Every finding on record at MyMichigan Skilled Nursing Facility

Based on observation, interview, and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens existing and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings include:On 04/14/2026 at 9:53am observed two spigots on dirty side of laundry room. During this observation, Housekeeping Manager C was interviewed on whether the spigots were used for anything, and she stated they are not used. On 04/14/2026 at 9:55am observed two dead-end lines coming down from the ceiling that are not connected to anything, adjacent to the washers. The unused piping looked identical to the washer hookups. During this observation, Housekeeping Manager C was interviewed on whether the lines were used for anything and stated they haven't used them since she's been working here. On 04/14/2026 at 9:57am observed a dead-end water line with what appears to be a filter attached, near the desk area in the laundry room. During this observation, Housekeeping Manager C was interviewed on whether the water lines were used for anything and she stated it hasn't been used since she's been working here. On 04/14/2026 at 12:12pm interviewed Maintenance Mechanic D on whether the dead-end plumbing in the laundry room is flushed on a regular basis, and he stated the unused water lines hanging from the ceiling adjacent to the washers are flushed monthly, but the two unused spigots on the dirty side and the water line with the filter near the desk area, are not flushed. According to the facility Water System Program and Risk Assessment, under dead legs/abandoned piping, Remove piping and fixtures that are no longer used. Flush dead piping that is not removed.According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Eliminate dead legs, which are sections of no- or low-water flow. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits.

Based on interview and record review, the facility failed to ensure appropriate indications for use of chemical restraints for 5 residents (Residents #4, #11, #12, #17 and #23), of 12 residents reviewed for chemical restraints, resulting in, decreased communication between professional staff, the protentional for unmet resident needs, care not tailored toward residents' needs, and sedation with falls. Findings Include: Review of the facility Behavior Management Monitoring Policy and Procedure last reviewed on 4/2025, stated The Behavioral Management Committee (BMC) shall monitor weekly and more frequently as needed: use of psychoactive medications and for potential to reduce/eliminate psychoactive medications. The BMC will seek to determine if there is justification for the initiation of psychoactive medications. The Social Worker will review the progress notes (nursing notes) and POC (Care Plans) prior to BMC reviews. During an interview done on 4/14/26 at 10:30 a.m., Social Service RN E, stated Our communication for our behaviors is done in our morning meeting; I can't read every nurse's note every day. Having someone on the floor more concentrating on behavioral health (including medications) would help. Social Service E said she was not aware of a Behavioral Management committee and was not familiar with the facility Behavioral Management policy; the way she got her information regarding resident behaviors and justification for psychoactive medications was per nursing notes/progress notes and at the 24-hour meetings. Resident #11: Review of the Face Sheet, nursing notes dated 4/26, physician orders dated 4/26, and care plans dated 4/6/26, revealed Resident #11 was [AGE] years old, alert, admitted to the facility on [DATE], and was dependent on staff for Activities of Daily Living/ADL's. The residents' diagnosis included kidney disease stage 3, spinal stenosis, low back pain, diabetes, chronic lung disease, arthritis, and was dependent on oxygen therapy. Review of the physician order dated 4/3/26, stated Sertraline tablet 50 mg (antidepression medication) once a day DX (diagnosis) depression. Review of the residents' Psychotic Drug Use care plan dated 4/6/26, stated Assess/record effectiveness of drug treatment, monitor and report signs of sedation, attempt non-pharmacological interventions, implement a mood management plan to complement drug therapy, monitor residents' mood and response to medication. Review of the residents' Psychosocial Well-Being care plan dated 4/6/26, stated Assess mood and potential for loneliness, address mood issues such as depression. Review of the residents' nurse's notes (progress notes) dated 4/3/26 through 4/13/26, revealed no entries of resident behaviors, assessing or monitoring of behaviors, no documentation of justification for Sertraline medication. Resident #12: Review of the Face Sheet, nursing notes dated 4/26, physician orders dated 4/26/26, and care plans dated 4/27/26, revealed Resident #12 was [AGE] years old, admitted to the facility on [DATE], alert with confusion, and dependent on staff for ADLs. The residents' diagnosis includes stroke with hemiplegia and hemiparesis, high blood pressure, chronic lung disease, neuromuscular dysfunction of bladder, gastro-esophageal disease, and psychotic disorder with delusions and skin picking. Review of the physician order dated 8/16/24, stated Lexapro tablet 5 mg once a day (anti-depressant medication), review of the physician order for Remeron 15 mg once daily for sleep/mental health (depression medication, not for sleep), and review of physician order dated 3/31/26, stated Buspirone tablet 5 mg (anti-anxiety medication) once a day for anxiety disorder. Review of the residents' Psychotropic Drug Use care plan dated 11/7/25, stated Assess/record effectiveness of drug treatment, monitor and report signs of sedation, attempt non-pharmacological interventions, monitor (Resident #12) mood and response to medication, implement a mood management plan to complement drug therapy. Review of the residents' Behavioral Symptoms care plan dated 8/8/24, stated Divert residents' behavior by providing distraction, addressing needs, observe and report socially inappropriate/disruptive behaviors when around others. Review of the residents' Mood State care plan dated 5/1/23, stated Monitor possible causes of insomnia (depression/anxious thoughts), if mood declines report to doctor for evaluation, and a list of target behaviors with individual interventions documented. Review of the residents' nursing notes dated 3/16/26 through 4/10/26, revealed no documentation of targeted behaviors with interventions, no assessment of behaviors, and no monitoring of behaviors. No justification for his psychoactive medications was found. During an interview done on 4/14/26 at 10:30 a.m., Social Service E said she was unable to find documented justification for his psychoactive medications. Resident #17: Review of the Face Sheet, nursing notes dated 4/26, physician orders dated 12/9/24, and care plans dated 10/1/24, revealed Resident of #17 was [AGE] years old, admitted on [DATE], able to answer questions, and dependent on staff for ADL's. The residents' diagnosis included Dementia, Diabetes, Psychotic disturbance, Mood disturbance and anxiety. Review of the physician order dated 12/9/25, stated Sertraline tablet; 25 mg (depression medication) once a day for major depressive disorder. Review of the physician order dated 12/9/24, stated Aricept 10 mg once a day for dementia, behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. Review of the residents' Psychotic Drug Use care plan dated 10/1/24, stated Assess/record effectiveness of drug treatment, monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms, assess if her behavioral symptoms present a danger to the resident and/or others, implement a behavior management plan, monitor residents' behavior and response to medication. Review of the only two Behavior Management Team notes dated 2/10/26 and 4/13/26, revealed no documentation of the residents' behaviors. During an interview done on 4/14/26 at 10:30 a.m., Social Service E said she only found two facility Behavior Management Team notes for the resident (on 2/10/26 and 4/13/26). Review of the residents nurses notes/progress notes dated 3/26 through 4/5/26, revealed only two entries of resident swatting at staff, on 4/3/26 and 4/4/26. During an interview done on 4/14/26 at 10:30 a.m., Social Service E said that was all the behaviors that she could find in the nurse's notes (on 4/3/26 and 4/4/26). Social Service E said that was not enough to justify psychoactive medications for this resident. Resident #23: Review of the Face Sheet, nursing notes dated 4/26, physician orders dated 4/26, and care plans dated 4/14/26, revealed Resident #23 was [AGE] years old, alert and able to answer questions, admitted to the facility on [DATE], and dependent on staff for ADL's, mobility, turning and repositioning in bed. The residents' diagnosis included, Cerebral infarction with left sided weakness, occlusion and stenosis of cerebral arteries, Hashimto's (autoimmune thyroiditis disease), generalized anxiety disorder, and high blood pressure. Review of the residents' physician order and Electronic Medication Administration/EMAR dated 4/9/26, revealed the resident had physician orders for Lorazepam .5mg every 6 hours (Ativan, anxiety disorder medication) and Buspirone 5mg three times a day (anxiety disorder medication). Review of the Psychotic Drug Use care plan dated 4/14/26 (survey, 4/13/26 through 4/15/26), stated attempt non-pharmacological interventions, assess for cause/condition of mood disturbance, assess if the residents behavioral/mood symptoms present a danger, implement a mood management plan to complement, monitor for drug use effectiveness, monitor residents' mood and response to medication. Review of nurse's notes from admission to 4/9/26 to 4/14/26, revealed no documentation of behaviors, an implemented mood management plan, or any monitoring of behaviors. During an interview done on 4/14/26 at 10:30 a.m., Social Service E said she was unable to find any documentation for psychoactive medications. Social Service E said she was not aware of a behavioral management program justifying the use of psychoactive medications for resident's. During an interview done on 4/15/26 at 1:16 p.m., the Administrator stated We have some room for improvement. Resident #4: Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included dementia and depression. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired, displayed no behaviors, and required maximum to total assistance for dressing and bathing. The MDS assessment detailed the Resident did not have anxiety and/or psychotic disorder. However, a diagnosis code indicating Unspecified dementia, severe, with psychotic disturbance was included. Review of prior MDS assessments revealed the diagnoses code for Unspecified dementia, severe, with psychotic disturbance was not present on Resident #4's MDS assessments until the assessment dated [DATE]. Review of the MDS assessments dated 2/7/25 and 5/6/25 revealed the Resident did not display any behaviors. Review of Resident #4's Health Care Provider (HCP) orders and Medication Administration Record (MAR) revealed the Resident was receiving the following psychotropic medications: - Fluoxetine (Prozac- antidepressant medication) 10 mg daily at bedtime (Start date: 6/6/25). The diagnosis/indication for the medication was listed as depressive episodes. - Buspirone (Buspar – medication used to treat anxiety) 5 milligrams (mg) daily (Start date: 3/30/26). The diagnosis Unspecified dementia, severe, with psychotic disturbance was listed as the indication for the medication use. - Zyprexa (Olanzapine- atypical antipsychotic medication indicated in the treatment of schizophrenia and bipolar disorder) 2.5 mg daily at bedtime (Start date: 10/13/25). The diagnosis/indication for use for Unspecified dementia, unspecified severity, with anxiety. Note: Zyprexa has a black box warning for increased mortality for elderly patients with dementia-related psychosis and is NOT approved for treatment of patients with dementia-related psychosis. Note: Use of Zyprexa and Fluoxetine together also has a Black Box Warning from the FDA which specifies treatment of elderly patients with dementia-related psychosis increase risk of death and the combination of the medications is NOT approved for patients with dementia-related psychosis. An interview was conducted with Social Service Registered Nurse (RN) E and RN F on 4/14/26 at 12:00 PM. When queried, RN E verbalized they monitored psychotropic medication use for residents at the facility. Resident #4's psychotropic medications were reviewed with RN E and RN F at this time. When queried regarding the appropriateness of the indications and diagnoses listed for use of Buspar and Zyprexa, RN E stated that was Not okay. RN F verbalized they were not acceptable diagnoses for the use of the psychotropic medication. When queried regarding consents for Resident #4's psychotropic medications, RN E located and provided copies of the consent documentation. Review of the Consent forms detailed the following: - Informed Consent/Risk Benefit Analysis. Prozac . Reason for use and benefits expected: Anxiety reduction, reduced crying . The form was signed by Resident #4's Durable Power of Attorney (DPOA) and RN I RN G on 3/11/25. - Informed Consent/Risk Benefit Analysis. Zyprexa. Reason for use and benefits expected: dementia with psychosis and paranoia, decrease paranoia, anxiousness. Signed by RN G on 3/11/25 and RN H on 3/12/26. On the Resident/Representative signature line, verbal notification/consent provided by (Resident #4's DPOA) was written with the date 3/11/25. - Informed Consent/Risk Benefit Analysis. Buspar . Reason for use and benefits expected: decrease anxiety. The form was signed by RN G on 10/25/24 and indicated verbal consent via phone was obtained via phone from (Resident #4's DPOA) on 10/25/24. RN E and RN F were asked if updated/new consents are obtained when psychotropic medication doses are changed and/or annually and both responded no. When queried why the Reason for use listed on the Informed Consent forms for Prozac and Zyprexa did not match the diagnosis/indication for use listed on the HCP order/MAR, an explanation was not provided. Documentation of Resident #4's behaviors and behavior monitoring was requested at this time. An interview was completed with the Director of Nursing (DON) and facility Administrator on 4/14/26 at 12:17 PM. When queried regarding Resident #4's psychotropic medications and the listed indications/diagnoses for use, the DON verbalized that the diagnosis of dementia with psychosis was added in 2025. When queried why the diagnosis was added, the DON indicated the Resident had behaviors. Documentation showing the reason for diagnosis was added was requested at this time. Review of Point of Care History documentation from 1/1/26 to 4/14/26 revealed documentation of behaviors two times. On 1/6/26, Resident #4 displayed crying/tearfulness and on 3/31/26 they displayed crying/tearfulness with Sad/pained/worried face expressions. No additional documentation was received from the facility.

