, but the resident was dead weight and they had to lower her to the floor. CNA J reported that while Resident #101 was on the floor they rolled her, side to side, to place a hoyer sling underneath her, then transferred her back to bed using the hoyer. CNA J reported that she informed Licensed Practical Nurse (LPN) F later that day about the incident. CNA J reported that in the days following the incident Resident #101 had been complaining of pain in her left leg but the nurses thought it was because she wasn't taking the strong pain medication anymore.In an interview on 7/29/26 at 12:00 PM, CNA H reported that CNA J had requested assistance with getting Resident #101 off the toilet and back into bed. CNA H reported that he and CNA J tried to stand Resident #101 up from the toilet, but the resident's legs gave out and she was complaining of pain. CNA H reported that they could not sit her back down on the toilet or get her to the chair, so they slowly lowered Resident #101 to the floor. CNA H reported that he went and got the hoyer lift and they transferred Resident #101 to bed. CNA H reported that he did not notify the nurse about the incident until afterwards, and the nurse was busy; the nurse did not assess Resident #101 until later that day.In an interview on 7/29/26 at 11:13 AM, regarding Resident #101 accident on 6/23/26, LPN F stated, .apparently the aides had to lower (Resident #101) to the floor. LPN F reported that CNA J had informed her sometime after lunch that day about the incident, so she went in to check on Resident #101. LPN F reported that she did not complete a range of motion assessment and Resident #101's pain seemed typical for the resident. LPN F reported that she did not document the incident or report it to management and it was her understanding that if there were no injuries then it wasn't considered a fall.In an interview on 7/29/26 at 10:11 AM, Physial Therapist (PT) K reported she worked with Resident #101 while the resident was at the facility. PT K reported Resident #101 needed extensive assistance of 2 staff to sit up in bed and to attempt to stand. PT K reported that Resident #101 had permission to stand and bear weight, but even with assistance, she could not stand or bear weight due to pain in her right leg and was not able to understand cueing to stand. PT K reported that Resident #101 was only able to get into a standing position with therapy staff physically holding her upright but did not put her feet on the ground or bear her own weight. PT K reported that Resident #101's transfer status remained completely dependent on 2 staff and the mechanical hoyer lift from admission on [DATE] until her discharge on [DATE], and Resident #101 was never found safe to stand or pivot for transfers.In an interview on 7/30/26 at 9:34 AM, Director of Nursing (DON) B reported that he was first made aware that Resident #101 had fallen from the therapy director on 6/26/26 at 2:07 PM and determined later that day that the CNA's had attempted to transfer the resident and had to lower the resident to the floor. DON B reported that CNA J should have called for assistance prior to attempting to transfer Resident #101 to the toilet. DON B confirmed that Resident #101 had very brittle bones, was at high risk for fractures, and was not supposed to be physically transferred by the CNA's. DON B reported that Resident #101 was only supposed to be transferred using the mechanical hoyer lift. DON B reported that the x-ray completed in the facility on 6/30/26 and at the hospital on 7/1/26 identified new fractures that were not on the x-rays from the hospital when Resident #101 admitted to the facility on [DATE].

Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 3 residents (Resident #102, #104 & #105) reviewed for the provision of nursing services, resulting in medication not administered following physician orders, the lack of assessment, monitoring, and documentation and the potential for the worsening of medical conditions.Findings include: Resident #102Review of an admission Record revealed Resident #102 was originally admitted to the facility on [DATE], with pertinent diagnoses which included type 2 diabetes mellitus.Review of Resident #102's Baseline Care Plan revealed no baseline care plan developed for diabetes.Review of Resident #102's Hospital Discharge Summary dated 7/10/26 revealed, .Hospital Course:.past medical history of DM (diabetes mellitus).Her sugars remained uncontrolled and her A1c (a blood test that shows the average blood sugar for the past 2-3 months).was 10.4 on admission (a level of 6.5 or higher is considered diabetic), so she will need stricter glucose control in the outpatient setting.Discharge Medications:.Humalog (fast-acting) insulin, inject 10 units under the skin 3 times a day before meals. Toujeo (long-acting) insulin.inject 22 units under the skin at bedtime.Glucose (blood sugar) monitoring kit: use to test blood sugars daily.Review of Resident #102's Medication Administration Record (MAR) revealed the following orders for insulin:Humalog insulin to be administered three times a day with meals beginning on 7/10/26 at 4:00 PM and discontinued on 7/10/26 at 9:09 PM. The record indicated LPN G administered one dose in the evening on 7/10/26 and Resident #102's blood sugar was 325.Novolog insulin (fast-acting) was ordered on 7/10/26 at 9:09 PM to replace the Humalog, but the order was not confirmed until 7/12/26 at 9:57 AM. Three doses were missed on 7/11/26.Toujeo insulin to be administered daily at bedtime beginning 7/10/26 at 7:00 PM. The order indicated not available on 7/10/26 by RN D and then discontinued on 7/10/26 at 9:06 PM. One dose was missed on 7/10/26.Lantus insulin (long-acting)was ordered on 7/10/26 at 9:06 PM to replace the Toujeo, but the order was not confirmed until 7/12/26 at 10:00 AM. One dose was missed on 7/11/26.In an interview on 7/29/26 at 1:08 PM, LPN G reported that Resident #102 had admitted to the facility on [DATE] during her day shift and the admission orders were put in the computer by one of the managers that were helping. LPN G checked Resident #102's blood sugar that day before supper and administered Humalog as ordered before meals. LPN G reported that she did not work the next day, but when she worked on 7/12/26 she noticed that Resident #102 orders for blood sugar checks and/or insulin had been discontinued on 7/10/26. After looking into it, LPN G reported that she had discovered that the pharmacy had switched the name brand of Resident #102's insulin orders shortly after admission on [DATE] which in turn deleted the original orders for insulin and the new orders required confirmation from the nurse to be activated and visible in Resident #102's MAR.In an interview on 7/29/26 at 11:24 AM, LPN F reported that she worked with Resident #102 on 7/11/26 and was not aware that the resident had orders for insulin in the pending orders section of the MAR.In an interview on 7/30/26 at 10:14 AM, RN D reported that she had tried to pull Resident #102's insulin and other medications from the backup supply at the facility on 7/10/26 and they were not available. RN D reported that she did not notify the physician to report that the medications were not available to administer on 7/10/26 and she did not remember checking the pending confirmation tab on 7/10/26 and/or 7/11/26.Review of Resident #102's Blood Sugar Checks revealed, on 7/10/26 at 5:30 PM the blood sugar level was 325 and on 7/12/26 at 7:32 AM it was 338.According to American Diabetes Association Standards of Medical Care in diabetes - 2026 a normal blood sugar for adults with diabetes before meals ranges from 80-130.In an interview on 7/30/26 at 8:50 AM, Director of Nursing (DON) B reported that the pharmacy frequently replaces medication orders with equivalent medications that are available and preferred by insurance. DON B reported that it was the nurse's responsibility to check all medication orders for pending confirmation orders at the beginning of each shift. DON B reported that RN D should have contacted that physician and got a replacement for Resident #102's Toujeo insulin when she identified that it was not available on 7/10/26 during the evening shift; LPN F should have checked pending orders at the start of day shift on 7/11/26; RN D should have checked pending orders at the start of evening shift on 7/11/26; LPN G should have checked pending orders at the start of day shift on 7/12/26. DON B reported that all nursing staff have access and the responsibility to confirm orders and ensure the physician is notified if a resident does not receive ordered medication. DON B reported that Resident #102's insulin medication was ordered correctly and the nurses failed to confirm the orders.Resident #104Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: orthostatic (caused by standing up) hypotension (low blood pressure).Review of Resident #104's Care Plan initiated on 7/28/26 revealed, the resident had altered cardiovascular (heart and blood vessels) status related to hypotension with interventions that included: avoid taking blood pressure reading after physical activity or distress but did not indicate that the resident was prescribed medication for hypotension.Review of Resident #104's MAR revealed, Midodrine oral tablet 2.5 mg, give 1 tablet by mouth three times a day (upon rising, afternoon, bedtime) for hypotension. Start date 7/28/26. Resident #104 had received 7 of 7 opportunities for dose of the medication. There were no parameters for blood pressure written in the order. There was no order to check blood pressure.Review of Resident #104's Blood Pressure Results revealed the following:7/30/26 at 12:14 PM: 98/637/30/26 at 4:36 AM 153/867/29/26 at 9:59 PM 99/587/29/26 at 8:08 AM 105/767/29/26 at 5:24 AM 112/617/28/26 at 11:17 AM 101/817/28/26 at 3:53 AM 96/63In an interview on 7/30/26 at 12:30 PM Unit Manager (UM) E reported Midodrine medication was prescribed for low blood pressure (BP) and should always include parameters for BP in the orders, because the medication would only be administered when the resident's BP is low. UM E reported that Resident #104's Midodrine order was not written with parameters. UM E reported that the blood pressure should be checked before every dose is administered (upon rising, afternoon, and bedtime) to ensure it was within the recommended parameters. UM E reported that Resident #104's blood pressure checks do not correlate with when the medication was scheduled to be given, and the blood pressure was not being checked on regular intervals.In an interview on 7/30/26 at 12:26 PM, RN C reported that she had not received any information in report regarding Resident #104's Midodrine; she noticed there were no parameters in the medication order after she had already given the medication.Review of Resident #104's Progress Note dated 12:51 PM by RN C revealed, Nurse contacted PA (Physician Assistant) to request parameters for Midodrine as none provided. (PA M) requested parameters to not give medication if systolic over 120.Resident #105Review of an admission Record revealed Resident #105 was originally admitted to the facility on [DATE], with pertinent diagnoses which included hypotension.Review of Resident #105's Care Plan created on 10/22/24 revealed, the resident had altered cardiovascular (heart and blood vessels) status related to hypotension with interventions that included: vital signs as tasked.Review of Resident #105's MAR revealed, Midodrine oral tablet 2.5 mg, give 1 tablet by mouth three times a day (upon rising, afternoon, bedtime) for hypotension systolic (top number of blood pressure) less than 90. Start date: 7/23/26. There was also a space to record the BP results with each medication administration. Resident #105 received 7 of 21 opportunities for the medication and 5 of the 7 times that the medication was administered, the systolic BP was above 90.Review of Resident #105's Progress Notes related to physician notification and/or orders to administer Midodrine outside of ordered parameters. There was one note in the record on 7/28/26 at 6:52 PM indicating that Resident #105 had requested the medication be administered due to feeling dizzy. There was no documentation that the physician had been notified regarding the other doses of Midodrine that were administered outside of ordered BP parameters.In an interview on 7/30/26 at 12:22 PM, UM E reported that she was not aware Resident #105 was receiving his Midodrine outside of the physician ordered parameters. UM E reported that the nurse should be documenting that a physician had been notified prior to administering the medication. UM E reported that she could not find any documentation and/or secured messaging between the facility and the physician related to the Midodrine. UM E reviewed the MAR and confirmed that there were several times the medication was administered when the BP was outside of the physician ordered parameters.Review of Fundamentals of Nursing ([NAME] and [NAME]) 8th edition revealed, Hypotension is present when the systolic BP falls to 90 mmHg or below .for most people low blood pressure is an abnormal finding associated with illness .record any signs of BP alteration in nurses notes. Report abnormal findings to nurse in charge or health care provider. [NAME], P. A., [NAME], A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 461 and 465.

This citation pertains to intake #3090808.Based on interview and record review the facility failed to ensure residents received care in accordance with professional standards for 1 resident (Resident #102) of 4 residents reviewed for quality of care, when nursing staff failed to ensure a newly admitted resident received monitoring and treatment for Type 2 diabetes mellitus (chronic high levels of sugar) resulting in missed insulin (medication that regulates blood sugar) doses, lack of blood sugar monitoring and the potential for worsening of health conditions and a delay in treatment.Findings include: Resident #102Review of an admission Record revealed Resident #102 was originally admitted to the facility on [DATE], with pertinent diagnoses which included type 2 diabetes mellitus.Review of Resident #102's Baseline Care Plan revealed no baseline care plan developed for diabetes.Review of Resident #102's Hospital Discharge Summary dated 7/10/26 revealed, .Hospital Course:.past medical history of DM (diabetes mellitus).Her sugars remained uncontrolled and her A1c (a blood test that shows the average blood sugar for the past 2-3 months).was 10.4 on admission (a level of 6.5 or higher is considered diabetic), so she will need stricter glucose control in the outpatient setting.Discharge Medications:.Humalog (fast-acting) insulin, inject 10 units under the skin 3 times a day before meals. Toujeo (long-acting) insulin.inject 22 units under the skin at bedtime.Glucose (blood sugar) monitoring kit: use to test blood sugars daily.Review of Resident #102's Progress Note dated 7/12/26 at 10:10 AM revealed, (Resident #102) was brought up to the front desk before breakfast, (Licensed Practical Nurse (LPN) G) mentioned needing to get a blood sugar before she went to the dining room cause (sic) remembered Friday pulling Humalog from backup for a 10 unit give with meals. Checked her blood sugar, which was 338. Checked her MAR (Medication Administration Record) and noted her insulin and blood sugar check had been discontinued. Put her blood sugar reading in, gave patient her medications and stated that it would be looked into today. After AM (morning) meds were finished, checked her orders and observed [NAME] (long-acting) and Humalog (sic) (should say Novolog) in the pending orders tab of the chart and under her orders as pending confirmation. Looked and they had been put in on 7/10/2026 at 9:10 PM by pharmacy. The [NAME] was to start at (9:06 PM) and the Novolog (fast-acting) at (9:09 PM) . Called (Registered Nurse (RN) C) on-call manager at 9:39 AM while trying to confirm the orders.this nurse put in a Humalog 10 unit order.and Gave the insulin to patient. This note was created by Director of Nursing (DON) B. LPN G noted that the insulin medication names Novolog and Humalog are sometimes used interchangeably when referring to short-acting insulins but are not exactly the same.Review of Resident #102's Progress Note dated 7/12/26 at 12:03 PM by LPN G revealed, (Family Member (FM) S) was in this morning with questions about patient's insulin over the last few days.Attempted to answer questions (FM S) had to explain that I fixed (Resident #102's) insulin this morning and was not here to know what happened yesterday.Was told by CNA that (FM S) was at the front door leaving with (Resident #102). Resident #102 discharged from the facility AMA (against medical advice).In an interview on 7/29/26 at 1:08 PM, LPN G reported that Resident #102 had admitted to the facility on [DATE] during her day shift and the admission orders were put in the computer by one of the managers that were helping. LPN G checked Resident #102's blood sugar that day before supper and administered Humalog as ordered before meals. LPN G reported that she did not work the next day, but when she worked on 7/12/26 she noticed that Resident #102 orders for blood sugar checks and/or insulin had been discontinued on 7/10/26. After looking into it, LPN G reported that she discovered the pharmacy had switched the name brand of Resident #102's insulin medications shortly after admission on [DATE] which in turn deleted the original orders for insulin and the new orders required confirmation from the nurse to be activated and visible in Resident #102's medication administration record. LPN G reported that Resident #102 had missed several doses of insulin and her blood sugar had not been checked since admission. LPN G reported that she contacted the on-call manager RN C for assistance but did not contact the physician at that time. LPN G reported that (FM S) was very upset when he discovered that Resident #102 had not received insulin for 2 days therefore, he immediately removed Resident #102 from the facility. In an interview on 7/29/26 at 11:24 AM, LPN F reported that she worked with Resident #102 on 7/11/26 and was not aware that the resident had orders for insulin in the pending orders section of the MAR.In an interview on 7/30/26 at 10:14 AM, RN D reported that she had tried to pull Resident #102's insulin and other medications from the backup supply at the facility on 7/10/26 and they were not available. RN D reported that she did not notify the physician to report that the medications were not available to administer on 7/10/26 and she did not remember checking the pending confirmation tab on 7/10/26 and/or 7/11/26.In an interview on 7/29/26 at 4:06 PM, RN C reported on 7/12/26 she was made aware Resident #102 had not received her insulin since 7/10/26 due to the pharmacy changing the orders on 7/10/26 and the orders being left in the pending confirmation. RN C reported that the nurses should be checking the pending confirmation tab at minimum once a shift. RN C did not notify the physician.Review of Resident #102's MAR revealed the following orders for insulin:Humalog insulin to be administered three times a day with meals beginning on 7/10/26 at 4:00 PM and discontinued on 7/10/26 at 9:09 PM. The record indicated LPN G administered one dose in the evening on 7/10/26 and Resident #102's blood sugar was 325.Novolog insulin was ordered on 7/10/26 at 9:09 PM to replace the Humalog, but the order was not confirmed until 7/12/26 at 9:57 AM. Toujeo insulin to be administered daily at bedtime beginning 7/10/26 at 7:00 PM. The order indicated not available on 7/10/26 by RN D and then discontinued on 7/10/26 at 9:06 PM.Lantus insulin was ordered on 7/10/26 at 9:06 PM to replace the Toujeo, but the order was not confirmed until 7/12/26 at 10:00 AM.Review of Resident #102's Blood Sugar Checks revealed, on 7/10/26 at 5:30 PM the blood sugar level was 325 and on 7/12/26 at 7:32 AM it was 338.According to American Diabetes Association Standards of Medical Care in diabetes - 2026 a normal blood sugar for adults with diabetes before meals ranges from 80-130.In an interview on 7/30/26 at 8:50 AM, Director of Nursing (DON) B reported that the pharmacy frequently replaces medication orders with equivalent medications that are available and preferred by insurance. DON B reported that it was the nurse's responsibility to check all medication orders for pending confirmation orders at the beginning of each shift. DON B reported that RN D should have contacted that physician and got a replacement for Resident #102's Toujeo insulin when she identified that it was not available on 7/10/26 during the evening shift; LPN F should have checked pending orders at the start of day shift on 7/11/26; RN D should have checked pending orders at the start of evening shift on 7/11/26; LPN G should have checked pending orders at the start of day shift on 7/12/26. DON B reported that all nursing staff have access and the responsibility to confirm orders and ensure the physician is notified if a resident does not receive ordered medication. DON B reported that Resident #102's insulin medication was ordered correctly and the nurses failed to confirm the orders. DON B reported the pharmacy frequently changes medication orders and nursing staff are very familiar with the practice of confirming pending medications.Review of Fundamentals of Nursing ([NAME] and [NAME]) revealed, Professional standards such as Nursing: Scope and Standards of Practice (ANA, 2010) .apply to the activity of medication administration. To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 39307-39313). Elsevier Health Sciences. Kindle Edition. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: re-education to licensed nursing staff, resident assessments, and quality assurance audits. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on interview, and record review, the facility failed to develop a comprehensive person-centered care plan in 1 of 17 residents (Resident #36) reviewed for comprehensive care plans, resulting in the potential for unmet medical and nursing needs.Findings include:Resident #36 Review of an admission Record revealed Resident #36 was a male, originally admitted to the facility on [DATE], with pertinent diagnoses which included stroke, diabetes with diabetic neuropathy (nerve damage causing numbness, tingling, burning and weakness), dementia, depression, anxiety, high blood pressure, and atrial fibrillation (an irregular heart rhythm that results in poor blood flow and can lead to blood clots). Review of a Quarterly Minimum Data Set (MDS) assessment for Resident #36, with a reference date of 12/30/25, revealed a Brief Interview for Mental Status (BIMS) score of 7, out of a total possible score of 15, which indicated he had severe cognitive impairment. Review of an Order Summary Report for Resident #36 revealed the active physician order .Eliquis Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for clot prevention . with a start date of 8/25/25. Review of an Order Summary Report for Resident #36 revealed the active physician order .Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 30 unit subcutaneously two times a day for (Type 2 Diabetes) . with a start date of 2/9/26. Review of an Order Summary Report for Resident #36 revealed the active physician order .NovoLOG Injection Solution 100 UNIT/ML (Insulin Aspart) Inject 15 unit subcutaneously with meals for (Type 2 Diabetes) . with a start date of 2/10/26. Review of a Physician Assistant Progress Note for Resident #36, dated 1/5/26, revealed .Blood sugars are reviewed and notable for persistent fluctuation, and recent hypoglycemic (low blood sugar) episodes. Parameters were added to long-acting insulin. Parameters are already in place to short acting insulin. Continue to monitor . Review of a Nursing Progress Note for Resident #36, dated 1/16/26 at 8:23 PM, revealed .Resident blood sugar was 568, notified on call provider .verbal orders to give Novolog 10 units once and to retake blood sugar, was 503, per provider monitor no further extra units given . Review of a Nursing: Hypoglycemic Conscious Event note for Resident #36, dated 1/28/26 at 8:02 AM, revealed .Initial Blood Sugar Result: 58 .Give Simple Carbohydrate .Orange juice .Recheck Blood Sugar after 15 minutes: 226 . Review of a Nursing: Hypoglycemic Conscious Event note for Resident #36, dated 2/7/26 at 7:58 AM, revealed .Initial Blood Sugar Result: 66 .Resident was (heading into) the dining room for breakfast .Recheck Blood Sugar after 15 minutes: 183 . Review of a Nursing: Hypoglycemic Conscious Event note for Resident #36, dated 2/8/26 at 7:09 AM, revealed .Begin Protocol for BS (blood sugar) 70 or less: Physical Symptoms of Conscious Resident Observed: Confusion .Initial Blood Sugar Result: 48 .Give Simple Carbohydrate .orange juice, fig snack bar .Recheck Blood Sugar after 15 minutes: 68 .If BS remains less than 100 Give Simple Carbohydrate again: orange juice, cookie .Continue these steps until BS is over 100: 105 .PA (Physician Assistant) notified . Review of a Nursing: Hypoglycemic Conscious Event note for Resident #36, dated 2/9/26 at 6:36 AM, revealed .Begin Protocol for BS 70 or less: Physical Symptoms of Conscious Resident Observed: (Blood Sugar) 56, confusion .med pass (nutritional supplement) administered .Recheck Blood Sugar after 15 minutes: (Blood Sugar) 70 . Review of a Physician Assistant Progress Note for Resident #36, dated 2/9/26, revealed .Blood sugars are reviewed and notable for significant fluctuation, recent hyperglycemia (high blood sugar), and multiple hypoglycemic (low blood sugar) episodes. He would benefit from a split in his long-acting insulin to 30 units twice daily, and reduction in short acting insulin to 15 units with meals. Continue to monitor blood sugars and trends . Review of a current Care Plan for Resident #36 revealed no specific focus related to Resident #36's diagnosis of diabetes, and no interventions to monitor for evidence of hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). Review of a current Care Plan for Resident #36 revealed no specific focus related to Resident #36's cardiac diagnoses, including atrial fibrillation, and no interventions related to monitoring for bruising or bleeding. In an interview on 2/12/26 at 10:44 AM, Registered Nurse (RN) Q reported comprehensive care plans are generally developed and modified by the Unit Managers. RN Q reported as a floor nurse, she has the ability to modify/update the care plan, but her role is typically limited to minor revisions/modifications. In an interview on 2/12/26 at 1:58 PM, MDS Coordinator BB reported he develops care plans based on items triggered during the Care Area Assessment (CAA) process. MDS Coordinator BB reported there is no CAA or trigger for development of a care plan related to diabetes/insulin use or anticoagulant use. MDS Coordinator BB reported the Unit Managers are responsible to address comorbidities (medical conditions) within the comprehensive care plan. In an interview on 2/12/26 at 2:07 PM, Unit Manager DD reported comprehensive care plans are developed after admission and include focus areas specific to a variety of conditions. Unit Manager DD reported a specific focus area is added for residents with a diagnosis of diabetes, and a cardiac care plan would be added for residents with cardiac issues such as atrial fibrillation. Unit Manager DD reported the use of anticoagulants and any interventions to monitor for adverse side effects (like bleeding) would be within the cardiac care plan. Unit Manager DD reported a focus area for diabetes would include interventions to address hyperglycemia and hypoglycemia. Unit Manager DD reported Resident #36 should have a care plan focus related to his diagnosis of diabetes and stated .especially since he is such a brittle diabetic . Unit Manager DD reported Resident #36 should have a cardiac care plan in place to address his diagnosis of atrial fibrillation and use of anticoagulants. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, October 2025, Chapter 4: Care Area Assessment (CAA) Process and Care Planning, revealed .As required at 42 CFR 483.21(b), the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care .