Based on interview and record review, the facility failed to ensure adequate monitoring for the presence of potential adverse consequences of anticoagulation medication therapy for one resident (Resident #6) of two residents reviewed for anticoagulation medication therapy. Findings include:Resident #6: Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, right and left foot drop foot contractures, and saddle embolus (blood clot) of pulmonary artery. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required moderate to total assistance to complete Activities of Daily Living (ADLs) with the exception of oral care and eating. Review of Resident #6's Health Care Provider (HCP) orders and Medication Administration Record (MAR) revealed the Resident was receiving Eliquis (anticoagulant or blood thinner medication) 5 milligrams (mg) twice a day (BID) (Start Date: 3/24/25). A review of Resident #6's care plans revealed the resident did not have a care plan in place related to anticoagulation therapy and/or monitoring. Review of Resident #6's MAR, Treatment Administration Record (TAR), and note documentation in the EMR revealed no documentation of monitoring for signs/symptoms of potential side effects of treatment including bleeding. An interview was completed with MDS Registered Nurse (RN) F on 4/14/26 at 3:04 PM. When queried regarding Resident #6, RN F confirmed the Resident was receiving an anticoagulant medication. RN F was asked how the facility monitored for signs/symptoms of adverse medication consequences and revealed residents will have a care plan which includes monitoring. When queried regarding a care plan for Resident #6, RN F reviewed the Resident's EMR and verbalized there was no care plan in place. When asked how the facility was monitoring for potential adverse consequences of anticoagulant therapy, RN F verbalized there was no monitoring in place but indicated they would implement a care plan. On 4/14/26 at 3:35 PM, an interview was completed with the facility Administrator. When queried regarding Resident #6 and lack of monitoring for potential adverse effects of anticoagulant medication therapy, the Administrator revealed they were aware of the concern, and it was being addressed. Upon request for a facility policy/procedure related to monitoring for potential adverse consequences of anticoagulant medication therapy, the Administrator revealed they would look but did not believe the facility had a specific policy/procedure. Review of facility policy/procedure entitled, Medication Management Policy and Procedure (Approved: 3/2026) did not include any information related to monitoring for signs/symptoms of potential adverse consequences of medication therapy.

Based on observation, interview and record review, the facility failed to ensure a medication administration error rate of less than 5% when two medication errors were observed for two residents (Resident #7 and Resident #16) from a total of 32 observations, resulting in a medication error rate of 6.25%. Findings include:Resident #7:On 4/15/26 at 7:27 AM, a medication pass observation for Resident #7 was completed with Registered Nurse (RN) K. RN K was observed preparing Resident #7's medication at the medication cart outside of the Resident's room. While preparing the medications, RN K removed one bethanechol chloride (medication commonly used to treat urinary retention) 10 milligram (mg) tablet from the blister pack and placed in a medication cup. The blister pack had a sticker on it with the instructions, Take on an empty stomach. Resident #7 was able to be visualized from the medication cart in the hallway. A food tray was observed on the overbed table in front of them. RN K proceeded to lock the medication cart and was stopped and asked if they were going to administer all the medications prepared to the Resident. RN K responded they were. RN K was then asked to review the administration instructions on the bethanechol chloride blister packet. RN K remove the medication blister package from the cart and identified the sticker which stated the medication had to be taken on an empty stomach. When queried regarding facility policy/procedure related to administration of medications with specific administration instructions, RN K revealed they were unsure. When asked what they would normally do, RN K responded they would still give the medication. At this time, an interview was completed with RN K and the Director of Nursing (DON). The DON was informed of Resident #7's bethanechol chloride medication and the instructions on the blister packet specifying the medication should be administered on an empty stomach. RN K asked the DON what they should do and the DON stated, Hold the medication and Inform the doctor. Resident #16:A medication pass observation for Resident #16 was completed on 4/15/26 at 8:19 AM with RN J. RN J was observed preparing Resident #16's medication at the medication cart. RN J removed one bethanechol chloride 5 mg tablet from the blister pack and placed in a medication cup. A sticker with the instructions, Take on an empty stomach was noted on the medication blister pack. RN J proceeded to enter Resident #16's room and administer their medications. After administration, RN J was queried regarding the sticker on the blister pack for Resident #16's bethanechol chloride. RN J proceeded to remove the blister pack from the medication cart and review the administration instructions on the sticker. RN J was asked if Resident #16 ate breakfast and replied, Yes. When asked if they knew the reason bethanechol chloride should be taken on an empty stomach, RN J revealed they would need to look up the medication. RN J verbalized they were administering the medication at the scheduled time, and they would speak to the DON as the administration times may need to be adjusted. At 8:41 AM on 4/15/26, the DON was informed of the medication pass observation completed with RN J for Resident #7. When queried regarding the mediation instructions specifying the medication should be given on an empty stomach and the Resident having ate breakfast, the DON verbalized understanding of the medication error but did not provide further explanation.Note: Bethanechol chloride should be taken on an empty stomach for optimal absorption and to reduce potential nausea/vomiting.An interview was completed with facility consultant Pharmacist L on 4/15/26 at 9:11 AM. Pharmacist L revealed facility staff informed them of the medication administration concern related to bethanechol chloride administration. Pharmacist L verbalized that both Resident #7 and #16 have had the medication scheduled at the same time for as long as they had been at the facility and they were unaware of any adverse effects. When queried why the label on the medication packet specified to take the medication on an empty stomach, Pharmacist L replied, We have to put it on there. That is the manufacturers' recommendation. No further explanation was provided. Review of facility policy/procedure entitled, Medication Management Policy and Procedure (Approved 3/2026) revealed, All medications will be administered only upon a clear and complete order and in a safe, accurate manner. 17. Personnel administering medications shall refer to an approved reference when unfamiliar with the pharmacology, potential side effects and contraindications. 20. Preparation for medication administration. Read the label on each medication three (3) times and check with medicine card: Before removing from the cart Before pouring the drug Before replacing the container. Remember always!! Right Patient Right Drug Right Dose Right Route Right Time.

Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure that informed consent was obtained prior to initiation of psychotropic medications for one resident (Resident #2) of five residents reviewed for unnecessary medication use. Findings include:Resident #2:Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required moderate to total assistance to complete Activities of Daily Living (ADLs) with the exception of supervision/set up for oral care and eating. The MDS further detailed the Resident displayed no behaviors. Review of Resident #2's Electronic Medical Record (EMR) revealed a care plan entitled, Psychotropic Drug Use: (Resident #2) is at risk for adverse consequence from receiving psychotropic medication: Lamictal (anticonvulsant medication frequently used as mood stabilizer in the treatment of bipolar disorder), Buspar (medication used to treat anxiety), Lexapro (medication used to treat depression and generalized anxiety) (Start Date: 2/11/26; Edited: 4/6/26). Review of Resident #2's Health Care Provider (HCP) orders and Medication Administration Record (MAR) revealed the Resident was receiving the following psychotropic medications and dosages:- Buspar 5 milligrams (mg) three times a day (Start Date: 2/6/26)- Lamictal 25 mg daily (Start Date: 2/6/26)- Lexapro 10 mg daily (Start Date: 2/23/26)A review of scanned documentation in Resident #2's EMR revealed an Informed Consent/Risk Benefit Analysis form. The form specified, In order to protect our residents from harm. it is sometimes necessary to utilize medication interventions. Ordered/Prescribed Medication: Lamotrigine (Lamictal). Buspirone (Buspar), Hydroxyzine (Vistaril used to treat anxiety, manage chronic itching, and as a sedative) . The form was signed by Resident #2's Durable Power of Attorney (DPOA) and a facility RN I on 2/6/26. The Physician Signature area of the form was blank. An interview was conducted with Social Service Registered Nurse (RN) E on 4/14/26 at 2:14 PM. When queried regarding consents for psychotropic medications, RN E responded that each psychotropic medication a resident received should be included on the consent form. When queried if new/updated consents are obtained when psychotropic medication doses are changed, RN E responded they are not. RN E was then asked to review consent obtained for Resident #2's psychotropic medications. RN E reviewed the Resident's EMR and the Informed Consent/Risk Benefit Analysis form dated 2/6/26. When asked, RN E confirmed the consent did not include Lexapro. After reviewing the Resident's EMR further, RN E verbalized the a consent not completed for Lexapro. RN E was asked if a consent should have been obtained prior to initiation of the medication and responded that it should have been. When asked if Resident #2 had been seen and/or evaluated by mental health care service provider, RN E responded that they had contacted them and it was in process. On 4/14/26 at 3:35 PM, an interview was completed with the facility Administrator. When queried if consents should be obtained for psychotropic medications prior to initiation of medication therapy, the Administrator verbalized consent should be obtained. The Administrator was informed Resident #2 was receiving Lexapro and did not have a consent. The Administrator verbalized that consent should have been obtained prior to therapy initiation. No further explanation was provided. A policy/procedure related to informed consent for psychotropic medication therapy was requested at this time but not received by the conclusion of the survey.

Based on observation, interview and record review, the facility failed to implement a restorative nursing program and ensure coordination with therapy services for one resident (Resident #6) of one resident reviewed for limited Range of Motion (ROM). Findings include:Resident #6: On 4/13/26 at 11:16 AM, Resident #6 was observed participating in an activity in the dining room. Resident #6 was in a highbacked wheelchair with both of their lower extremities positioned on the footrests of the wheelchair. Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus, saddle embolus (blood clot) of pulmonary artery, right and left foot drop foot contractures. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact, had impaired ROM in both lower extremities, and was dependent upon staff for bathing, toileting, and transferring. The MDS further detailed the Resident was not receiving any therapy and/or restorative nursing services. Review of Resident #6's care plans in the Electronic Medical Record (EMR) revealed the Resident did not have a care plan and/or Health Care Provider (HCP) order in place pertaining to their bilateral foot drop contractures, ROM, and/or Restorative Nursing services. Review of documentation in Resident #6's EMR revealed the following related to ROM and/or Restorative: - 3/29/25 at 1:59 PM: Resident. expresses would like therapy to strengthen legs and improve bilateral foot drop. Explained that this would be available depending on (insurance) benefits, otherwise we are happy to offer the restorative program. (Resident #6) verbalizes understanding and will work with restorative for now. - 7/10/25 at 2:09 PM: Type of Care Conference: Quarterly. Therapies receiving: None. How can we better meet your needs? Wants to be able to stand, this nurse spoke to resident and family about restorative and disease progression. - 4/15/26 at 9:48 AM: Nursing. Staff in and applied boots to residents' feet bilaterally. Resident complaining of pain and wanted boots removed, boots removed per resident's request. Approximately 2 minutes of boots applied before removed. On 4/15/26 at 8:56 AM, an interview was completed with Restorative Registered Nurse (RN) F. When queried if Resident #6 had bilateral foot drop contractures, RN F stated, Yes. RN F was asked if Resident #6 was receiving Restorative Nursing services to prevent worsening of contractures and pain associated with contractures and replied, (Resident #6) is not in the restorative program anymore. When asked why the Resident was no longer receiving Restorative Nursing Services, RN F replied, (Resident #6) didn't want to do it. When queried regarding documentation pertaining to Restorative Nursing, RN F revealed they complete a monthly Restorative Assessment for Resident's receiving Restorative. Resident #6's EMR was reviewed with RN F at this time and revealed the most recent Restorative assessment was completed on 7/23/25. Review of the assessment detailed the following: 7/23/25. Monthly Restorative Summary. Description: June. What restorative program: ROM. Plan description: BLE (Bilateral Lower Extremities) -Quad sets, ankle pumps-work on flexion and extension, leg lifts. Do 3 sets of 15 reps each exercise. 1# AW (marches, kickout, side steps) 1# dumbbells (curls, arm raises) Green/blue t-band resistance around knees (may use ball for ball squeezes). Goal Description: Maintain current level of function. Monthly summary/evaluation of resident's progress Resident refusing w/ multiple attempts and multiple days noted. Educated resident on importance of participation in order to maintain current level of function and independence, resident understood but continued to participate in program. Continue w/ present goal? Change Goal? No, see above. Discharge. When queried, RN F revealed the Resident was discharged from Restorative Nursing Services in July 2025. On 4/15/26 at 9:35 AM, an observation and interview was completed with Resident #6 in their room. Certified Nursing Assistant (CNA) P and CNA Q were present in the room and had just assisted the Resident to bed from their wheelchair utilizing a mechanical lift. The Resident was positioned on their back and their toes on both feet were pointed straight down, away from their head with the top of their foot level with the top of their leg. When queried if they were receiving Therapy services, Resident #6 responded they were not. When asked if they were able to move and flex their ankle, Resident #6 lifted their entire leg slightly but did not flex or move their ankle. Ankle flexion and extension were demonstrated to the Resident. When asked if they were able to flex or move either of their ankles, Resident #6 stated, Mine don't do that. When queried if facility staff work with them and move/stretch their ankles for them, Resident #6 replied, I don't know. When asked if they want staff to work with them and move their ankles and joints so they do not become stiffer, Resident #6 stated, Yes. CNA P and CNA Q were queried if Resident #6 was receiving Restorative Nursing services and both responded they were not. When queried regarding Resident #6's Passive Range of Motion (PROM), CNA P attempted to flex both the Resident's feet upward with minimal movement noted. Resident #6 verbalized pain with gentle, minimal PROM attempt. When queried, both CNA P and CNA Q verbalized Resident #6 has pain with any movement. A pair of hard bottom PRAFO (Pressure Relief Ankle Foot Orthosis) style contracture boots were observed sitting in the room. An interview was completed with the Director of Nursing (DON) on 4/15/26 at 9:44 AM. The DON was asked when Resident #6 was last evaluated by Physical/Occupational therapy specifically related to contractures and/or ROM. The DON reviewed Resident #6's EMR and verbalized they did not see any documentation from Physical and/or Occupational therapy in the Resident's EMR. When queried how the facility assessed Resident #6's contractures to ensure they were not worsening, without therapy evaluation and measurement of contractures, the DON did not provide an explanation. Review of Point of Care task completion in Resident #6's EMR from 3/1/25 to 10/1/25 revealed documentation for number of minutes and how the Resident tolerated Active Range of Motion (AROM). The Resident did not have a task for PROM and/or PRAFO boot application. The documentation did not indicate what specific AROM was being completed and how often the task was supposed to be completed. Review revealed the task was completed three times per week on average. There was no documentation of refusal in the EMR. An interview was completed with Therapy Director M on 4/15/26 at 10:29 AM. When queried regarding Resident #6 including initial evaluation and measurements of contracture and ROM, Director M stated, We (therapy services) haven't seen (Resident #6) and didn't do an assessment for initial evaluation. Director M was asked who does the ROM evaluation for the MDS assessment and replied, (RN F) does. When asked about the Restorative Nursing program at the facility and Therapy services involvement including contracture management and prevention, Director M revealed Therapy does not see every resident for an evaluation as it is based upon the individual resident's insurance. With further inquiry, Director M revealed Therapy does not implement a restorative program for residents they do not see/treat but will recommend Restorative Nursing services following therapy service discontinuation if appropriate. When queried if Therapy staff are the most qualified to provide input related to appropriate interventions for contracture prevention and management, Director M confirmed they were. When asked how residents who do not receive therapy obtain Restorative Nursing services with appropriate interventions for contracture prevention/management without Therapy input, Director M indicated they are available for questions. On 4/15/26 at 10:35 AM, Resident #6 was observed in their room in bed speaking with two visitors. The PRAFO boots were sitting on the wheelchair in the room. An interview was completed with Restorative CNA O on 4/15/26 at 10:40 AM. When queried regarding Resident #6, CNA O revealed they had not seen Resident #6 for Restorative in a long time but were unable to recall a specific date. With further inquiry, CNA O verbalized the Resident had bilateral foot drop contractures when they were receiving Restorative. An observation of Resident #6 was completed with CNA O at this time. The Resident's feet and ankles remained in the same position as prior observation and the PRAFO style boots remained in the chair. While in the room, Resident #6's family member was overheard telling Resident #6, Need to get rid of your ballerina feet. The family member then asked CNA O why Resident #6 was not wearing the PRAFO boots and CNA O responded that the Resident doesn't like to wear them. After exiting the room, CNA O was queried regarding the PRAFO boots and revealed the Resident does not like to wear them because they hurt. A follow-up interview was conducted with RN F on 4/15/26 at 10:48 AM. When queried why Resident #6 did not have a care plan in place for bilateral foot drop contractures, RN F stated, There should be. RN F reviewed Resident #6's EMR, confirmed there was no care plan, and stated, I messed up. When asked about the PRAFO style boots observed in the Resident's room, RN F reviewed the Resident's EMR and verbalized there was no order and no care plan in place for PRAFO boots. RN F stated, I'm not sure where they came from and indicated the Resident's family will bring things into the facility from home. With further inquiry, RN F went to speak to Resident #6 and their family regarding the boots. RN F returned and stated the family brought in the boots when (Resident #6) first came in. When asked why there was no documentation regarding the boots, an explanation was not provided. RN F was then asked who completes section GG on the MDS assessment and replied, I do. When queried if therapy services ever completes the section of the MDS, RN F revealed they do not as they are part of the hospital side of the facility. RN F was asked to clarify the reason Resident #6's Restorative Nursing was discontinued and indicated the Resident had refused to participate. When queried if Resident refusals should be documented, RN F verbalized they should. Resident #6's Point of Care documentation for Restorative Nursing from 3/1/25 to 10/1/25 was reviewed with RN F at this time. When queried regarding the lack of documentation of care refusals, RN F confirmed and indicated staff also document on a paper form. RN F proceeded to look for the paper documentation and stated, I cant find the paper documentation for Restorative for (Resident #6). When queried regarding the Resident only having AROM documentation, RN F confirmed. When asked if Resident #6 had AROM in their bilateral ankles with their known foot drop contractures, RN F indicated they did not have much AROM if they had any. When asked why PROM was not implemented, RN F was unable to provide an explanation. When asked if PROM would be appropriate for an individual with foot drop contracture, RN F confirmed it would be. RN F was then asked if they agreed it appeared that Resident #6 had AROM in July 2025 when Restorative Nursing was discontinued does not have any AROM in their ankle at this time when asked to demonstrate, RN F stated, I can't argue that. No further explanation was provided. An interview was completed with the DON on 4/15/26 at 11:48 AM. When queried regarding Resident #6's bilateral foot drop contractures including lack of qualitative measurement assessment of ROM and lack of ongoing Restorative/ROM to prevent worsening, the DON verbalized understanding of concern. On 4/15/26 at 1:38 PM, an interview was completed with the Administrator. When queried regarding Resident #6's bilateral foot drop contractures including lack of measurements/monitoring and interventions to prevent worsening including Restorative Nursing Services, the Administrator verbalized understanding. No further explanation was provided. Review of facility policy/procedure entitled, Restorative ADL (Dated: 1/23) revealed, Restorative ADL Program is to provide the opportunity for patients/residents in long term care to attain their highest level of independence in self-care. Restorative programs will be conducted once per day, 3 to 5 days/week. Other staff must be familiar with the patient/resident POC status to follow through on off days. The Restorative Nurse or designee will evaluate through a screening process or referred by therapy services for continuation of strengthening ADL care. Potential Candidates: Patients with physical limitations which include, but are not limited to: Decreased range of motion.