Based on observation, interview, and record review the facility failed to ensure the appropriate therapeutic diet food textures were provided consistently for 3 (Residents #13, 71, and a confidential informant) of 3 residents reviewed for therapeutic diet food textures resulting in dissatisfaction with food provided, decreased oral intake, and weight loss.Findings include:Resident #13: Review of Resident #13's face sheet, undated, noted an admission date of 1/16/2026 and a pertinent diagnosis of oropharyngeal phase dysphagia (a swallowing disorder occurring in the mouth and throat). Review of Resident #13's brief interview for mental status, dated 1/23/26, was scored 9 which reflected moderately impaired cognition. During an interview on 02/10/2026 at 10:42 AM, Resident #13 reported she was on a mechanically altered minced and moist diet (Minced and Moist is a level 5 mechanically altered diet from the International Dysphagia (difficulty swallowing) Diet Standardisation (sic) Initiative (DDSI) characterized by lumps of food no bigger than 4 millimeters in size and minimal chewing required) to help prevent choking or aspirating (when something other than air gets into the airway). Resident #13 reported she has been on the minced and moist diet since she was admitted and the food tasted bad to her because the texture is almost always pureed. During an observation and interview on 02/10/2026 at 12:43 PM, Certified Nurse Aide (CNA) U was assisting Resident #13 with her meal in her room and identified the three foods on the plate as pureed green beans (green color appearance), pureed meat (white color appearance), and pureed bread (brown color appearance). The pureed items covered the entire surface of the plate as the white puree was runny/thin and had pooled/spread out. Resident #13's meal ticket on the tray stated, Texture: 5-Minced and moist. Resident #13 reported the food she had been served had almost always been that consistency, pureed with no lumps, and confirmed it wasn't minced or diced up food. Resident #13 reported this was part of why she didn't like the food and felt it had limited her intake. During an interview on 02/12/2026 at 10:04 AM, Speech Therapist (ST) HH confirmed Resident #13 was on a level 5 minced and moist diet, the facility's menus came from the facility's corporate team, and the therapy department was a separate company. ST HH reported the food items and their texture provided for level 5 minced and moist diets didn't always line up with the IDDSI's texture criteria and the kitchen at times would provide pureed items when a minced option was possible. ST HH confirmed minced and moist level 5 should have food pieces that were no larger than 4 millimeters and should be able to have the food squish up through the prongs of a fork when pressed. ST HH confirmed green beans could have had their texture altered to be in line with minced and moist and they didn't need to be further altered to a pureed consistency when discussing Resident #13's lunch from 2/10/26. During an observation and interview on 02/11/2026 at 12:32 PM, Registered Nurse (RN) Q delivered Resident #13's lunch to her room. The lunch served included pureed carrots which had liquid running out from the puree and onto the plate. Resident #13 reported she had worked with the speech therapist that morning. During an observation and interviews on 02/11/2026 at 12:40 PM, in the kitchen on the steam table there were two different pans of prepared carrots available for the 2/11/26 lunch service. These were pureed carrots and cooked sliced carrots (which appeared to be crinkle cut and were not minced or diced). [NAME] L reported they only prepared pureed carrots and regular texture cooked carrots. Corporate Registered Dietitian (CRD) AA opened a binder to reveal the menu and three different recipes for carrots. The menu noted Minced & Moist carrots under the minced and moist diet. The three recipes for carrots indicated that one was for the general/regular texture diet, one was for the minced and moist level 5 diet, and one was for the level 4 pureed diet. The minced and moist carrot recipe was compared to the pureed carrot recipe and the recipes were different. One difference was the pureed carrots used a thickener and the minced and moist did not. CRD AA reported the minced and moist carrots should have been different than the pureed carrots. CRD AA confirmed only regular cooked carrots and pureed carrots were made and served for lunch on 2/11/26. CRD AA confirmed a third carrot texture should have been made and provided to those on the minced and moist diet. Review of the facility's minced and moist and pureed carrot recipes, dated 10/3/25, stated, Carrots Pureed.food processor and process until smooth in texture.Add a food thickener. and Carrots Minced & Moist.Crinkle Cut Slcd (sliced) Carrots.Cook vegetables.Pulse or grind until all food pieces are tender and <4mm (less than 4 millimeters). During an interview on 02/12/2026 at 7:50 AM, Registered Dietitian (RD) MM confirmed Resident #13 had poor oral intake, experienced weight loss since admission, and was being seen by the speech therapist for dysphagia (difficulty swallowing). RD MM reported the menus were made at the corporate level and they follow the IDDSI (International Dysphagia Diet Standardization Initiative) for food textures. RD MM confirmed the minced and moist diet was different than the pureed diet. RD MM confirmed there were 5 residents in the building on a minced and moist diet. RD MM reported Resident #13 had lost 11 pounds which triggered for a significant weight loss of 5 percent over 30 days on 2/6/25. Review of Resident #13's physician orders included a diet order, dated 1/21/26, General diet, 5-Minced and moist texture, Mildly thick/nectar consistency.Liberalized diet for low intakes. Review of Resident #13's Nutritional Assessment, dated 1/21/26, stated, Admission.Type of Diet.5-Minced and moist texture, nectar thick liquids.At Nutritional Risk due to.Intakes are 31% of daily meals.Spoke with resident (Resident #13).resident states food is tasting bad. Review of Resident #13's weight change progress note, dated 2/2/26, stated, .WEIGHT WARNING:.-5.0% change [Comparison Weight 1/23/2026, 222.3 Lbs (pounds), -5.6%, -12.5 Lbs] Resident is triggering for a significant weight loss of 13 lbs. Weight loss likely r/t (related to) low intakes, which is not beneficial. Diet: General diet 5-Minced and moist texture, nectar consistency. Intakes are 45% of daily meals.which is meeting 61% of estimated energy needs. Review of Resident #13's speech therapy note, dated 2/10/26, stated, .The International Dysphagia Diet Standardisation (sic) Initiative.Oral Intake.Current Foods / Solids = Minced + Moist Foods MM5 (level 5 diet).Functional Status as a Result of Skilled Interventions.Oral Intake.Current Solids = Mechanical soft/ground texturess (sic). Review of the facility's Food Quality and Palatability policy, dated 7/23/21, stated, .Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs . Menu items are prepared according to the menu .standardized recipes .Food and liquids/beverages are prepared in a manner, form and texture that meets each resident's needs . R71 According to R71's MDS dated [DATE], the resident scored 15/15 on her BIMS indicating she was cognitively intact with diagnoses that included Bipolar disorder and drug induced subacute dyskinesia (involuntary, repetitive movements (e.g., facial twitching, tongue protrusion, lip-smacking) developing within days to weeks of starting medications that block dopamine receptors, such as antipsychotics). Section K-Swallowing/Nutritional Status indicated R71 received a mechanically altered diet. Section N-Medications indicated R71 received antipsychotic (on a routine basis), antidepressant, and anticonvulsant medications. During an observation and interview on 2/10/2026 at 12:50 PM, R71, sitting at bedside eating lunch, stated, Staff cut up my food, but they did not cut up my peanut butter sandwich today for lunch. I have tardive dyskinesia (TD) and my tongue moves around my mouth in a way it pushes my food into a ball, and I need my food cut up so I don't choke. Observed R71's peanut butter sandwich to be whole and not cut up into bite-sized pieces. Observed R71 telling staff her sandwich was not cut up. Noted staff did not cut up R71's sandwich and continued to pass lunch trays to other residents in the same hall. Review of R71's Order Summary dated 12/10/25, revealed, General diet 6-Soft and bite sized texture, Thin consistency, Bread ok cut into quarter size pieces. According to https://www.iddsi.org, The Level 6 diet, also known as the Soft and Bite-Sized diet, is designed for individuals who have difficulty swallowing but can chew small pieces of food safely. Foods must be soft, tender, and moist. All pieces should be bite-sized, no larger than 1.5 cm x 1.5 cm, about a 1/2 inch, to minimize choking risk. Review of R71's Care Plan Nutritional Status initiated 8/2025 with a review date of 2/4/26 indicated R71 required supervision while eating, preferred to eat in her room and was on a level 6 diet. It was noted that during the observation of R71 on 2/10/26 there was no observation of staff supervising the resident eating the uncut sandwich in her room. During an interview and record review on 2/12/26 at 12:10 PM, RD MM reviewed R71's diet orders that stated the resident's sandwich was to be cut into quarter-size pieces. RD MM stated, It would be dietary's responsibility to make sure food orders were correct. RD MM with further review of R71's medical chart reported she was not sure why R71 needed her sandwich cut into quarter-sized pieces. During an interview and record review on 2/12/26 at 12:45 PM, Unit Manager (UM) S stated while reviewing R71's medical chart, (R71) had tardive dyskinesia (TD) which causes her tongue to roll and move about in her mouth. Her diet order states to cut food into quarter-size pieces. R71 is on a Level 6 diet; cutting into quarter-size pieces is due to the TD so she does not choke. Review of R71's Progress Note dated 2/4/26 at 8:55 AM, revealed, .nutritional status was evaluated.diet if General diet, 6-soft and bite sized.I have difficulty chewing/swallowing.Modified diet texture in place to accommodate.Current diet: General diet, 6-soft and bite-sized texture. Review of R71's Nutritional assessment dated [DATE] indicated R71 was to receive a Level 6 diet. During a Resident Council meeting on 2/12/26 at 10:06 AM a confidential informant (CI) stated they personally receive a soft-textured diet due to missing teeth and at times receives the wrong textured food. The CI will notify staff of the wrong-textured food and by the next meal the correct textured food will be on their tray. The CI stated, Thank goodness the texture is on the ticket.

Based on interview and record review, the facility failed to ensure that 1.) a physician order was in place for dialysis treatments (procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions) and 2.) post (after) dialysis assessment and monitoring was documented for 1 (Resident #11) of 1 resident reviewed for dialysis care, resulting in an incomplete reflection of the resident's care.Findings include:Resident #11Review of an admission Record revealed Resident #11 was a male, with pertinent diagnoses which included: chronic kidney disease, stage 4 (severe) (a disease in which the kidneys don't filter excess waste and fluid from the blood effectively), and acute kidney failure (a condition in which the kidneys lose the ability to filter waste from the blood). On 2/11/2026 at 8:09 AM, this surveyor attempted to visit Resident #11 and was informed by nursing staff that the resident was at dialysis.On 2/12/26 at 9:48 AM, a review of Resident #11's Order Summary revealed no physician's order for dialysis care and treatment.In an interview on 2/12/26 at 10:36 AM, Director of Nursing (DON) B reviewed Resident #11's physician's orders and reported there was no order in place for dialysis care and treatment. DON B reported there should be an order from the physician in place for the resident's dialysis treatment. DON B reported the MAR (medication administration record) should also reflect an order to monitor Resident #11's dialysis site post dialysis, but that there was no such order.In an interview on 2/12/2026 at 10:38 AM, Regional Director of Clinical Operations (RDCO) P confirmed the facility should have orders in place and for monitoring the access site for signs/symptoms of infection or complications.In an interview on 2/12/26 at 11:16 AM, Licensed Practical Nurse (LPN) CC reported when Resident #11 returned from dialysis, she would check the access site dressing to make sure the dressing was intact and there were no signs of bleeding or signs of infection. LPN CC reported there was nowhere to document these observations.In an interview on 2/12/26 at 12:51 PM, LPN J reported when a resident returned from dialysis, he would check the access site and if there was an issue, he would put in a progress note, but that otherwise, there was not a place to document that a post dialysis assessment was completed.In an interview on 2/12/26 at 1:48 PM, RDCO P reported nurses would put in progress notes for exception charting documenting a change in condition for concerns related to a resident post dialysis but that the facility did not have regular documentation for post dialysis assessments.

Based on observation, interview, and record review, the facility failed to ensure the proper use of personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP) during high-contact resident care activity for 1 (Resident #8) of 4 residents reviewed for EBP, and to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for the spread of infection and an increased risk of respiratory infection among all residents in the facility.Findings include:Resident #8 Review of an admission Record revealed Resident #8 was a female, with pertinent diagnoses which included: dependence on renal (kidney) dialysis (procedure that removes excess water, solutes, and toxins from the blood in people whose kidneys cannot perform these functions). Review of a Physician's Order for Resident #8 revealed, Enhanced Barrier Precautions while performing high-contact care activities.Start Date 01/28/2026 Review of a current Care Plan for Resident #8 revealed, I require enhanced barrier precautions d/t (due to) increased risk of MDRO (multi-drug resistant organism) acquisition due to port cath (a small medical device placed under the skin to provide long-term easy access to a central vein) site with a date initiated of 1/2/25 and care planned interventions which included ENHANCED BARRIER PRECAUTIONS: [NAME] (sic) / Gloves should be worn during high-contact resident care activities (Dressing, Bathing, Transferring, Hygiene, Linen changes, Toileting/Brief changes, device or wound care) with a date initiated of 1/2/25. During an observation on 2/10/26 at 12:29 PM, Certified Nurse Aide (CNA) Y was seen scratching/rubbing Resident #8's back on bare skin and then assisted to reposition her up in her bed. CNA Y was not wearing gloves or a gown. In an interview on 2/10/26 at 12:31 PM, CNA Y reported Resident #8 was on enhanced barrier precautions and he should have worn gloves and a gown while performing care. In an interview on 2/11/26 at 8:22 AM, Infection Control Preventionist (ICP) F reported Resident #8 was on enhanced barrier precautions because she had a central line (port cath). ICP F reported PPE should be worn during high-contact patient care activity. ICP F reported the CNA should have worn PPE during rubbing/scratching Resident #8's back and repositioning her in bed. On 2/10/2026 at 12:29 PM, an interview with Maintenance Director (MD) NN found that he took over the position about a year ago and the Water Management Plan has been a work in progress. When asked if there were control measures and control limits that he had put in place to reduce risk of the facility developing Legionella or OPPP, MD NN stated that he maintains the ice machines and cleans the fountain in the summertime. When ask if the facility flushes minimal use or unused domestic water fixtures, MD NN stated that he flushes taps every couple of days and has some fixtures he flushes he knows are not used much. When asked if there was any sampling of disinfection levels in the water supply, MD NN stated there was not currently sampling for disinfection performed. On 2/10/2026 at 12:51 PM, observation of the [NAME] Hall soiled utility room found a hopper with an attached hose sprayer, and an over hopper sink. When asked if the hopper is used by staff, MD NN stated he flushes the hopper (flushes like a toilet or commode) but have not flushed the sprayer or the over hopper sink (ran water for minutes to remove stagnation). At this time, brown and discolored water came out of the cold and hot water lines on the over hopper sink as well as the hose sprayer. After finding the discolored water, MD NN stated he would start flushing the full fixture and look at getting the hopper removed if staff do not use it. On 2/10/2026 at 1:10 PM, observation of the south shower room found two capped off water lines protruding from the wall. Observation of the lines found they extended into the ceiling and were at least 6 to 8 feet from the main water line. When the lines were pointed out, MD NN stated he would start flushing or look in to getting them removed. A record review of the facility provided document entitled Water Management Program policy, not dated, found that Control measures will be applied to address potential hazards at each control point. A variety of measures may be used, including physical controls, temperature management, disinfectant level control, visual inspections, or environmental testing for pathogens. The measures shall be specified in the water management program action plan. Further review of the policy found that, Testing protocols and control limits will be established for each control measure. a. Individuals responsible for testing or visual inspections will document findings. b. When control limits are not maintained, corrective actions will be taken and documented accordingly. Further record review of the facilities Water Management Plan binder found a document entitled, Operation, Maintenance, and Control Limits, not dated. The document states that, Flushing is listed under the heading, Control Measures. Listed under the heading Routine Maintenance, Monitoring, and Cleaning, it states that Monthly, hand sinks, showers, and whirlpool baths, should have a disinfectant residual test performed.