Based on observation, interview and record review, the facility Failed to 1) Ensure that kitchen food items are dated with received by dates and use by dates and 2) Ensure that foods brought into the facility from family are dated, resulting in an increased likelihood for food borne illness with the potential to affect 22 Residents residing at the facility who consumed oral nutrition from the kitchen. Findings include: Review of the U.S. Public Health Service 2009 Food Code, as adopted by the Michigan Food Law, effective 10/1/2012, directs that open or partially used foods that are refrigerated. ready-to-eat and potentially hazardous are required to have use-by-date or date to be consumed. During the initial tour of the facility kitchen done on 2/19/2025 from 8:50 AM through 10:00 AM accompanied by Certified Dietary Manager I, the following was identified: Observation and interview on 02/19/25 at 08:50 AM with Certified Dietary Manager (CDM) I, of the line of in kitchen refrigerators revealed in a refrigerator clear elongated manual thermometers to be reading 8 degrees, and the outside thermometer reading of 38.4 degrees. Observation of the next in line refrigerator observed in refrigerator thermometer of 5 degrees and when checked electronic thermometer 38.8 degrees. Observation of the in refrigerator clear elongated manual thermometers were noted to be clipped to the front of the shelves next to the refrigerator doors and not in the middle of the refrigerator for a more accurate temperature. Observation and interview on 2/19/2025 at 9:10 AM with CDM I of the bread rack in the kitchen noted a full 12 pack bag of hamburger buns and a partially used bag with 4-6 buns left in the bag to be located on the top shelf with no use-by-date noted. The CDM I stated that those should have had a date on them and tossed the unmarked items out. Observation and interview on 02/20/25 at 10:17 AM with CDM I of the dry storage area and walk-in cooler freezer area revealed three (3) 16 oz. bags of marshmallows not dated and out of the manufactures box. CMD I stated that the marshmallows should have a received by date on those, but they are out of the box, and we now don't know when they came in or how old they are. The CDM I stated that everyone is responsible for dating the food items. Either she or the Supervisor assist in the shipments and putting items away. We do mark the boxes that the items come in when placing in the dry goods area. Record review of the facility 'Food and Supply Storage' policy, dated 1/2024, revealed all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . Cover, label, and date unused portions and open packages. Complete all sections on a touchpoint orange label or use and approved labeling system. Products are good through the close of business on the date noted on the label . In an observation on 02/19/25 at 1:40 AM, Registered Nurse (RN) C was observed with the zip lock bag of 5-6 tangerines going into the Director of Nursing (DON) office . Observation on 02/20/25 at 10:30 AM of the Resident pantry refrigerator located in the resident/family dining room revealed the zip lock bag of 5-6 tangerines labeled with resident's name with no date and a box of blueberries 12 oz with the resident's hospital name tag on the box but there was no orange sticker of use-by-date. In an observation and interview on 02/20/25 at 10:54 AM with the Director of Nursing (DON, the state surveyor walked to the resident/family dining room refrigerator and observed the bag of 5-6 tangerine undated, and the box of blueberries undated. The DON stated that there should have been dates put on when placed in the refrigerator. Both items were tossed out by the DON at this time and resident name label form hospital was not removed. An interview was conducted on 02/20/25 at 11:23 AM with Certified Dietary Manager (CDM) I. When asked about foods brought into the facility and placed in the Residents/family dining room refrigerator, it was stated that food brought in from outside/family items we (facility) follow policy. Record review of the facility 'Food Brought in to Patients from the Outside' policy ,dated 4/2024, revealed: 1.) the patient/resident food must be clearly labeled with the patient/resident's name, room number, and date the food was brought to the patient/resident. If not eaten within 3 days, the refrigerated foods should be discarded . 2.) When food/beverages have been labeled with patient/resident identification, this label and product are now considered 'protected health information' (PHI) and will need to be disposed of appropriately .