This citation pertains to intake MI00150276 Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from resident-to-resident mental and psychosocial abuse for 1 (Resident #106) of 4 residents reviewed for abuse, resulting in Resident #106 experiencing mental anguish, intimidation, and fear. Findings include: Review of Signs and Symptoms of Mental Abuse, Sanjana [NAME], 5/8/23, www.verywellmind.com revealed Mental abuse, also known as psychological or emotional abuse, involves deliberately . causing .emotional pain, or trying to control or manipulate them through verbal or non-verbal communication. These are some of the different types of mental abuse .Intimidation .Harassment .Controlling behaviors .Verbal displays of anger, such as yelling .Mental abuse .can cause deep emotional wounds that take time to heal. Resident #106 Review of an Admission Record revealed Resident #106 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: weakness and nontraumatic intracerebral hemorrhage (rupture of blood vessels causing bleeding in the brain). Review of a Minimum Data Set (MDS) assessment for Resident #106 with a reference date of 1/7/25, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #106 was cognitively intact. In an interview on 3/3/25 at 11:53am, Registered Nurse (RN) F reported she saw Resident #105 watching Resident #106 when Resident #106 was seated in the doorway of her room. RN F reported Resident #105 regularly sat in the doorway of the cafe in recent months and watched Resident #106 through the windows of the double doors that separated the 2 hallways. RN F described Resident #105's behavior as stalking other residents, including Resident #106. In an interview on 3/3/25 at 3:09pm, Resident #106 reported she noticed Resident #105 staring at her many times in recent months and as a result, she no longer sat in her doorway or in the hallway. Resident #106 stated most of the time I just stay in my room because I feel like I can't go in the hallway because he'll watch me. Resident #106 reported she felt uncomfortable because of Resident #105 behavior of watching her but has become more fearful of him. Resident #106 reported she was walking down the hall with a therapist approximately 1 week earlier when Resident #105 moved toward her abruptly and began repeatedly saying in an aggressive, loud tone of voice, Can I be with you?! Do I need to give you space?! Can I talk to you?!. Resident #106 reported Resident #105 was in her face and would not stop asking her those questions despite staff directing him to stop. Resident #106 reported the confrontational and aggressive behavior of Resident #105 made her think he was going to hit her, and she instinctively drew her forearms up by her face. Resident #106 reported staff attempted to redirect Resident #105 but he would not stop. Resident #106 reported when verbal redirection did not stop Resident #105, Licensed Practical Nurse (LPN) H placed herself between her and Resident #105 which seemed to get his attention, and he began wheeling his wheelchair toward his room. However, a few minutes later while Resident #106 continued therapy, now in the therapy gym, Resident #105 approached her aggressively for a second time, and asked the same questions in a growly voice while glaring at her. Resident #106 reported after the incident, she feels more fearful and worried Resident #105 might come into her room at night. Resident #106 reported she continues to feel harassed by Resident #105. During an observation from the south hall, on 3/3/25 at 3:17pm, it was noted that Resident #106's doorway could be seen through the windows of the double doors that separated the east hall (where Resident #106 resided) and the south hall (where Resident #105 resided). During the same observation, it was noted that Resident#106's doorway could be seen from the doorway of the cafe on the south hall. In an interview on 3/4/25 at 10:25am, Certified Nursing Assistant (CNA) G reported Resident #105 frequently appeared to stare hard at Resident #106 and tried to go through the double doors toward her room at times. CNA G described Resident #105's behaviors as targeting toward Resident #106. CNA G reported seeing Resident #105 waiting in the cafe and watching Resident #106 when she came down the hall for therapy. When further queried, CNA G reported he worried about the safety of certain residents, including Resident #106, because the facility did not provide enough supervision for Resident #105, who had demonstrated sexually abusive behavior toward a resident in the past. In an interview on 3/4/25 at 10:43am, LPN H reported she intervened during both incidents in which Resident #105 approached Resident #106 in an aggressive manner. LPN H reported she immediately directed Resident #105 to leave the area because he was in her face (Resident #106) and Resident #106 appeared scared. LPN H reported Resident #105 continued to direct aggressive comments to Resident #106 until LPN H physically intervened and moved his wheelchair. LPN H reported Resident #105 had been preoccupied with Resident #106 and directing his attention to her for several weeks. LPN H reported she did not feel the facility had provided enough supervision to Resident #105 given his behaviors. LPN H reported although she did not report the incident immediately, she felt it constituted abuse and when she told Nursing Home Administrator (NHA) A about the incident the following morning, and offered to write a late entry behavioral note summarizing the incident, NHA A told her not to do so because the note might have a negative impact on admission referrals the facility had made to other facilities for Resident #105. In an interview on 3/4/25 at 2:53pm, Unit Manager (UM) E reported the facility's policy regarding accusations of abuse was that the NHA would be immediately notified, and an investigation would begin to determine if the accusation should be reported to the state agency. UM E reported she was told to err on the side of caution if there was any concern of potential abuse and report it immediately. When further queried about types of abuse, UM E stated a lot of things can fall under abuse, any violation of the resident's right to be respected, to be care for, to have their property, to be treated like a human. UM E confirmed that if one resident's actions directed toward another caused the resident to be fearful, it could be considered abuse. In an interview on 3/4/25 at 3:14pm, NHA A reported he did not conduct an abuse investigation after the incident between Resident #105 and Resident #106 on 2/26/25. NHA A reported he felt some staff were overly reactive to Resident #105's behaviors and were more upset about the incident than Resident #106 was. When further queried about what action he would have taken if he had completed an investigation and Resident #106 had told him she was fearful, NHA A stated I would have talked to Resident #105. NHA A stated regarding Resident #106's behaviors, I don't think he's going to do anything. NHA A confirmed Resident #105 had sexually abused another resident of the facility within the last six months. In an interview on 3/5/25 at 12:14pm, Physical Therapy Assistant PTA L reported on 2/26/25, during a therapy session with Resident #106, Resident #105 approached them in the hallway and began speaking to Resident #106 in a verbally aggressive manner and began repeating Do I need to give you your space?! PTA L reported staff intervened and after several attempts were able to redirect Resident #105 to his room. PTA L confirmed that approximately 10 minutes later, while Resident #106's therapy continued, now in the therapy gym, Resident #105 again approached Resident #106 aggressively and this time had to be physically removed from the area. PTA L reported she felt she had to act when Resident #105 was in her face (Resident #106). PTA L reported Resident #106 was physically shaking after the incident and reported she felt scared. Resident #106 voiced to PTA L that she was worried Resident#105 was going to attempt to touch her inappropriately in the future. PTA L reported she told her immediate supervisor about the incident. In an interview on 3/5/25 at 1:32pm, Resident #106 she was concerned she might be viewed as a troublemaker, so she was hesitant to talk about the incident involving Resident #105. Resident #106 became tearful and stated, sometimes I'm losing sleep over worrying about him getting into my room at night. Resident #106 reported she was worried Resident #105 might try to touch her inappropriately and she might not have the physical strength to fight him off. Resident #106 reported she had been harassed by men several times throughout her life and this situation felt the same way. Resident #106 balled up her fist and stated, I'm trying to get stronger in therapy, but I'm still weak. In an interview on 3/5/25 at 11:47am, CNA I reported Resident #105 was supposed to be supervised if he left the south hall, but she has found him in the east hall unattended. CNA I reported Resident #105's attention was fixated on females and often could not be redirected. CNA I reported Resident #105 became confrontational when his thoughts were fixated. In an interview on 3/5/25 at 12:14pm, Rehab Director (RD) M reported she was informed of the incident that happened between Resident #106 and Resident #105 on 2/26/25 and saw Resident #106 while she was still in the therapy gym that day. RD M reported Resident #106 voiced that she did not trust Resident #105 and concerned he that he had ill intent toward her. RD M reported the Interdisciplinary Team (IDT) was aware of the incident and discussed additional interventions to supervise Resident #105, but none had been implemented. In an interview on 3/5/25 at 2:37pm, Director of Nursing (DON) B reported the IDT discussed the incident that occurred on 2/26/25 between Resident #106 and Resident #105 as well as staff concerns that Resident #105 appears preoccupied with Resident #106. IDT determined it was necessary to place an alarm on the double doors of the south hallway that would sound only when Resident #105 exited. IDT planned to provide additional supervision for Resident #105 by alerting staff when he left the area. However, at the time of this interview, the door alarm had not been installed. Resident #105 Review of an Admission Record revealed Resident #105 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: depression and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #105 with a reference date of 1/14/25, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #105 was cognitively intact. Further review of the MDS revealed Resident #105 exhibited verbal behaviors e.g. threatening others, screaming at others, cursing at others and received an antipsychotic medication. Review of a Care Plan for Resident # 105 with a reference date of 9/27/24, revealed a focuses/goals/interventions of: Focus: I have a history of physical touching myself and others inappropriately. Goal: I will not have behaviors that cause harm to myself or others .Interventions: 2 staff with personal care .motion sensor doorbell in my room .encourage me to stay on my unit .I may make sexual statements or ask .other residents to join me in sexual acts . Review of a Behavioral Health Provider Note for Resident #105 with a reference date of 10/10/24 revealed Since the last visit the resident had episodes of sexual behaviors .masturbating, verbal behaviors and auditory hallucinations .nursing notes report on 9/12 was reported to this nurse that this resident exposed himself and started to masturbate in front of minor staff .9/15 .talking about paying people for sex .physician note 10/8 he has auditory hallucinations and delusional thinking. He is talking to himself or an imaginary person frequently .behavior log review for past 30 days .episodes of sexually inappropriate behaviors x12 .Assessment and plan .4. Add dx (diagnosis) paraphilia (intense or recurring sexual arousal from atypical situations, objects, fantasies, behaviors, individuals or places). Review of a Behavioral Health Provider Note for Resident #105 with a reference date of 1/23/25, revealed Nursing notes: 1/03 while using his wheelchair for ambulation he would look into (sic) all the female rooms .1/4/25 resident roaming the hallway, stalking family members and watching younger children closely .lurking in hallway. going in and out of the small dining room looking towards East hall (Resident #106's room) for about 2 minutes, several times for about 2 hours. Review of a Behavior Log for Resident #105 with a reference date of 2/3-3/4/25 revealed Resident #105 was observed wandering 6 times during that time frame. Review of an Abuse, Neglect and Exploitation policy with a reference date of 10/24 revealed Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident .Definitions: Abuse means the willful infection of .intimidation .mental anguish . which can include resident to resident altercations .mental abuse includes .harassment . Prevention The facility will implement policies and procedures to prevent and prohibit all types of abuse .and that achieves: .care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict .

This citation pertains to intake #MI00150233 Based on observation, interview and record review, the facility failed to provide adequate supervision and implement effective interventions to prevent falls with injury for a resident with a history of multiple falls in 1 (Resident #100) of 3 residents reviewed for falls, resulting in Resident #100 falling and sustaining a humerus (bone of the upper arm) fracture and significant pain. Findings include: Review of an Admission Record revealed Resident #100 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unsteadiness on feet, repeated falls, cognitive communication deficit, weakness, and need for assistance with personal care. Review of a Minimum Data Set (MDS) assessment for Resident #100 with a reference date of 2/11/25, revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #100 was severely cognitively impaired. Section A of the MDS revealed Resident #100 was admitted to the facility from a short-term general hospital. Section GG revealed Resident #100 required maximal (helper does more than half the effort) assistance to come to a standing position and was dependent (helper does all the effort) to transfer from the bed to a chair. Review of a Care Plan for Resident # 100 with a reference date of 2/5/25, revealed focuses/goals/interventions of: Focus: I am at an increased risk for falls .Goal: My risk for falls will be reduced through the next review. Interventions: Be sure my call light in within reach. I need prompt response to all requests .ensure that I am wearing non-skid footwear . Review of a an Admission Assessment for Resident #100 with a reference date of 2/5/25 revealed the resident had a history of falls, had fallen within the last month, and had suffered a fracture because of a fall in the last 6 months. Further review revealed Resident #100 had symptoms of orthostatic hypotension (low blood pressure which may cause dizziness or fainting upon rising), and restlessness. During an observation, it was determined that the room in which Resident #100 resided, was at the far end of the south hall, near an emergency exit, approximately 100' from the common areas and nurses station for the unit. Review of a Daily Staffing document with a reference date of 2/6/25 revealed 2 staff were scheduled to provide cares on Resident #100's hall from 11pm-7am. Review of a Census Report for 2/7/25 revealed 21 residents resided on Resident #100's hall. Review of an Incident Report with a reference date of 2/7/25 revealed: Nursing Description: Resident was found on the ground after an unwitnessed fall. Resident was unable to lift right arm post fall. Resident stated they fell on to their right arm/shoulder. Injuries observed at time of incident: unable to determine type of injury, injury location right shoulder. Review of a section labeled Predisposing Situation Factors revealed Resident #100 displayed increased behaviors, increased agitation, poor safety awareness and transferring without assistance prior to his fall. Review of an Emergency Department Provider Note for Resident #100 with a reference date of 2/7/25 at 6:33am revealed: Diagnosis at time of disposition: 1. Other closed nondisplaced fracture of proximal end of right humerus (break in the upper arm bone near the shoulder joint) initial encounter (first time a patient is seen by a healthcare provider for a specific condition or injury). 2. Fall, initial encounter. 3. Other closed fracture of twelfth thoracic vertebra, initial encounter. Review of a History and Physical physician assessment for Resident #100 with a reference date of 2/7/25 revealed he (Resident #100) was hospitalized at (name of hospital omitted) from 2/3/25 to 2/5/25 for multiple falls. He has memory loss. He said his legs buckle. He was sent to (name of skilled nursing facility omitted). On 2/7/25 he fell out of bed and fractured his R (right) humerus and T10 (thoracic vertebrae). Review of a Post Fall Documentation note for Resident #100, with a reference date 2/8/25 revealed Pain Assessment: c/o (complained of) RUE (right upper extremity) once during the night 10 (worst pain possible on pain scale) (name of opioid medication omitted) given with good relief. In an interview on 3/3/25, at 11:53am, Registered Nurse (RN) F reported on 2/7/25 she was standing at the medication cart at approximately 4:00am, when she heard Resident #100's roommate calling to her from the far end of the hall. The roommate reported Resident #100 needed help. RN F found Resident #100 on the floor near his bed when she arrived in his room. RN F reported Resident #100 was unable to say what he was trying to do, but he did say he fell and hit his right arm. RN F reported Resident #100's roommate had activated the call light. RN F reported she noted a decrease in Resident #100's ability to move his right arm and a complaint of pain. RN F reported she was new to the hall and did not know if Resident #100 was considered at risk for falls at that time. RN F reported the facility staffed Resident #100's hall with 1 nurse and 1 Certified Nursing Assistant (CNA) from 11pm-7am and staff were not able to provide close supervision/frequent checks to him. In an interview on 3/3/25 at 12:40pm, Family Member (FM) R reported he was present when Resident #100 was admitted to the facility and told the resident's nurse that he (Resident #100) became confused and restless at night and frequently needed close supervision to remain safe. FM R reported he stressed to the facility that Resident #100 was unsafe without close supervision and an immediate response to his needs during the nighttime hours. FM R reported Resident #100 resided in his own home prior to his recent fall and was not used to using a call light for assistance. In an interview on 3/4/25 at 11:47am, CNA I reported she and 1 other staff member were responsible for providing cares to all the residents on Resident #100's hall on 2/7/25. CNA I reported Resident #100 was very confused during the night of 2/6-2/7/25. CNA I reported Resident #100 was constantly talking about trying to leave, did not understand where he was, didn't use a call light, and was unaware that he could not safely walk on his own. CNA I reported she found Resident #100 sitting at the edge of his bed trying to get up at which time she lowered is bed as far as it would go. CNA I described Resident #100 as restless and anxious throughout the night. CNA I reported it was inevitable that Resident #100 was going to fall that night because he needed more supervision than the staff could provide. CNA I reported she tried to provide frequent checks to Resident #100, who's room was at the far end of the hall, but was also had to provide cares to other residents and she had last seen Resident #100 about 30 minutes before his roommate came into the hall and notified staff he had fallen. CNA I reported she was in another room providing cares at the time of Resident #100's fall. CNA I reported several residents on the hall required the assistance of 2 staff members for cares that night. CNA I reported she was not aware of any actions the facility had taken to provide increased supervision to Resident #100. In an interview on 3/5/25 at 2:37pm, Director of Nursing (DON) B reported Resident #100 came to the facility on [DATE] after having multiple falls at home. DON B described Resident #100 as very restless from the time of his admission to the facility. Review of a Fall Reduction Policy with a reference date of 4/23 revealed Policy: Our residents have the right to be free from falls, or to sustain no or minimal injury from falls. Compliance Guidelines: 1. The facility utilizes a standardized risk assessment for determining a resident's fall risk upon admission .2. The nurse will initiate interventions on the resident's baseline care plan, in accordance with the resident's identified risks.

This citation pertains to intake number MI00150233. Based on interview and record review, the facility failed to notify a responsible party of a change in care/condition for 1 of 3 residents (Resident #102) reviewed for notification of change, resulting in the responsible party not participating in medical decisions regarding care and treatment. Findings include: Review of a Change of Condition policy with a reference date of 7/24 revealed: Policy: It is the policy of this facility to inform residents/legal representative, attending physician or designee of a change in a resident's condition. 2. The facility will inform the .resident representative (s) when there is- .b. a deterioration in health . Review of an Admission Record revealed Resident #102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: huntington's disease (an inherited disorder that causes nerve cells in parts of the brain to gradually break down and die), dementia (disease that causes a progress decline in cognitive skills) and adult failure to thrive (syndrome in older adults characterized by a decline in physical or mental functioning). Review of a Minimum Data Set (MDS) assessment for Resident #102 with a reference date of 2/4/25, revealed a Brief Interview for Mental Status (BIMS) could not be conducted. Section C revealed the resident had short- and long-term memory problems. Review of a Weekly Skin Sweep with a reference date of 3/2/25 revealed Resident #102 was found to have an open area on right ankle. Review of diagnoses list for Resident #102 revealed the resident was diagnosed with localized edema on 1/10/25. In an interview on 3/4/25, at 9:05am, Family Member/Durable Power of Attorney (FM/DPOA) P reported the facility had not called to inform her of any change in the resident's condition since her admission. FM/DPOA P denied having any knowledge of recent diagnoses including localized edema or an open area on Resident #102's right ankle. FM/DPOA P reported she only was made aware of Resident #102's new health issues (other than quarterly care conferences) when she asked the resident's nurse while at the facility. FM/DPOA P reported she frustrated by the lack of communication. In an interview on 3/5/25 at 2:37pm, Director of Nursing (DON) B reported a resident's DPOA should be informed by the floor nurse or by the provider when there is an acute change in their health.

This citation pertains to intake #MI00150276 Based on interview and record review, the facility failed to operationalize its abuse policy and procedure for 3 residents (Resident #105, Resident #106 and Resident#107) of 3 residents reviewed for resident-to-resident abuse, resulting in 1.staff not reporting resident to resident observations of abuse to the Nursing Home Administrator immediately, 2. the facility not initiating a thorough investigation 3. the facility not reporting allegations of abuse to the state agency,and the potential for further resident to resident observations of abuse to go unreported and uninvestigated. Findings include: Resident #105 Review of an Admission Record revealed Resident #105 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: depression, paraphilia (intense or recurring sexual arousal from atypical situations, objects, fantasies, behaviors, individuals or places), unspecified dementia with psychotic disturbance (loss of contact with reality), and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #105 with a reference date of 1/14/25, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #105 was cognitively intact. Further review of the MDS revealed Resident #105 exhibited verbal behaviors e.g. threatening others, screaming at others, cursing at others and received an antipsychotic medication. Review of a Care Plan for Resident # 105 with a reference date of 9/27/24, revealed a focuses/goals/interventions of: Focus: I have a history of physical touching myself and others inappropriately. Goal: I will not have behaviors that cause harm to myself or others .Interventions: 2 staff with personal care .motion sensor doorbell in my room .encourage me to stay on my unit .I may make sexual statements or ask .other residents to join me in sexual acts . In an interview on 3/4/25 at 10:43am, LPN H reported she intervened during two incidents in which Resident #105 approached Resident #106 in an aggressive manner on 2/26/25. LPN H reported she immediately directed Resident #105 to leave the area because he was in her face (Resident #106) and Resident #106 appeared scared. LPN H reported Resident #105 continued to direct aggressive comments to Resident #106 until LPN H physically intervened and moved his wheelchair. LPN H reported Resident #105 had been preoccupied with Resident #106 and directed his attention to her for several weeks. LPN H reported she did not report the incident immediately, but she felt it constituted abuse and she told Nursing Home Administrator (NHA) A about the incident the following morning. LPN H reported she offered to write a late entry behavioral note summarizing the incident, but NHA A told her not to do so because the note might have a negative impact on admission referrals the facility had made to other facilities for Resident #105. LPN H reported documentation of the incident in a behavioral note would have ensured the provider was aware of the incident. In an interview on 3/4/25 at 2:53pm, Unit Manager (UM) E reported the facility's policy regarding accusations of abuse was that the NHA would be immediately notified, and an investigation would begin to determine if the accusation should be reported to the state agency. UM E reported she was told to err on the side of caution if there was any concern of potential abuse and report it immediately. When further queried about types of abuse, UM E stated a lot of things can fall under abuse, any violation of the resident's right to be respected, to be care for, to have their property, to be treated like a human. UM E confirmed that if one resident's actions directed toward another caused the resident to be fearful, it could be considered abuse. In an interview on 3/4/25 at 3:14pm, NHA A reported he did not conduct an abuse investigation after the incident between Resident #105 and Resident #106 on 2/26/25. NHA A reported he felt some staff were overly reactive to Resident #105's behaviors and were more upset about the incident than Resident #106 was. When further queried about what action he would have taken if he had completed an investigation and Resident #106 had told him she was fearful, NHA A stated I would have talked to Resident #105. NHA A stated regarding Resident #106's behaviors, I don't think he's going to do anything. In an interview on 3/5/25 at 12:14pm, Physical Therapy Assistant PTA L reported on 2/26/25, during a therapy session with Resident #106, Resident #105 approached them in the hallway and began speaking to Resident #106 in a verbally aggressive manner and began repeating Do I need to give you your space?! PTA L reported staff intervened and after several attempts were able to redirect Resident #105 to his room. PTA L confirmed that approximately 10 minutes later, while Resident #106's therapy continued, now in the therapy gym, Resident #105 again approached Resident #106 aggressively and this time had to be physically removed from the area. PTA L reported she felt she had to act when Resident #105 was in her face (Resident #106). PTA L reported Resident #106 was physically shaking after the incident and reported she felt scared. Resident #106 voiced to PTA L that she was worried Resident#105 was going to attempt to touch her inappropriately in the future. PTA L reported she told her immediate supervisor about the incident. In an interview on 3/5/25 at 2:37pm, Director of Nursing (DON) B reported it was expected that any staff member who witnessed a potential situation of resident abuse would immediately report it to NHA A. DON B reported she did not know why this incident wasn't reported or documented. Resident #106 Review of a Minimum Data Set (MDS) assessment for Resident #106 with a reference date of 1/7/25, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #106 was cognitively intact. In an interview on 3/3/25 at 3:09pm, Resident #106 reported she was walking down the hall with a therapist approximately 1 week earlier when Resident #105 moved toward her abruptly and began repeatedly saying in an aggressive, loud tone of voice, Can I be with you?! Do I need to give you space?! Can I talk to you?!. Resident #106 reported Resident #105 was in her face and would not stop asking her those questions despite staff directing him to stop. Resident #106 reported the confrontational and aggressive behavior of Resident #105 made her think he was going to hit her, and she instinctively drew her forearms up by her face. Resident #106 reported staff intervened and diffused the situation but a few minutes later while Resident #106 continued therapy, now in the therapy gym, Resident #105 approached her aggressively for a second time, and asked the same questions in a growly voice while glaring at her. Resident #106 reported the second altercation didn't end until staff physically moved Resident #105 out of the area. Resident #106 reported after the incidents, she began to feel more fearful and worried Resident #105 might come into her room at night. Resident #106 reported she felt harassed by Resident #105. Resident #107 Review of an Admission Record revealed Resident #107 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia (progressive disease resulting in loss of cognitive skills), anxiety disorder, and major depressive disorder(persistent sad mood impacting daily life). Review of a Minimum Data Set (MDS) assessment for Resident #107with a reference date of 12/3/24, revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #107 was severely cognitively impaired. Review of a Care Plan for Resident # 107 with a reference date of 5/4/23, revealed a focus/goal/interventions of: Focus: I have severe(sic) impaired cognitive function. Goal: I will be able to communicate basic needs . In an interview on 3/3/25, at 3:40pm, Family Member (FM) O reported she regularly visited Resident #107's roommate. FM O reported Resident #107's roommate voiced concerns during several different visits that a male staff member was sexually assaulting Resident #107. FM O reported this information to Unit Manager (UM) E so the concerns could be investigated. In an interview on 3/4/25 at 2:53pm, UM E reported when FM O informed her about the concern of a potential sexual abuse of Resident #107, she contacted a manager for further instruction. UM E reported she verified that Resident #107 felt safe per instructions and because there were limited male staff in the facility at that time, it was determined there was no concern for sexual abuse and the incident was not reported to the state agency or further investigated. In an interview on 3/4/25 at 3:19pm Director of Nursing (DON) B confirmed the facility abuse policy was not followed because there was no obvious sign of injury, the resident stated they felt safe, and the reporting resident was suspected of having an acute illness. Review of an Abuse, Neglect and Exploitation policy with a reference date of 10/24 revealed Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident .Definitions: Abuse means the willful infection of injury (including sexual intercourse by force or incapacitation) .intimidation .mental anguish . which can include resident to resident altercations .mental abuse includes .harassment .(V.) Investigation A. An immediate investigation is warranted when suspicion of abuse .or reports of abuse .occur. (VI.) The facility will make efforts to ensure all residents are protected .during the investigation .A. Responding immediately to protect the alleged victim .B. Examining the alleged victim for any sign of injury, including .psychosocial assessment .C. Increased supervision of the alleged victim and residents .F. provide emotional support and counseling to the resident during the investigation .VII. The facility will implement the following: 1. Reporting of all alleged violations to the facility Administrator immediately. 2. Reporting of all alleged violations to the state agency .4. Promoting a culture of safety and open communication in the work environment .