Based on observation, interview and record review, the facility failed to provide for safe wheelchair transport for two residents (#7 and 17) of two residents reviewed, resulting in residents being pushed in wheelchairs without footrests and the potential for injury. Findings include: Resident #7: On 2/19/25 at 10:14 AM, Activity Staff L was observed pushing Resident #7 down the hallway in their wheelchair without footrests. Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included dementia, anxiety, left hip injury, and bone density disorder. Review of the Minimum Data Set (MDS) assessment, dated 1/31/25, revealed the Resident was severely cognitively impaired and required substantial assistance with toileting, personal hygiene, and dressing. The MDS specified the Resident was independent with wheelchair mobility. Review of Resident #7's Electronic Medical Record (EMR) revealed a care plan entitled, (Resident #7) is at risk of falls r/t (related to) history of falls, weakness (Start Date: 11/18/23; Edited: 1/28/25). Resident #17: On 2/20/25 at 10:32 AM, Certified Nursing Assistant (CNA) M was observed pushing Resident #17 down the hallway in their wheelchair without footrests. At 11:44 AM on 2/20/25, CNA M was observed pushing Resident #17 down the hallway in their wheelchair without footrests again. Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses which included depression, dementia, anxiety, and repeated falls. Review of the MDS assessment dated [DATE] revealed the Resident was severely cognitively impaired and required substantial to total assistance with toileting, personal hygiene, and dressing. The MDS specified the Resident was independent with wheelchair mobility. An interview was completed with the Director of Nursing (DON) on 2/20/25 at 2:02 PM. When queried regarding staff pushing residents down the hallway in wheelchairs, the DON stated, Should have foot pedals. Observations of Resident #7 and Resident #17 being pushed without footrests/pedals were discussed with the DON at this time. The DON reiterated foot pedals should always be utilized when pushing residents in wheelchairs for safety but did not provide further explanation. Review of facility provided policy/procedure entitled, Transportation Guidelines for LTC Residents (Effective: 1/2025) did not address wheelchair mobility/transport.

Based on interview and record review, the facility failed to implement and operationalize policies and procedures for psychotropic medication use for one resident (Resident # 7) of five residents reviewed resulting in a lack of appropriate diagnoses and indications for treatment, a lack of Gradual Dose Reductions (GDR), and the potential for ineffective and inappropriate treatment. Findings include: Resident #7: On 2/19/25 at 10:00 AM, Resident #7 was observed sitting in their wheelchair in their room with a forlorn look on their face. An interview was completed at this time. When asked how they were doing, Resident #7 made eye contact but did not provide a verbal response. When asked if they were sad, Resident #7 shook their head yes and began to cry. On 2/19/25 at 10:05 AM, the Director of Nursing (DON) was informed the Resident began crying when asked if they were sad but did not provide any information regarding the reason they were sad. The DON stated, That is (Resident #7's) normal. (Resident #7) startles easy. With further inquiry, the DON stated, Anything or anyone new and (Resident #7) begins to cry. The DON was then asked if the Resident was receiving behavioral health services and treatment and responded that they were not. Record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance and with anxiety, Chronic Obstructive Pulmonary Disease (COPD), and bone density disorder. Review of the Minimum Data Set (MDS) assessment, dated 1/31/25, revealed the Resident was severely cognitively impaired and required substantial assistance with toileting, personal hygiene, and dressing. The MDS specified the Resident displayed no behaviors and no signs/symptoms of depression. The MDS assessments. dated 5/1/24 and 10/31/24. also specified the Resident displayed no behaviors. An interview was completed with Certified Nursing Assistant (CNA) P on 2/20/25 at 10:38 AM. When queried regarding Resident #7, CNA P stated, (Resident #7) gets upset easy and indicated the Resident cries frequently for no reason. CNA P verbalized Resident #7 has a history of trauma but was unable to provide any additional information related to the type of trauma and/or triggers. Review of Resident #7's Electronic Medical Record (EMR) revealed the Resident was deemed incompetent to make medical decisions on 8/11/24. A review of Resident #7's Medication Administration Record (MAR) and Health Care Provider (HCP) orders revealed the Resident was taking the following psychotropic medications: - Buspirone (Buspar- anti-anxiety medication) . 10 mg (milligrams) . Every 12 hours . (for) Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety . (Start Date: 11/18/24) - Fluoxetine (Prozac- antidepressant medication) . 20 mg . at bedtime . (for) Unspecified dementia . with anxiety . (Start Date: 11/18/24) Review of Resident #7's EMR revealed a care plan entitled, Psychotropic Drug Use . Resident is at risk for adverse consequence from receiving psychotropic medication: Prozac, Buspar (Start Date: 8/28/24; Edited: 1/28/25). The care plan included the interventions: - Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, anticholinergic and/or extrapyramidal symptoms (Start Date: 8/28/24) - Attempt a gradual dose reduction (if not contraindicated) (Start Date: 8/28/24) - Attempt to give the lowest dose possible (Start Date: 8/28/24) - Monitor resident's behavior and response to medication. Prior to starting Prozac would have multiple outbursts of crying, shaking, saying 'I'm sorry' repeatedly and 'please don't hurt me'. (Start Date: 8/28/24) - Try non-pharmacological interventions before initiating drug therapy. Staff approach from the front. Talk . throughout any cares given explaining each step prior to completing (Start Date: 8/28/24) An interview was conducted with Social Services Designee (SSD) Registered Nurse (RN) A and the Director of Nursing (DON) on 2/21/25 at 9:38 AM. When queried regarding the facility policy/procedure related to informed consent for psychotropic medications, SSD RN A revealed a paper consent is obtained. When asked where Resident #7's consent was located as it was not noted in their EMR, SSD RN A revealed they were having issues scanning paper documents into the EMR and indicated they the paper consent form. SSD RN A provided a paper Informed Consent/Risk Benefit Analysis form for Prozac for Resident #7. The form detailed the Reason for use and benefits expected: anxiety, tearfulness, crying out . The form was signed by Resident #7 and a facility RN on 8/12/24. The Form included a section for physician documentation which detailed, Doctor's Statement: I have reviewed and recommend the medication plan and included the following areas for the physician to check as completed, Resident gives consent to take these medications . Resident gives verbal consent, but unwilling/unable to sign . Emergency. Given medication without consent . Unable to understand risks and benefits, therefore cannot consent . other . comments . The Physician signed the form on 8/23/24 but all the sections were blank (not checked). A consent for Buspar was also provided by SSD RN A. The consent form specified, Reason for use and benefits expected: decreased anxiety . The consent form indicated verbal consent was obtained by the Resident's Durable Power of Attorney (DPOA) on 10/25/24. When queried why the consent for Prozac was signed by the Resident on 8/12/24 when they were deemed incompetent to make medical decisions on 8/11/24, SSD RN A stated, I really can't give you that answer. When asked if a resident who is deemed incompetent is able to provide consent for psychotropic medications, SSD RN A verified they cannot. When queried if Resident #7 was seen by a mental health provider, SSD RN A replied, No. SSD RN A was asked of the facility had a mental health provider who came to the facility and stated, No. SSD RN A then stated, We would have to send them out to community mental health if needed. When asked if Resident #7 goes out to see community mental health, SSD RN A stated they do not. When asked why they do not, RN A replied, (DPOA) does not want (Resident #7) to go out because leaving is scary to them. RN A then stated, I can't even get the notes from (community mental health) when residents do go out for treatment. When asked how they are able to coordinate care if they are not able to get notes, RN A did not provide an explanation. When asked, SSD RN A indicated the Resident's physician manages psychotropic medications. When asked if unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety is an appropriate indication for use for Buspar, both the DON and SSD RN A indicated they were unable to provide comment or explanation.

Based on observation, interview and record review, the facility failed to ensure that a call bell communication device was responded to for two residents (#9, #72), of 22 sampled residents, resulting in Resident #9 and #72 being seated in the dining room with a silver metal service bell which was rung with no response from facility staff. Findings include: Observation on 2/19/2025 during the initial tour of the facility resident dining room at the noon meal revealed that there was no electronic call bell system with resident push buttons noted in the dining room area. Observation and interview was made on 02/19/25 at 09:34 AM with Resident #9 who stated that she was thirsty and wet (wet brief) and wanted to lay down. Resident #9 was observed with a silver metal service bell in dining room on the table. Resident #9 was able to demonstrate ringing the bell which rang 3-4 times. The State surveyor observed two staff members seated across the hall at the nursing station, Certified Nurse Assistant (CNA)/ward clerk H and Registered Nurse (RN) E. Neither staff member responded to see what the resident needed. The state surveyor went out into the hallway to look and see if there were other staff members available. Resident #9 stated to yell out while she was seated in the dining room to get attention of the staff. On 02/19/25 at 09:52 AM, Certified Nurse Assistant (CNA) B came into the room when Resident #9 was yelling out to get attention. CNA B asked Resident #9 what she needed and then Brought the resident a glass of water. The state surveyor asked CNA B about the manual silver call bell on the table and the response was if she (Resident #9) needs something, she will just yell out. Observation was made on 02/19/25 at 10:21 AM with Certified Nurse Assistant (CNA) B and Registered Nurse (RN) D of a Hoyer transfer of Resident #9 back to bed, a brief change and peri-care. Observation on 02/20/25 at 11:38 AM of the dining/TV room revealed Resident #9 and #72 and 6 other residents seated in the room with only a silver manual call bell on one table. No staff were present. The silver manual call bell was located in the middle of a large round table and out of reach of both Resident #9 and Resident #72, who were seated at the table. Record review of the facility 'Emergency/Call Bell' policy and procedure, dated 4/5/2024, revealed the purpose was to establish guidelines to alert staff when the call light system is down, or when a resident is in a non-centralized location without a call light system. To provide safety for all residents of the skilled nursing unit, and to ensure that residents needs are being met . Call bells will be located in non-centralized areas that do not have a call light system. When needed call bells will be placed within the resident's reach at all times when in their rooms or in non-centralized locations without a call light system . All staff are to respond as promptly and as soon as possible to call bells . Observation on 2/20/2025 of the Resident/Family visitor lounge revealed that there was a manual silver call bell located on a table. The state surveyor rang the bell and staff did not respond to the bell.