This citation pertains to Intake # MI00150276. Based on interview, and record review, the facility failed to report allegations of abuse to the State Agency in a timely manner in 3 of 3 residents (Resident #105, Resident #106 and Resident #107) reviewed for abuse and reporting, resulting in the potential for additional allegations of abuse and to go unreported and delayed investigation. Findings include: Review of an Abuse, Neglect and Exploitation policy with a reference date of 10/24 revealed Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident .Definitions: Abuse means the willful infection of .intimidation .mental anguish . which can include resident to resident altercations .mental abuse includes .harassment .VII. Reporting/Response .2. Reporting of all alleged violations to the state agency .within the specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . Resident #105 Review of an Admission Record revealed Resident #105 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: depression, paraphilia (intense or recurring sexual arousal from atypical situations, objects, fantasies, behaviors, individuals or places), unspecified dementia with psychotic disturbance (loss of contact with reality), and anxiety. Review of a Care Plan for Resident # 105 with a reference date of 9/27/24, revealed a focuses/goals/interventions of: Focus: I have a history of physical touching myself and others inappropriately. Goal: I will not have behaviors that cause harm to myself or others .Interventions: 2 staff with personal care .motion sensor doorbell in my room .encourage me to stay on my unit .I may make sexual statements or ask .other residents to join me in sexual acts . In an interview on 3/4/25 at 10:43am, LPN H reported she observed Resident #105 approach Resident #106 in an aggressive manner twice within a few minutes on 2/26/25. LPN H reported she immediately directed Resident #105 to leave the area because he was in her face (Resident #106) and Resident #106 appeared scared. LPN H reported Resident #105 continued to direct aggressive comments to Resident #106 until LPN H physically intervened and moved his wheelchair. LPN H reported she did not report the incident immediately, but she felt it constituted abuse. In an interview on 3/5/25 at 12:14pm, Physical Therapy Assistant PTA L reported on 2/26/25, during a therapy session with Resident #106, Resident #105 approached them in the hallway and began speaking to Resident #106 in a verbally aggressive/confrontational manner and began repeating Do I need to give you your space?! PTA L reported staff intervened and after several attempts were able to redirect Resident #105 to his room. PTA L confirmed that approximately 10 minutes later, while Resident #106's therapy continued, now in the therapy gym, Resident #105 again approached Resident #106 aggressively and this time had to be physically removed from the area. PTA L reported she felt she had to act when Resident #105 was in her face (Resident #106). PTA L reported Resident #106 was physically shaking after the incident and reported she felt scared. Resident #106 In an interview on 3/3/25 at 3:09pm, Resident #106 reported she was walking down the hall with a therapist approximately 1 week earlier when Resident #105 moved toward her abruptly and began repeatedly saying in an aggressive, loud tone of voice, Can I be with you?! Do I need to give you space?! Can I talk to you?!. Resident #106 reported Resident #105 was in her face and would not stop asking her those questions despite staff directing him to stop. Resident #106 reported the confrontational and aggressive behavior of Resident #105 made her think he was going to hit her, and she instinctively drew her forearms up by her face. Resident #106 reported staff intervened and diffused the situation but a few minutes later while Resident #106 continued therapy, now in the therapy gym, Resident #105 approached her aggressively for a second time, and asked the same questions in a growly voice while glaring at her. Resident #106 reported the second altercation didn't end until staff physically moved Resident #105 out of the area. Resident #106 reported after the incidents, she began to feel more fearful and worried Resident #105 might come into her room at night. Resident #106 reported she felt harassed by Resident #105. In an interview on 3/4/25 at 2:53pm, Unit Manager (UM) E reported the facility's policy regarding accusations of abuse was that the NHA would be immediately notified, and an investigation would begin to determine if the accusation should be reported to the state agency. UM E reported she was told to err on the side of caution if there was any concern of potential abuse and report it immediately. UM E confirmed that if one resident's actions directed toward another caused the resident to be fearful, it could be considered abuse. In an interview on 3/4/25 at 3:14pm, NHA A reported he did not conduct an abuse investigation or file a report with the state agency after an incident between Resident #105 and Resident #106 on 2/26/25. NHA A reported he was not aware of any abuse concerns related to that incident. NHA A reported he felt some staff were overly reactive to Resident #105's behaviors and were more upset about the incident than Resident #106 was. NHA A reported he was aware that Resident #106 was not comfortable being around Resident #105. Resident #107 Review of an Admission Record revealed Resident #107 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia (progressive disease resulting in loss of cognitive skills), anxiety disorder, and major depressive disorder (persistent sad mood impacting daily life). Review of a Minimum Data Set (MDS) assessment for Resident #107with a reference date of 12/3/24, revealed a Brief Interview for Mental Status (BIMS) score of 7/15 which indicated Resident #107 was severely cognitively impaired. Review of a Care Plan for Resident # 107 with a reference date of 5/4/23, revealed a focus/goal/interventions of: Focus: I have severe(sic) impaired cognitive function. Goal: I will be able to communicate basic needs . In an interview on 3/3/25, at 3:40pm, Family Member (FM) O reported she regularly visited Resident #107's roommate. FM O reported Resident #107's roommate voiced comments during several different visits that a male staff member was sexually assaulting Resident #107. FM O reported this information to Unit Manager (UM) E so the concerns could be investigated. In an interview on 3/4/25 at 2:53pm, UM E reported when FM O informed her about the concern of a potential sexual abuse of Resident #107, she contacted a manager for further instruction. UM E reported she verified that Resident #107 felt safe per instructions and because there were limited male staff in the facility at that time, it was determined there was no concern for sexual abuse and the incident was not reported to the state agency or further investigated. In an interview on 3/4/25 at 3:19pm Director of Nursing (DON) B confirmed that the facility did not report the allegation of abuse to the state agency. Review of an Abuse, Neglect and Exploitation policy with a reference date of 10/24 revealed Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident .Definitions: Abuse means the willful infection of injury (including sexual intercourse by force or incapacitation) .intimidation .mental anguish . which can include resident to resident altercations .mental abuse includes .harassment .(V.) Investigation A. An immediate investigation is warranted when suspicion of abuse .or reports of abuse .occur. (VI.) The facility will make efforts to ensure all residents are protected .during the investigation .A. Responding immediately to protect the alleged victim .B. Examining the alleged victim for any sign of injury, including physical assessment .psychosocial assessment .C. Increased supervision of the alleged victim and residents .F. provide emotional support and counseling to the resident during the investigation .VII. The facility will implement the following: 1. Reporting of all alleged violations to the facility Administrator immediately. 2. Reporting of all alleged violations to the state agency .4. Promoting a culture of safety and open communication in the work environment .

This citation pertains to intakes MI0015276 Based on interview and record review, the facility failed to investigate an allegation of abuse for 3 residents (Resident #105, Resident #106 and Resident #107) of 3 total residents reviewed for abuse resulting in the potential for the allegation to not be thoroughly investigated and further abuse to occur. Findings include: Resident #105 & Resident #106 Review of an Admission Record revealed Resident #105 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: depression, paraphilia (intense or recurring sexual arousal from atypical situations, objects, fantasies, behaviors, individuals or places), unspecified dementia with psychotic disturbance (loss of contact with reality), and anxiety. In an interview on 3/3/25 at 3:09pm, Resident #106 reported she was walking down the hall with a therapist approximately 1 week earlier when Resident #105 moved toward her abruptly and began repeatedly saying in an aggressive, loud tone of voice, Can I be with you?! Do I need to give you space?! Can I talk to you?!. Resident #106 reported Resident #105 was in her face and would not stop asking her those questions despite staff directing him to stop. Resident #106 reported the confrontational and aggressive behavior of Resident #105 made her think he was going to hit her, and she instinctively drew her forearms up by her face. Resident #106 reported staff intervened and diffused the situation but a few minutes later while Resident #106 continued therapy, now in the therapy gym, Resident #105 approached her aggressively for a second time, and asked the same questions in a growly voice while glaring at her. Resident #106 reported the second altercation didn't end until staff physically moved Resident #105 out of the area. Resident #106 reported after the incidents, she began to feel more fearful and was worried Resident #105 might come into her room at night. Resident #106 reported she felt harassed by Resident #105. In an interview on 3/4/25 at 10:43am, LPN H reported she intervened during two incidents in which Resident #105 approached Resident #106 in an aggressive manner on 2/26/25. LPN H reported she immediately directed Resident #105 to leave the area because he was in her face y (Resident #106) yelling and Resident #106 appeared scared. LPN H reported Resident #105 continued to direct aggressive comments to Resident #106 until LPN H physically intervened and moved his wheelchair. LPN H reported Resident #105 had been preoccupied with Resident #106 and directing his attention to her for several weeks. LPN H reported she did not report the incident immediately but should have. LPN H reported she felt the incident constituted abuse and she told Nursing Home Administrator (NHA) A about the incident the following morning. LPN H reported she offered to write a late entry behavioral note summarizing the incident, but NHA A told her not to do so because the note might have a negative impact on admission referrals the facility had made to other facilities for Resident #105. In an interview on 3/4/25 at 2:53pm, Unit Manager (UM) E reported the facility's policy regarding accusations of abuse was that the NHA would be immediately notified, and an investigation would begin to determine if the accusation should be reported to the state agency. UM E confirmed that if one resident's actions directed toward another caused the first resident to be fearful, it could be considered abuse. In an interview on 3/4/25 at 3:14pm, NHA A reported he did not conduct an abuse investigation after the incident between Resident #105 and Resident #106 on 2/26/25. NHA A reported he felt some staff were overly reactive to Resident #105's behaviors and were more upset about the incident than Resident #106 was. When further queried about what action he would have taken if he had completed an investigation and Resident #106 had told him she was fearful, NHA A stated I would have talked to Resident #105. NHA A stated regarding Resident #106's behaviors, I don't think he's going to do anything. Resident #107 In an interview on 3/3/25, at 3:40pm, Family Member (FM) O reported she regularly visited Resident #107's roommate. FM O reported Resident #107's roommate voiced concerns during several different visits that a male staff member was sexually assaulting Resident #107. FM O reported this information to Unit Manager (UM) E so the concerns could be investigated. In an interview on 3/4/25 at 2:53pm, UM E reported when FM O informed her about the concern of a potential sexual abuse of Resident #107, she contacted a manager for further instruction. UM E reported she verified that Resident #107 felt safe per instructions and because there were limited male staff in the facility at that time, it was determined there was no concern for sexual abuse and the incident was not reported to the state agency or further investigated. In an interview on 3/4/25 at 3:19pm Director of Nursing (DON) B confirmed that a full investigation of the sexual abuse concerns for Resident #107 was not completed. Review of an Abuse, Neglect and Exploitation policy with a reference date of 10/24 revealed Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident .Definitions: Abuse means the willful infection of injury (including sexual intercourse by force or incapacitation) .intimidation .mental anguish . which can include resident to resident altercations .mental abuse includes .harassment .(V.) Investigation A. An immediate investigation is warranted when suspicion of abuse .or reports of abuse .occur. (VI.) The facility will make efforts to ensure all residents are protected .during the investigation .A. Responding immediately to protect the alleged victim .B. Examining the alleged victim for any sign of injury, including physical assessment .psychosocial assessment .C. Increased supervision of the alleged victim and residents .F. provide emotional support and counseling to the resident during the investigation .VII. The facility will implement the following: 1. Reporting of all alleged violations to the facility Administrator immediately. 2. Reporting of all alleged violations to the state agency .4. Promoting a culture of safety and open communication in the work environment .

This citation pertains to intake #MI00150276 Based on interview and record review, the facility failed to ensure a referral was made for a level II evaluation (a comprehensive evaluation completed by the local (state mental health authority) for one (Resident #105) of one resident reviewed for PASARR (Preadmission Screening/Annual Resident Review) screenings, resulting in a potential for unmet behavioral health needs. Findings include: Review of a facility policy Resident Assessment-Coordination with PASARR Program with a reference date of 9/24 revealed Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental health disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs .9. Any resident who exhibits a newly evident or possible serious mental disorder .will be referred promptly to the state mental health authority for a level II review . Resident #105 Review of an Admission Record revealed Resident #105 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: depression and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #105 with a reference date of 1/14/25, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #105 was cognitively intact. Further review of the MDS revealed Resident #105 exhibited verbal behaviors e.g. threatening others, screaming at others, cursing at others and received an antipsychotic medication. Review of a Care Plan for Resident # 105 with a reference date of 9/27/24, revealed a focuses/goals/interventions of: 1. Focus: I use an anti-psychotic medication r/t (related to) psychoses. Goal: I will utilize the lowest effective dosage of my psychotropic medication without significant side effects .Interventions: Consult with pharmacy. 2. Focus: I have a history of physical touching myself and other inappropriately. Goal: I will not have behaviors that cause harm to myself or others .Interventions: 2 staff with personal care .motion sensor doorbell in my room .encourage me to stay on my unit .I may make sexual statements or ask .other residents to join me in sexual acts . Review of an OBRA PASARR CORRESPONDENCE document regarding Resident #105 with a reference date of 5/29/24 revealed Based on a review of available information, the recipient does not meet criteria for a serious mental illness .the recipient may be admitted to or remain in the nursing facility .Further PASARR Level II Evaluations are not required unless a significant change has been reported by the nursing facility .This does not alter the facility's requirement for .reporting significant changes to (mental health authority). Review of Physician Orders for Resident #105 revealed the resident was started an antipsychotic medication on 9/27/24. Review of a Behavioral Health Provider Note for Resident #105 with a reference date of 10/10/24 revealed Since the last visit the resident had episodes of sexual behaviors .masturbating, verbal behaviors and auditory hallucinations .nursing notes report on 9/12 was reported to this nurse that this resident exposed himself and started to masturbate in front of minor staff .9/15 .talking about paying people for sex .physician note 10/8 he has auditory hallucinations and delusional thinking. He is talking to himself or an imaginary person frequently .behavior log review for past 30 days .episodes of sexually inappropriate behaviors x12 .Assessment and plan .4. Add dx (diagnosis) paraphilia. Review of a list of medical diagnoses for Resident #105 revealed the resident was diagnosed with paraphilia (intense or recurring sexual arousal from atypical situations, objects, fantasies, behaviors, individuals or places) on 12/12/24. In an interview on 3/5/25, at 1:31pm, Licensed Medical Social Worker (LMSW) T from mental health authority reported the facility should promptly refer any nursing home resident who begins taking an antipsychotic medication and/or begins to display symptoms of a significant mental health issue to the agency for a PASARR Level II assessment. LMSW T reported a PASARR Level II assessment provides an in-depth evaluation of resident needs, determination of appropriate setting, and a set of recommendations for services for the individual. LMSW T reported he had no referral for a PASARR Level II evaluation for Resident #105. In an interview on 3/5/25 at 2:37pm, Director of Nursing (DON) B reported the facility had struggled to determine how to address Resident #105's psychosocial needs and behaviors and was concerned that a skilled nursing facility may not be the most appropriate placement for him. DON B reported to her knowledge a referral for a PASARR Level II assessment had not been completed.

This citation pertains to intake #MI00150276 Based on interview, and record review, the facility failed to maintain complete and accurate medical records in 1 of 3 residents (Resident #105) reviewed for complete documentation, resulting in the lack of proper documentation of evaluation of abusive behaviors. Findings include: Review of Principles for Nursing Documentation published by the American Nurses Association, 2010, revealed Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Review of Resident #105's progress notes, incident reports and behavioral logs revealed no documentation of resident-to-resident altercations on 2/26/25. In an interview on 3/4/25 at 10:43am, LPN H reported she witnessed Resident #105 aggressively confront Resident #105 in the hallway and again in the therapy gym on 2/2/6/25. LPN H reported Resident #106 appeared scared as Resident #105 got in her face and made comments about wanting to spend time with her. LPN reported she was concerned for Resident #106's wellbeing and initially tried to verbally redirect Resident #105 but when that didn't resolve Resident #105's behaviors, she had to physically remove Resident #105 from the situation. LPN H reported she felt Resident #105 behavior toward Resident #106 was abusive in nature and that she should have immediately reported it to Nursing Home Administrator (NHA) A. LPN H confirmed she did not document the incident in Resident #105's chart at the time. LPN H reported she informed NHA A of the incident the following day and planned to enter a late entry note in Resident #105's medical chart regarding the incident that took place on 2/26/25. LPN H reported NHA A told her not to enter the incident because it could negatively impact the outstanding transfer referrals for Resident #105. LPN H reported if the incident had been entered in a behavioral note, it would have ensured the provider was aware of Resident #105's behavior that day. In an interview on 3/5/25 at 12:14pm, Physical Therapy Assistant PTA L reported on 2/26/25, during a therapy session with Resident #106, Resident #105 approached them in the hallway and began speaking to Resident #106 in a verbally aggressive manner and began repeating Do I need to give you your space?! PTA L reported LPN H intervened and after several attempts she and LPN H were able to redirect Resident #105 to his room. PTA L confirmed that approximately 10 minutes later, while Resident #106's therapy continued, now in the therapy gym, Resident #105 again approached Resident #106 aggressively and this time had to be physically removed from the area. PTA L reported she felt she had to act when Resident #105 was in her face (Resident #106). PTA L reported Resident #105 was physically assisted out of the gym by LPN H. PTA L reported Resident #106 was physically shaking after the incident and reported she felt scared. Resident #106 voiced to PTA L that she was worried Resident#105 was going to attempt to touch her inappropriately in the future. PTA L reported she told her immediate supervisor about the incident. In an interview on 3/5/25 at 10:47am, Physician's Assistant (PA) N reported she was responsible for managing medical interventions to reduce Resident #105's inappropriate behaviors. PA N reported to her knowledge, the interventions in place for Resident #105 were effective. PA N reported she was not aware of any recent resident to resident altercations involving Resident #105. PA N reported it was very important that staff document Resident #105's behaviors so she could review precipitating factors and evaluate the situation that arose. When further queried, PA N reported she would be concerned for the safety of other residents if Resident #105's behaviors were not appropriately documented and monitored. In an interview on 3/5/25 at 2:37pm, Director of Nursing (DON) B reported it was expected that any staff member who witnessed a potential situation of resident abuse would immediately report it to NHA A. DON B reported she did not know why this incident wasn't reported or documented.

This citation pertains to intake #MI00148287 Based on interview andrecord review, the facility failed to protect the residents right to be free from resident to resident sexual abuse in 1 of 1 residents (Resident #30) by Resident #58 Findings include: Review of Incident Report dated 11/3/24 revealed Reported resident (Resident #30) was outside the south cafe door when another male resident (Resident #58) was seen with his hand in her pants. It is reported by witness resident (Former Resident (FR) VV) that resident (Resident #30) tried to roll away and male resident (Resident #58) grabbed her (Resident #30) hair and pulled her back. Resident #30 Review of an Admission Record revealed Resident #30 had pertinent diagnoses which included: dementia and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #30, with a reference date of 11/19/24 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #30 was severely cognitively impaired. Review of Care Plan for Resident #30 revealed Focus, Goals, and Interventions: I have severe impaired cognitive function r/t (related to) dementia; I have difficulty understanding situations: please encourage me to stay on East/West unit. I have communication problem r/t sometimes not understanding verbal communication r/t advance dementia. I will attempt to sit away from male residents at meal times and group activities, I do propel myself around the room. monitor behavior symptoms that include wandering. No noted care plan related to trauma informed care. Review of Kardex (a document that instructs workers how to care for the resident) for Resident #30 dated 12/10/24 revealed safety - wandering; please remove me from stressful situations. Resident #58 Review of an Admission Record revealed Resident #58 had pertinent diagnoses which included: dementia and anxiety. Review of a Minimum Data Set (MDS) assessment for Resident #58, with a reference date of 10/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated Resident #58 was cognitively intact. Review of Care Plan for Resident #58 revealed Focus, goal and interventions: I have the potential to exhibit behaviors that sound or appear sexual in nature. I have a hx (history) of requesting others give me oral pleasure (10/8/2024) I also have a history of touching myself and others inappropriately: I will not engage in behaviors that sound or appear sexual in nature in a public place. I make statements or ask staff/other residents to join me in sexual acts. Interventions: two staff with all personal care, I may make sexual statements or ask staff/other residents to join me in sexual acts. Please inform me this in inappropriate: initiated 9/13/2024 Review of Progress Note for Resident #58 dated 9/12/24 revealed was reported to this nurse that resident exposed himself and started to masturbate in front of a minor staff who was delivering dinner trays . Review of Progress Note for Resident #58 dated 9/14/24 revealed .cna went in to help resident and he said, 'would $20 make you get freaky with me? Review of Progress Note for Resident #58 dated 9/29/24 revealed resident asked CNA 2 times if she would take $200 in exchange for sexual favors with resident. Review of Progress Note for Resident #58 dated 10/8/24 revealed A resident .was passing out crafts to other resident. When she entered this resident's room, he asked her to suck my cock for $5 . Review of Progress Note for Resident #58 dated 10/16/24 revealed .resident's sexual behaviors are not stopping even after medication adjustments . Review of Progress Note for Resident #58 dated 11/3/24 revealed resident was witnessed by another resident putting his hands in a female residents pants. In an interview on 12/9/24 at 5:32 PM., Resident #58 stated I did an inappropriate to her and they called the police on me. Resident #58 stated she made me feel good, and a guy saw us and told on us. This surveyor asked Resident #58 how she (Resident #30) made him feel good and Resident #58 stated She let me touch her and that made me feel good. Resident #58 stated I did not rape her, I just touched her. In an attempted interview on 12/8/24 at 9:41 AM., Resident #30 was in bed in her room, eating breakfast, and did not engage in any meaningful conversation with this surveyor. In a telephone interview on 12/9/24 at 12:07 PM., Former Resident (FR) VV reported he observed Resident #58 blocking Resident #30 in the hallway near the cafe on the south unit and Resident #58 had his hand down Resident #30's pants. FR VV reported he pulled Resident #58 away from Resident #30 and Resident #58 went right back to Resident #30 and put his hand up her shorts along her leg, grabbed her hair, and was pulling her in her wheelchair to him. FR VV reported he then yelled for help. FR VV reported Resident #30's face was grim, she was crying, and she appeared to be completely helpless. In an interview on 12/8/24 at 11:52 AM., Certified Nurse Assistant (CNA) D reported Resident #58 was alert and oriented and aware of what he was doing. CNA D reported Resident #58 did grab Resident #30, pull her to him, and put his hand down her pants. CNA D reported she heard Resident #58 state he was giving her (Resident #30) what she was asking for. CNA D reported Resident #30 was mostly non-verbal, did not speak much, if at all, was confused and unaware of what was going on around her. In an interview on 12/8/24 at 2:56 PM., Unit Manager (UM) C reported Resident #58 has had many behaviors during his stay, he had a resident-to-resident incident, and he had asked staff for oral sex in exchange for money. UM C reported Resident #58 had been observed by staff exposing his genitalia and masturbating in the open doorway of his room. UM C reported when the incident on 11/3/2024 between Resident #30 and Resident #58 occurred Resident #58 was touching Resident #30 inappropriately (Resident #58 had his hand in Resident #30's pants), Resident #30 tried to escape, and Resident #58 grabbed Resident #30 by the hair and pulled her back to him. In an interview on 12/9/24 at 9:11 AM., CNA QQ reported Resident #30 did wander around the facility while sitting in her wheelchair and she was very confused. CNA QQ reported Resident #58 had offered her (CNA QQ) 200 dollars cash to get freaky with him while she was assisting him with personal care. In an interview on 12/9/24 at 9:25 AM CNA QQ reported staffing on the south unit during meals was one CNA and one nurse. The second assigned CNA to the unit was required to assist with the dining room. In an interview on 12/9/24 at 12:22 PM., Licensed Practical Nurse (LPN) DD reported Resident #58 had escalating behaviors prior to the incident with Resident #30 and Resident #58 continues to display inappropriate behaviors including exposing himself to others. LPN DD reported on 11/3/24 FR VV yelled out for her and when she rounded the corner near the cafe on the south unit, she saw Resident #58 aggressively trying to get ahold of Resident #30. LPN DD reported she made herself a barrier between the two residents as Resident #58 aggressively continued to grab Resident #30. LPN DD reported she separated Resident #30 and Resident #58. LPN DD reported Resident #58 was taken to his room and Resident #30 was taken to her room. In an interview on 12/9/24 at 12:35 PM., LPN DD reported staffing on the south unit during meals was one CNA and one nurse. The second assigned CNA to the unit was required to assist with the dining room. LPN DD reported the incident that occurred on 11/3/24 between Resident #30 and Resident #58 occurred during breakfast and staffing was only one nurse and one CNA, who was assisting a resident in a room, on the unit at that time. In an interview on 12/9/24 at 1:29 PM., Scheduler (S) T reported Resident #30 would wander around the facility in her wheelchair. S T reported Resident #58 would fixate on sex and his behavior would escalate. S T stated we are doing our best to keep the environment safe. S T reported staffing on the south unit during meals was one CNA and one nurse. The second assigned CNA to the unit was required to assist with the dining room. During an interview on 12/9/2024 at 2:34 PM., Director of Nursing (DON) B reported her expectations were that one of the two CNAs scheduled on the South unit assisted with the main dining room during meals. DON B reported the staffing on south unit during meals was one CNA and one nurse. In an interview on 12/9/24 at 2:48 PM., Physician Assistant (PA) XX reported she recognized when Resident #58 admitted that something was off with him, he would talk to himself, he would hallucinate, and it progressed to behaviors sexual in nature. PA XX reported medications have been adjusted for Resident #58 and the sexual behaviors have lessened but were not eliminated. In an interview on 12/10/24 at 10:26 AM., Social Services Manager (SSM) X reported Resident #58 was observed by another resident with his hand down Resident #30's pants. SSM X reported Resident #30 did not verbalized anything during follow up sessions with her. SSM 'X reported Resident #58 did not recall the incident on the first of three follow up sessions, but did recall the incident on the second and third follow up session. SSM X reported Resident #58 appeared unphased by the incident. SSM X reported Resident #58 was aware of his actions. In an interview on 12/10/24 at 12:56 PM., CNA Z reported Resident #30 was touched inappropriately by Resident #58, and that incident was the second time Resident #30 had been touched inappropriately by a male resident. CNA Z reported Resident #58 had put his hand in Resident #30's pants and when it happened Resident #30 was crying. CNA Z reported staffing on the south unit during meals was one CNA and one nurse. The second assigned CNA to the unit was required to assist with the dining room. Using the reasonable person concept, though Resident #30 had decreased ability to verbally express her own thoughts due to mental diagnosis, witness accounts of Resident #30 crying during the incident with Resident #58 on 11/3/24 clearly indicated she was upset. This emotional response has the potential to continue well past the date of the incident based on the reasonable person concept. During a telephone conversation on 12/9/24 at 4:45 PM., Family Member (FM) WW (a family member of Resident #30) reported Resident #30 would have been upset, angry, and wound have tried to slap Resident #58 during the altercation.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent falls, in one of four residents reviewed for accidents (Resident #57), resulting in an additional fall with fracture. Findings include: Resident #57 (R57) In an observation and interview on 11/01/22 at 2:13 PM, R57 was observed sitting in her wheelchair in her room. R57 stated she fell at the facility and sustained a back fracture that required surgery. Review of R57's Minimum Data Set (MDS) assessment dated [DATE] indicated she admitted to the facility on [DATE], and had the diagnoses of [CONDITION(S)], anxiety, depression, and pulmonary disease. R57 had a Brief Interview for Mental Status (BIMS, a short performance-based cognitive assessment) score of 15 (13-15 cognitively intact). The same MDS assessment revealed R57 required extensive assist of two plus persons physical assistance, for bed mobility, transfer, and toilet use. The same MDS revealed R57 fell in the last two to six months prior to admission. The Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.17.1, October 2019, manual indicated a previous fall, especially a recent fall, recurrent falls, and falls with significant injury were the most important predictors of risk for future falls and injurious falls. A previous fall was the most important predictor of risk for future falls. And the same source revealed a fall should stimulate evaluation of the resident's need for rehabilitation, ambulation aids, modification of the physical environment, or additional monitoring (e.g., toileting, to avoid incontinence). Review of a Physical Therapy Evaluation and Plan of Treatment dated 6/22/22 through 7/21/22 indicated R57 demonstrated good rehabilitation potential and her goal was to be able to walk to and from the dining room with her walker without having to take rest breaks. Review of a Progress Note dated 7/12/22 at 2:10 PM, indicated the note was a late entry, documented on 8/04/22 at 11:36 AM, that R57 fell on [DATE] at 2:10 PM. R57's roommate was in the hall yelling help, she fell , the writer documented she and another staff member arrived in the room and found R57 on the floor in front of her bed laying on her left side. Review of a Progress Note dated 7/13/22 at 9:59 AM, originated as a secure conversation note, sent to the nurse practitioner on 7/12/2022 at 3:14 PM, indicated R57 fell at 2:10 PM and she did not have injuries; the nurse practitioner sent a reply the message was noted on 7/13/22 at 9:48 AM. Review of a Post-Fall/Fall Risk assessment dated [DATE] at 2:10 PM and signed on 8/04/22 at 11:36 AM indicated R57's immediate intervention (new or revised) implemented to help prevent additional accidents included to be in sitting position in bed, in the lowest position if coughing was uncontrolled. This intervention was not included in R57's care plan. Review of R57's increased risk for falls care plan initiated 6/13/22 instructed to review fall risk factors and root cause(s) of falls to remove any potential. Review of fall risk factors and the root cause of fall from 7/12/22 was not completed per care plan. In an interview on 11/3/22 at 10:25 AM, Licensed Practical Nurse (LPN) S stated she recalled R57's fall on 7/12/22. LPN S was asked why the fall from 7/12/22 was documented late on 8/04/22; LPN S stated she had started her employment as a full-time nurse in January 2022 and only received one and one-half days of training due to staffing issues. LPN S stated she had notified the physician, family, and clinical coordinator of R57's fall on 7/12/22. LPN S stated she had received fall documentation education after this fall. Review of a Progress Note dated 7/15/22 at 8:15 PM indicated R57 was sitting on the edge of her bed and fell forward onto the floor. R57 reported she had a sharp back spasm that led to leaning too far forward and falling. Review of a Progress Note dated 7/15/22 at 10:04 PM, originated as a secure conversation note, revealed the fall on 7/15/22 at 8:15 PM was witnessed and R57 had hit her left jaw on the over-the-bed table, resulting in a bruise on her left jaw. Review of a Progress note dated 7/17/22 at 11:04 PM indicated R57 had called 911 to request transfer to the hospital due to severe back pain, muscle spasm and shortness of breath. Review of a Progress note dated 7/18/22 at 7:12 AM revealed the hospital notified the facility that R57 had a thoracic vertebra (T7) back fracture and was hypoxic (absence of enough oxygen in the tissues to sustain bodily functions) upon arrival to the emergency room . Review of a Progress Note dated 7/18/22 at 10:40 AM revealed the nurse sent a message on 7/15/22 at 10:04 PM, regarding R57's fall and the nurse practitioner sent a message back at 7/18/22 at 8:34 AM indicating the communication was noted, and fall likely contributed to the fracture she sustained. Noted that she was admitted to hospital. Review of a Hospital Discharge Summary dated 7/24/22 revealed R57 had an acute compression fracture of the T7 vertebra and chronic obstructive pulmonary disease ([CONDITION(S)], lung disease) on 7/17/22, spine surgery was recommended and completed on 7/22/22. R57 returned to the facility on [DATE]. In an interview on 11/03/22 at 9:43 AM Director of Nursing (DON) B stated the nurse on duty on 7/12/22 that was R57's nurse was no longer employed at the facility. DON B stated risk management did not investigate R57's fall from 7/12/22, because the nurse did not trigger risk management documents. In an interview and record review on 11/03/22 at 10:55 AM Nursing Home Administrator (NHA) A presented a document titled Record of Verbal Counseling Session, dated 7/28/22, that revealed LPN S received counseling because the risk management piece for two incidents (not involving R57) that occurred on 7/25/22 and 7/27/22 were not completed. The same form indicated LPN S was not completely familiar with the risk management process. In an interview on 11/03/22 at 11:20 AM Clinical Coordinator (CC) BB stated she wrote the Progress Note after the physician responded to the nurse communication following a fall. CC BB stated she was head of the fall meeting, and the team meets every week. CC BB stated she was not responsible for ensuring the nurse triggered the appropriate risk documentation after a fall, that was the DON's responsibility. In an interview on 11/03/22 at 1:00 PM Nurse Consultant W and DON B stated the nurse on 7/12/22 did not complete R57's incident report or update R57's care plan with an immediate intervention. Nurse Consultant W and DON B confirmed the Interdisciplinary Team (IDT) did not review R57's fall from 7/12/22.