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for fall prevention for one resident (Resident #6) of five residents reviewed, resulting in a lack of implementation of Physical Therapy recommendations, lack of enactment and reevaluation of planned care plan interventions, and Resident #6 experiencing a fall with a head laceration necessitating emergency medical treatment, staples, unnecessary pain, and the likelihood for additional falls with injury. Findings include: Resident #6: On 3/4/24 at 11:23 AM, Resident #6 was not in their room. An observation of their room was completed. There were no fall prevention interventions, including a fall mat observed in the room. Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included dementia, left hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke), atrial fibrillation (irregular heart rhythm), and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required substantial/maximum assistance for toileting hygiene and transferring. Review of Resident #6's Electronic Medical Record (EMR) revealed an Event Report dated 11/07/23 pertaining to an unwitnessed fall. The Event detailed, Fall . Shower room bathroom . Does resident exhibit or complain of pain related to the fall? . Yes, LLE (Left Lower Extremity) . Note any injury to the head, extremities, or trunk . Abrasion . Laceration . ROM (Range of Motion) Painful/Limited in Lower Extremity . Possible Contributing Factors . Recent Change in Appetite . Recent Decline in ADL Abilities . adaptive equipment in use at the time of the fall? No . Immediate measure taken . First Aid . Direct Pressure to Wound . Sent to ER . Change in Mental Status of new onset . Laceration with uncontrolled bleeding . New onset of moderate to severe pain . Evaluation Notes: Per documentation and statements, resident was put on the toilet in the large shower room between 0845-0850. At 0905 resident was observed on the floor on left side with head between the front wheels of wheelchair . taken to the ER due to bleeding from the Occipital head and pain with palpation of the left hip was positioned angled to the right on the toilet seat. Resident has a history of falling asleep sitting in wheelchair. Resident has left hemiplegia from a previous CVA. The wheelchair was positioned in front of the toilet and the brakes were locked. Resident receives many medications that increase the risk for falls. Resident has a suprapubic catheter in place . recently placed on Part B services (therapy) due to increased weakness post COVID. Root Cause: Resident most likely fell asleep and leaned to the left and fell off of the toilet . most likely received the laceration to the left Occipital area from the inner foot pedal mechanism on the wheelchair . received a large contusion to left hip . was care planned to not be left alone in the bathroom . Further review of Resident #6's EMR documentation revealed the following: - 11/7/23 at 9:05 AM: Resident on floor in large shower room laying on left side with head laying in between lock wheelchair front wheels complaining of lower back hurting. Noted blood on floor under left side of head. Resident does not know how fell on floor . Resident does complain of head hurting . to head where bleeding was happening . complains of left hip pain upon palpation and redness noted . Resident was assisted on back board and onto gurney and taken to ER . Unable to obtain BP due to position of resident . - 11/7/23 at 9:05 AM: At approximately 0905 on 11-7-2023. This writer heard a faint voice yelling for help. Thinking it was another resident's TV, I initially checked room with loud TV playing. When I made my way back to the station, I heard resident's voice faintly from shower room bathroom, saying 'help me.' I opened shower room door and observed resident on floor, partially under wheelchair with head between front wheels, left side lying, pants down between legs, with catheter attached to bag under chair. This writer yelled for help, stating resident was on floor. When asking what happened, resident said they did not know how they fell . Staff moved wheelchair out of way and observed moderate amount of dark red blood to resident's hair, sweater, and puddle on floor. Observed resident's head, coagulated blood appeared to be coming from left posterior side of head. Resident states head hurts. Applied pressure using washcloth until DON (Director of Nursing) arrived, who then held pressure. This writer assessed, limited ROM to both LUE (Left Upper Extremity) and LLE (Left Lower Extremity), as per resident baseline d/t (due to) history of CVA (Cerebrovascular Accident- Stroke) with left affected side . pain to left hip with palpation, with noted redness . Unable to check upper back and complete LUE due to heavy sweater. Attempted to check mentation, resident alert to self only. Vitals attempted by aides. Back board applied under resident, and resident lifted onto hospital bed to be transported to ER. - 11/7/23 at 10:59 AM: Resident brought back to room with head x-ray negative along with x-ray of left hip was negative. 2 staples to back of left side of head present . abrasion noted on left buttock region and back of left side of head has 2 staples intact with dried blood noted . - 11/7/23 at 12:40 PM: Resident . was given Tylenol . due to head hurting . - 11/7/23 at 8:35 PM: Resident with complaint of left hip pain, upon assessment left hip with large firm protrusion approximately the size of palm of hand, red in color, no noted bruising. Noted internal rotation of left hip and difficult for resident to have moved without increased pain. Will notify Doctor. - 11/7/23 at 8:38 PM: Doctor notified by phone with resident condition, order received for CT stat . and Norco (narcotic pain medication) 5-325 mg (milligrams) every 6 hours as needed for pain . Review of Resident #6's EMR revealed a care plan entitled, (Resident #6) at risk for falling R/T (related to) CVA (stroke) with Left Hemiparesis, history of falls at home, impaired mobility, weakness . (Start: 1/14/19; Edited: 12/12/23). The care plan included the interventions: - Provide resident with safety device/appliance: bilateral bed bolsters for awareness of edge of bed (Start: 4/7/20; Edited: 12/12/23) - Soft mat to active side of bed . (Start: 6/10/19) - Place resident in a fall prevention program (Start: 1/14/19) Review of Resident #6's hospital documentation dated 11/7/23 at 9:24 AM revealed, ED Provider Note . Patient has longstanding history of dementia . atrial fibrillation (currently on Xarelto [blood thinner]) . and prior stroke . presents to the emergency room . after fell from the toilet . struck the left occiput (back) area of head on the floor and was complaining of left hip pain. The incident was not witnessed by (staff) did hear the patient hollering for help . did have some active bleeding from the left occiput . unknown loss of consciousness . mild left hip pain . (Resident #6) is heavily demented .does not remember the fall . The hospital ER documentation revealed Resident #6's head laceration was closed with staples and the Resident was transferred back to the facility. Review of left hip CT results dated 11/7/23 at 9:11 PM in Resident #6's EMR revealed the Resident had a subcutaneous contusion (bruise under the skin) in their upper, outer left thigh. On 3/6/24 at 8:51 AM, Resident #6's room was dark with the lights off and the window blinds closed. The Resident was in bed, positioned on their back with their eyes closed. A fall mat was not present in the room. An interview was completed on 3/6/24 at 8:58 AM with Certified Nursing Assistant (CNA) N. When queried if they were working on 11/7/23, CNA N revealed they were. When queried regarding Resident #6's fall on 11/7/23, CNA N stated, I wasn't in there. (Resident #6) was in the shower room alone. When asked the reason Resident #6 was in the shower room, CNA N indicated the Resident was using the restroom. CNA N was asked if Resident #6 required assistance to use the restroom in November 2023 and revealed they did. CNA N stated, (Resident #6) leans so bad and I don't like leaving them alone anyway. When asked to clarify if they were referring to the Resident currently or in November at the time of the fall, CNA N verbalized they were referring to when the Resident fell in November but indicated the Resident still leans. When queried if they had assisted Resident #6 to use the restroom in November 2023 prior to their fall, CNA N revealed they had and specified they always stayed with them because they were uncomfortable leaving them alone due to the Resident being unable to sit up straight without assistance. CNA N was then asked if Resident #6 is supposed to have a fall mat in their room and replied, Used to but they took it out. When queried who took it out and when, CNA N indicated they could not recall. When queried how they know what level of assistance and/or care plan interventions residents require, CNA N replied it was in the computer (EMR). When asked, CNA N showed this Surveyor what saw when they looked at Resident #6's EMR care plan. The care plan displayed on their screen only showed the care plan title and no interventions. When asked if they knew how to view the specific interventions for each care plan, CNA N replied, I really don't. An interview and observation of Resident #6 was completed with Registered Nurse (RN) Q on 3/6/24 at 9:21 AM. Upon entering the Resident's room, Resident #6 was observed in bed, positioned on their back with their eyes closed. RN Q was asked if the Resident had a fall mat in place and after looking replied, No. After exiting Resident #6's room, their care plan was reviewed with RN Q. When queried, RN Q confirmed the Resident's care plan specified the Resident should have a fall mat and they did not have one. On 3/6/24 at 9:30 AM, an interview was conducted with RN I. When queried regarding Resident #6 not having a fall mat per their care plan intervention, RN I stated, They are not supposed to have a fall mat. When asked why they are not supposed to have a fall mat when it is on their care plan, RN I replied, I don't know. RN I then stated, I am guessing they just put it (fall mat intervention) on there (care plan). I will just take it off. When asked if they were going to complete a fall risk assessment prior to discontinuing the evaluation, RN I did not provide a response. When queried why the intervention was implemented in the first place, RN I indicated the Resident most likely had a fall, but the intervention was no longer needed. RN I was asked why the intervention was on the care plan if it was no longer appropriate and stated, That is on me. I have reviewed the care plan a couple of times. When asked, RN I stated, If it (fall mat) is on the care plan, it should be in there (Resident #6's) room. An interview was completed with the Director of Nursing (DON) on 3/6/24 at 9:50 AM. When queried regarding Resident #6's fall mat not being in place, the DON indicated they were aware of the concern. The DON indicated they have been working with the nursing staff to have them help update Resident care plans with any changes. On 3/6/24 at 10:07 AM, an interview was completed with CNA M. When asked what occurred when Resident #6 fell on [DATE], CNA M revealed they assisted the Resident into the shower room, transferred them onto the toilet, and then left them alone to have a bowel movement. CNA M revealed as they were waiting outside of the shower room for Resident #6, another call light went off and they went to answer it. When queried what time of the day the fall occurred, CNA M stated, It was right after breakfast. CNA M was then asked if they observed and/or assisted the Resident after the fall and stated, I helped get (Resident #6) into the bed and took them to the ER. I don't understand how they fell that way. (Resident #6) was sitting perfectly strait on toilet. When asked to explain, CNA M stated, I sat (Resident #6) perfectly (on the toilet). I got (Resident #6) positioned on the toilet and the wheelchair was kind of in front of them locked. When asked if Resident #6 would try to stand up on their own, Resident #6 indicated the Resident did not attempt to stand on their own. CNA M indicated the Resident would lean when they were sitting and always hangs on to the metal bar in the shower room bathroom no matter what. When asked if they normally wait by the door when Resident #6 was using the restroom, CNA M did not provide a direct response but stated, We always let everyone know the Resident was in the restroom. At 10:38 AM on 3/6/24, an interview was conducted with Physical Therapy Assistant (PTA) P and Occupational Therapist (OT) O. When queried if Resident #6 was receiving therapy in November 2023, PTA P and OT O reviewed the Resident's EMR and revealed the Resident was First seen by therapy on 11/2/23 for an initial evaluation. A review of Resident #6's Physical Therapy Initial Evaluation dated 11/2/23 was completed with PTA P and OT O at this time. The Evaluation form detailed, Subjective: Recent onset of COVID 19 infection led to isolation, resulted in weakness, tightness of LLE (Left Lower Extremity), poor posture, decreased functional transfers/bed mobilities . Patient wants to be able to use LLE, sit straight, and help CNA's with transfers . Sitting with Back Unsupported but Feet supported on the Floor or on a Stool: Unable to sit without support 10 seconds . Observations . Patient is wheelchair bound, has a 45 contracture present on LLE . Poor postural awareness . Balance: sitting/standing static, dynamic: Poor . Transfers, Bed mobilities . Max . Dependent . Assessment . decreased P (Passive)/AA (Active Assisted)/AROM (Active Range of Motion), Decreased Motor Control on both LE's, Trunk . Impaired sitting/standing balance . When queried if sitting on a toilet was considered Sitting with Back Unsupported but Feet supported ., OT O stated it was. PTA P and OT O were then asked if Resident #6 was safe to leave unattended while sitting on the toilet, per the therapy evaluation. Both staff verbalized the Resident required assistance to maintain sitting balance and should not have been left unattended in the bathroom. When asked how therapy recommendation are communicated to nursing staff, OT O indicated therapy staff verbally communicate with nursing staff and nursing staff also have access to review therapy documentation in the EMR. An interview was conducted with the DON and facility Administrator on 3/6/24 at 11:40 AM. When queried regarding the facility policy/procedure related to communication of ADL care assistance from therapy, both the DON and Administrator indicated that evaluations, concerns, and changes are discussed at the morning meeting. When asked if Therapy staff enter orders in the EMR and/or update Resident care plans related to ADL assistance/transfer status, the Administrator and DON revealed Therapy staff do not. When queried why Resident #6's was left unattended on the toilet on 11/7/23 after their therapy evaluation on 11/2/23 detailed they were unable to sit without support for 10 seconds, both the DON and Administrator indicated they were unaware of the evaluation. The Administrator and DON reviewed Resident #6's Physical Therapy Initial Evaluation. When asked if the Resident should have been left unattended in the bathroom when they were unable to sit without support, both the Administrator and DON verified the Resident should not have been left unattended. Review of facility policy/procedure entitled, Skilled Nursing Facility; Falls Management (Reviewed 4/21/23) detailed, The Falls Management Process guides the staff through a structured risk assessment and planning process, is utilized to evaluate appropriate interventions to minimize the risk of falls and fall related injuries . The personal safety of each resident of the Skilled Nursing Facility is of primary importance . Any decisions to remove or modify safety or fall prevention measures, will be made by the multi-disciplinary Falls Committee team members. 9. Orders to remove safety devices or to decrease the level of assistance to the resident will be written after the multi-disciplinary Falls Committee team has had an opportunity to review the recommendations. 10. Care Plans will be updated to communicate changes to the staff to reflect the orders written .