This citation pertains to MI 98. Based on interview and record review the facility failed to keep residents free from significant medication errors for 1 of 8 residents (Resident #101) reviewed for medication administration resulting in the hospitalization for Resident #101. Findings include: Review of the Policy Medication Administration-General Guidelines dated 5/2019 revealed, Medications are administered as prescribed in accordance with good nursing principles and practices . The policy further revealed, The five rights (Right resident, Right drug, Right dose, Right route and Right time) are applied for each medication being administered. Review of the Face Sheet revealed Resident #101 was admitted to the facility in 2021 and diagnosed with heart failure and [CONDITION(S)]. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #101 had modified independence for decision making abilities. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/4/21 at 1:57 pm, Registered Nurse (RN) D stated, on 1/20/21, I gave him (Resident #101) the wrong medications; I got distracted. RN D stated, the next shift sent him (Resident #101) out to the hospital. Review of the Progress Notes dated 1/20/21 at 6:56 pm revealed Resident #101 was .not alert. unarousable .pupils not reactive to light .VS (vital signs) diminishing. loc (level of consciousness) diminishing. sent to emergency department for treatment. Review of the Emergency Department (ED) Provider notes dated 1/20/21 at 7:48 pm revealed Resident #101 had a Chief Complaint of altered mental status and Narcotic Overdose . The Provider notes continued at 11:09 pm with Resident #101 .given a dose of IV [MEDICATION(S)] (medication to reverse the effects of narcotic medication) and now has complete reversal of his alteration in mental status. Is now awake, alert, conversant, oriented x3. Review of the Discharge Summary dated 2/8/21 at 11:16 am revealed, Resident #101 .presented to the .Hospital Emergency Department on 1/20/21 with confusion. He (Resident #101) was admitted to ED observation unit. Urine drug screen was positive for opiate . These medications were not on patient's list, so it is possible that he (Resident #101) was given wrong medications at . the nursing home. Review of the Urine Drug of Abuse Screen dated 1/20/21 at 11:40 pm revealed Resident #101's urine was positive for opiate medication. Review of the Hospital Records Problems List dated 1/21/21 revealed Resident #101 had an Acute drug overdose, accidental or unintentional, initial encounter. During an interview on 5/4/21 at 1:03 pm, Director of Nursing (DON) B stated, there was a medication error for Resident #101 on 1/20/21. DON B stated Resident #101 was given (medications) for a different resident. Past noncompliance was accepted. -Identification of residents affected or likely to be affected. -All residents were assessed for any signs and symptoms related to adverse reactions from opiates on 1/22/2021. -Medication administration general guidelines policy was reviewed and deemed appropriate by DON and administrator on 1/22/2021. -1/22/21: 1:1 education and verbal counseling was provided to nurse that was found to be deficient. -1/22/21: Relias (on line education) education was sent to all licensed nurses on medication administration; avoiding common errors. This was to be completed before returning to scheduled shifts. -1/22/21: Medication administration competency started for all licensed nursing staff. -1/26/21: Mandatory nurses meeting to discuss preparation and general guidelines for medication administration. -1/28/21: Medication administration audits started for all licensed nursing staff. -Incident reviewed by QAPI committee. Next review date is 5/20/21. -Monthly audits still being completed.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a burn for 1 of 19 residents (Resident #4) reviewed for accidents and safety resulting in Resident #4 sustaining a 2nd degree burn. Findings include: Review of the facility policy Handling Hot Liquids last revised 11/17 revealed, The elderly are more susceptible [MEDICAL CONDITION] younger persons, particularly those residents immobilized in a wheelchair .2. The facility will provide supervision to residents who receive hot food and beverages in an attempt to prevent hot liquid/food spills which may result [MEDICAL CONDITION].a. supervise the area .g. place beverage away from the edge of the table and near resident's dominate hand h. Explain to the resident that a hot liquid is being served and place the beverage in the resident's field of vision .j. Full [MEDICAL CONDITION] occur at temperatures at or above 120 (degrees). Review of a Face Sheet revealed Resident #4 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #4, with a reference date of 4/10/19 revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which indicated Resident #4 was cognitively intact. Review of Resident #4's Food Preference Record dated 6/12/19 revealed, Hot Beverage Needs: 1. No lids necessary 8d. Further modification 2. No. During an interview on 09/05/19 at 12:58 P.M., Resident #4 reported that he had recently sustained a burn injury from hot soup spilling onto his left side. Resident #4 reported that a Certified Nursing Assistant heated his soup in the microwave and brought it to his room. Resident #4 reported that the soup fell off of his tray table and landed onto his abdomen. Resident #4 reported that initially the wound was painful but was not painful at this time. Review of Resident #4's Incident Report dated 8/13/19 revealed, This nurse and CENA was in the hallway on south heard someone yell out than the call light for room (number omitted) went on. Upon entering room resident in bed 2 stated I dropped it this is going to be a bad one, asked resident what was he talking about he stated my noodles. CENA stated that resident was hungry and request that the ramen noodles be heated up to 4 minutes cause he does not like cold/cool noodles .(sic) Review of Resident #4's Physician Assessment Form dated 8/14/19 revealed, Per Staff: Early this morning resident requested CENA (certified nursing assistant) to microwave a cup of ramen noodles and to makes sure that it is hot. CENA took the noodles back to resident's room and told resident to be careful cause it was hot unfortunately resident did not listen well he dropped the noodles on the left side of his torso at first it was just red applied cool compress immediately checked back on resident after 2 hours and observed several fluid filled blisters starting on the upper portion of his chest all the way down to his left hip area. -PA (physician assistant) on call recommended applying triple A ointment available until [MEDICATION NAME] ointment could be delivered from pharmacy. -there is a large area on L (left) thorax of superficial skin excoriation, clear serous drainage soiling bedding. Recommend [MEDICATION NAME] topical treatment with gauze dressing changes. Patient refuses this treatment; agreed to at least wear a clean T-shirt that can be changed bid (twice a day). Will need to monitor bedding and change prn (as needed) to keep dry. Patient states he cannot feel any pain. -change clean T-shirt bid. -document if patient refuses -monitor for healing and for signs of infection -recheck in 2 days; will d/c (discontinue) previously ordered topical abx (antibiotics) if patient still refusing .Skin burn 2nd degree from scalding liquid -on left thorax -Recommended [MEDICATION NAME] cream bid, change Tshirt bid while draining. Patient refuses topical treatment; but agrees to wearing clean T-shirt bid. -monitor for healing and signs of infection. (sic) Review of Resident #4's Weekly Skin Sweep dated 8/13/19 revealed, 2 blisters that have popped near left hip/waist area-several fluid filled blister starting at left breast and going down to the left hip area. Review of Resident #4's Weekly Skin Sweep dated 8/20/19 revealed, chest and abdomen scar. refused skin sweep but what seen is noted. Review of Resident #4's Weekly Skin Sweep dated 8/27/19 revealed, refused skin sweep. Review of Resident #4's Weekly Skin Sweep dated 9/3/19 revealed, refused skin sweep. left torso red and scaley. treatment in place. (sic) Review of Resident #4's Physician Assessment Form dated 9/3/19 revealed, Patient requesting to be seen for concern of possible infection of chest wall burn. The wound is now covered with crusted scabbing with serosanguinous drainage dripping from under the scab, malodorous (foul odor). Pt also c/o (complains of) pain around the skin, tenderness. Has been treated with silvadine cream bid. Would expect to see less drainage at this point, about 2 weeks out from the injury -increased application of silvadine to tid (three times a day). -Keflex (antibiotic) 250mg q.i.d. (four times a day) x 7 days. (sic) During an observation on 09/05/19 at 1:25 P.M., Resident #4's wound was assessed. The wound was in the shape of a large oval and was 9.5 inches (length) by 8 inches (width). The wound was in different stages of healing. 2/3rds of the wound was covered in thick [MEDICATION NAME] exudate (scab like in appearance) and the remaining area was bright pink in color. The wound had a foul odor and there was scant drainage noted on the sheet. Resident #4 did not have any symptoms of pain (grimacing, guarding, and moaning). During an interview on 09/05/19 at 10:40 A.M., Registered Nurse (RN) N reported that Resident #4's burn did occur due to the CNA heating up soup to an unsafe temperature. RN N reported that interventions for wound healing were put into place immediately following the incident and Resident #4's wound is improving. During an interview on 09/05/19 at 4:00 P.M., Director of Nursing (DON) B reported that the facility implemented interventions to prevent another incident of a hot liquid burn. Nursing staff were educated on safe temperatures and a new policy was put in place to monitor hot liquid temperatures. Review of the educational documents provided by the facility revealed all staff had not yet received the education.

This citation pertains to intake #MI 073 Based on interview and record review, the Facility failed to accommodate the needs for 2 of 7 sampled incontinent and dependant (Resident's #102 and #104), from a total sample of 7 residents, resulting in emotional stress for Resident #102 and Resident #104 due to being left in soiled briefs for an extended period of time (over 2 hours). Findings include: Resident #102 Review of the face sheet revealed Resident #102 was a [AGE] year old woman admitted to the facility on [DATE]. Review of the Minimum (MDS) data set [DATE] revealed Resident #102 had [DIAGNOSES REDACTED]. Her BIM'S (Brief Interview for Mental Status) score was 13 out of a total of 15 points which indicated minimal cognitive deficits. During an interview on 5/29/12 at 9:10 AM, when asked if she was left wet or soiled for an extended period of time Resident #102 replied, "Yes, about a month ago. The 3rd shift didn't change me and I was left wet until the 1st shift came." Resident #102 said from midnight until 7:00 AM, she was left to lay in her urine soaked brief. Resident #102 said, "it's not just the urine they leave you in. I had defecated after supper last week and they let me sit in it until I absolutely couldn't stand it. It happened on second shift (about 7:00 PM), and I couldn't get help until almost 11:00 PM." Resident #102 began to cry, tears rolling down her cheeks as she said, "If I could I'd get out of here but I have to be here. I have no place else to go. I pee a lot." Resident #102 continued to cry and said, "they say to me, You're going again? What's the matter with you?" Resident #102 said there is one nurse aide on night shift that argues with her when she says she needs to be changed and another nurse aide who changes her "under protest". Resident #102 said the older nurse aide is a leader to the younger ones and is setting a bad example. The Surveyor ended the interview due to the sadness and emotional stress the Facility's inability to accommodate her needs had caused Resident #102. In an interview on 5/29/12 at 3:15 PM, Resident #102's sister said she visited Resident #102 on a daily basis and said, "sometimes they come in and turn the call light off and say I got 3 people on the toilet and I'll be back but they don't come back." Resident #102's sister said she tells Resident #102 to turn her call light on again because maybe they forget. Resident #102's sister said, "it happens all the time:". Resident #104 Review of the face sheet revealed Resident #104 was a [AGE] year old woman admitted to the facility on [DATE]. Review of the Minimum (MDS) data set [DATE] revealed Resident #104 had [DIAGNOSES REDACTED]. Resident #104 required extensive assistance of two people for toilet use and personal hygiene. Her BIM'S (Brief Interview for Mental Status) score was 15 out of a total of 15 points which indicated no cognitive deficits. During an interview on 5/29/12 at 9:20 AM, when asked if she was left wet or soiled for an extended period, Resident #104 said, "I take a water pill and a few times, I was wet and they neglected me. It's always first shift, just walk right by my room." Resident #104 said she put her call light on and the staff would ignore it. Review of the Resident Council meeting minutes dated 5/14/12 at 10:05 AM, revealed Resident #104, who attended the meeting, voiced a complaint which was written in the meeting minutes as, "(Certified Nurse Assistant #11) tells (Resident #104), to wait to get up or just wait.. Still having issues of getting up on time for AM group and not being changed enough and leaking through her clothes." #