Based on observation, interview and record review, the facility failed to prevent the development of facility-acquired pressure ulcer injuries for one resident (Resident #8), resulting in facility-acquired (in-house) development of pressure ulcers, pain, discomfort, and the likelihood for prolonged illness or hospitalization . Findings include: Record review of the facility provided 'Skilled Nursing Facility Skin Conditions Prevention and Treatment' policy, dated 11/20/2023, revealed the purpose was to promote the prevention of pressure ulcer development, healing of those that are present and prevention of additional pressure wounds. Pressure injury- is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination of shear. Stage II (2): Partial thickness skin loss with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Stage IV (4): Full-thickness skin and tissue lose with exposed or directly palpable fascia, muscle, tendon, ligament. cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. Record review of the facility- provided Department of Health and Human Services Centers for Medicare & Medicaid Services Form CMS-802 matrix revealed Resident #8 to have a facility-acquired Stage IV pressure ulcer. Resident #8: Record review of Resident #8's Minimum Data Set (MDS), dated [DATE], revealed an elderly female with a Brief Interview of Mental Status (BIMS) score of 14 out of 15, cognitively intact and able to make decisions. Medical diagnoses included: Debility, heart failure, high blood pressure, diabetes, anxiety, and depression. Section GG: Functional abilities assessed Resident #8 as substantial/maximal assistance (helper/staff does more than half the effort) for: laying to sitting on side of bed, sit-to- standing, chair/bed-to chair transfer, toileting transfer and tub/shower transfers. Record review of the Section M: Skin Conditions- revealed no pressure ulcers or skin injuries. Record review of Resident #8's Electronic Medical Record (EMR) census tab revealed that the resident was out of the facility for hospital care in October of 2023, returned/readmitted to the facility and has remained at the facility since that date. An interview on 03/04/24 at 10:41 AM with Resident #8 revealed that she did have a left hip wound. Resident #8 stated that she did not know if she came with it, but that they (staff) are doing dressing daily and they measure it. Resident #8 stated that she did believe that she got the sore at the facility because she went to the hospital last October and when she came back, she wasn't moving a lot. Record review of Resident #8's Minimum Data Set (MDS), dated [DATE], revealed an elderly female with a Brief Interview of Mental Status (BIMS) score of 14 out of 15, cognitively intact able to make decisions. Medical diagnoses included: Debility, heart failure, high blood pressure, diabetes, anxiety, and depression. Section GG: Functional abilities assessed Resident #8 as substantial/maximal assistance (helper/staff does more than half the effort) for: laying to sitting on side of bed, sit-to- standing, chair/bed-to chair transfer, and toileting transfer. Record review of the Section M: Skin Conditions- revealed a pressure ulcer staged at Level IV-full thickness skin and tissue loss. An interview on 03/04/24 02:31 PM with Registered Nurse (RN)/Wound Care Nurse I revealed that Resident #8 likes to lay on her left side. The left hip wound started in December 2023 at the facility and was a facility-acquired pressure ulcer. RN I stated that skin assessments found a bump or sack on the outside aspect of the left hip in November 2023. In December of 2023 the left hip bump/sack sides/rim of wound became necrotic with dry eschar. The facility started treatment of Santyl ointment debridement of the wound area, and the necrotic tissue came off. RN I stated that he was able to see wound bed and depth and staged the wound at a Stage IV pressure ulcer. RN I stated that the wound has a depth of around 2.7 cm (centimeters) and changed treatment to Melgisorb antimicrobial alginate cut to fit the wound bed and used to absorb exudate (drainage). Record review of Resident #8's 'Wound Management Detail Reports', dated 12/19/2023 through 2/28/2024, revealed a left hip wound that started on 12/19/2023 at 11:27 AM measuring length 3 cm X width 3.2 cm X depth 0.2 cm with serosanguineous exudate, Stage III. The wound management report on 01/19/2024 at 3:13 PM noted length 2.4 cm X width 1.5 cm X depth 1 cm with moderate exudate of seropurulent (yellow or tan, cloudy and thick) drainage with mild foul odor. The wound was staged as a Stage IV pressure ulcer-full thickness skin and tissue loss. Observation of wound care on 03/05/24 at 09:04 AM with Registered Nurse (RN) I (wound care nurse) revealed an old dressing date 3/4/24 was removed. Observed wound bed pink and with moderate serosanguineous drainage, no odor. Dermal wound cleanser spray was applied and the wound bed was dabbed with 4 x 4 gauze. Wound measurements taken: 1.3 cm length, X 1.1 cm width, X depth 1.9 cm. Observed treatment of Melgisorb alginate cut to size, (debride with silver per RN I), applied to wound bed, and covered with an Allevyn 4 x 4 foam border dressing. An interview was conducted on 03/05/24 at 09:12 AM with Resident #8 while in the room with Registered Nurse (RN) I, Resident #8 stated that the wound was painful, and rated at a scale of 7-8 out of 10. Resident #8 stated that it goes down to a 5 after she gets her pain pill. Resident #8 stated that she kept complaining of pain after her fall a while ago. RN I and state surveyor observe Fentanyl patch to right shoulder, dated 03/04/24, for pain control. In an interview on 03/06/24 at 10:35 AM with the Director of Nursing (DON) regarding Resident #8's Stage IV pressure ulcer, the DON stated that the Stage IV pressure ulcer was facility-acquired and Resident #8 had a [NAME]-sized lump to that area. Resident #8 had a fall on October 10/26/2023, where she slid off of the edge of the bed. There was no noted injury at that time, but she kept complaining of pain. The facility did further testing and found a hematoma to the left hip area in November 2023, which is how they believe it opened. It was facility-acquired. Record review of Resident #8's 10/26/2023 at 1:30 AM 'Event Report' noted a fall in the resident's room with no witnesses. The resident complained of pain rated at moderate (distressing/miserable per report). The resident put on the (call) light and was found on her knees next to bed, laying over the bed. Record review of Resident #8's left hip X-Ray dated, 11/24/2023 (30-days post fall), revealed a contusion/hematoma peri trochanteric without an acute fracture noted.

Based on observation, interview and record review, the facility failed to label food items with Use by dates, resulting in an increased likelihood for food borne illness with hospitalization and potentially affecting all 24 residents who consume oral nutrition from the facility kitchen. Findings include: Record review of facility provided 'Food and Supply Storage' policy, dated 1/2024, revealed all food, non-food items and supplies used in food preparation be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Procedure: Most, but not all products contain an expiration date. The words sell-by, best-by or use-by should precede that date. The sell-by date is the last date that food can be sold or consumed: do not sell products in retail area or place on patient trays/residents' plates past the date on the product. Cover, label, and date unused portions and open packages. Complete all sections on a Touchpoint orange label or use and approved labeling system . Discard food past the use-by or expiration date. Kitchen: Observations of the kitchen on 03/04/24 at 11:34 AM with the Certified Dietary Manager (CDM) A of the Cook freezers (side by side style) located in the kitchen revealed three (3) bags of tater tots with orange use-by stickers dated 2/28/2024. There were two (2) partially used bags a one full One bag, each bag use-by date of 2/28/2024 were noted. An interview on 03/04/24 at 11:34 AM with the CDM A revealed that there are the wrong dates and that a Received by date, instead of the Use by date was placed on the sticker. There was no Received by date located on the items. The CDM explained about the orange labeling system that when food item is received or opened an orange sticky label is placed with the date that product is to be used by. Observation was made on 03/04/24 at 11:37 AM of the dry goods storage room, boxes, and cans with orange Use by labels noted. Observations on 03/04/24 at 11:41 AM of the walk-in cooler revealed a cardboard box of about 10 heads of cauliflower with no orange Use by label noted. Observation of the cauliflower by the CDM on all side of the box revealed the only label was by the food shipping company of 2/1/2024. The cauliflower was over a month old. Observation of a large box of 20-30 oranges was also unlabeled. The box had no food shipping company label and/or Use-by date orange sticky label noted. Observation on 03/04/24 at 11:44 AM of the walk-in freezer revealed that a box of hotdogs had a food shipping company label dated for the first week of February. The year was torn off the label.

Based on interview and record review, the facility failed to operationalize policies and procedures to ensure that appropriate notification of a resident's condition, per the resident's request, for one resident (Resident #6) of one resident reviewed, resulting in the potential for inappropriate and undesired communication of private healthcare information and a breach in confidentiality. Findings include: Resident #6: Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included dementia, left hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke), atrial fibrillation (irregular heart rhythm), and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required substantial/maximum assistance for toileting hygiene and transferring. A review of Resident #6's face sheet included three family member contacts. The Notes section for one contact, Witness R detailed, Please Notify with ALL changes even if (Resident #6) says not to as this is what (Witness R) would like. Review of Advance Directive documentation in Resident #6's Electronic Medical Record (EMR) revealed Resident #6 had not been deemed incompetent and made their own decisions for healthcare. An interview was conducted with Social Services Registered Nurse (RN) Q on 3/5/24 at 12:20 PM. When queried if Resident #6 made their own health care decisions, RN Q revealed they did. RN Q was then asked about the note on Resident #6's facesheet pertaining to Witness R and indicated they would need to review further. A follow up interview was conducted with Social Services RN Q and the Director of Nursing (DON) on 3/5/24 at 2:09 PM. When queried regarding the note on Resident #6's facesheet indicating that Witness R should be contacted regardless of Resident #6's wishes, RN Q verified that was inappropriate to have on the Facesheet as the Resident is not deemed incompetent and needs to provide permission to discuss their care. The DON confirmed and RN Q stated they would remove the note from Resident #6's facesheet. When asked if Witness R had been contacted and provided information that the Resident did not want provided, both RN Q and the DON were unable to provide a response.

Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure sanitary storage of respiratory and oxygen equipment, oxygen administration per Health Care Provider (HCP) order, and comprehensive respiratory care planning for two residents (Resident #12 and Resident #16) of two residents reviewed, resulting in the likelihood for unmet respiratory needs, illness, and a decline in overall health status. Findings include: Resident #12: On 3/5/24 at 9:11 AM, Resident #12 was observed sitting in a wheelchair in their room. The Resident was receiving supplemental oxygen via nasal cannula from the portable tank attached to their wheelchair. The oxygen delivery rate was 3 Liters (L) per minute. An oxygen concentrator was present in the room but not in use. An interview was completed at this time. When queried how long they have had supplemental oxygen, Resident #12 replied, Oxygen is new to me. The Resident reviewed they had been sick for a while and just started wearing it (oxygen) here. When queried regarding the plan of care related to the oxygen, Resident #12 revealed they did not want to have to use it long term. Record review revealed Resident #12 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), heart failure, and hemiplegia and hemiparesis (one sided paralysis) following stroke. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required total assistance to perform Activities of Daily Living (ADL) with the exception of setup/supervision for eating and oral hygiene. The MDS further detailed the Resident was not receiving oxygen therapy. Review of Resident #12's Electronic Medical Record (EMR) revealed a care plan entitled, Respiratory . has the potential for compromised respiratory status r/t (related to) COPD . (Started and Edited: 12/12/23). The care plan did not include an intervention related to the Resident receiving oxygen therapy. Review of Resident #12's active HCP orders revealed the order, Oxygen at 2L per nasal cannula for shortness of breath or respiratory distress. Oxygen saturation rate to be done prior to initiation of oxygen therapy. Notify physician if initiated PRN (as needed) (Start Date: 12/12/23). On 3/5/24 at 3:37 PM, an interview was conducted with Registered Nurse (RN) J. RN J was queried regarding Resident #12's oxygen delivery rate and stated, I got in report it is supposed to be at 3L. When queried regarding Resident #12's HCP order for oxygen, RN J reviewed the orders and confirmed Resident #12's HCP order was for oxygen at 2L/minute. RN J indicated the order must not have been changed when the oxygen rate was increased. Resident #16: On 3/4/24 at 11:14 AM, Resident #16 was observed sitting in a wheelchair in their room. The Resident was receiving oxygen via nasal cannula at 3.5 L/minute from the wall unit. On the back of the Resident's wheelchair, uncontained oxygen tubing was observed uncontained and wrapped around the top of the portable oxygen tank. A CPAP machine was present on the Resident's bedside dresser. A nasal cannula style CPAP mask was observed behind the CPAP machine on the top of the dresser. The mask was uncontained. When queried regarding the oxygen, Resident #16 revealed they wear it around the clock. On 3/5/24 at 9:06 AM, Resident #16 was observed in their room. The Resident was sitting in their wheelchair and was receiving supplemental oxygen via nasal cannula at 2L/minute via the portable tank on their wheelchair. Uncontained/uncovered Oxygen tubing was hung over the wall mounted oxygen regulator which was on Resident #16's roommates' side of the room curtain divider. When queried, Resident #16 confirmed that was their tubing hanging on the concentrator and indicated their roommate does not wear oxygen. The CPAP mask was observed uncovered/uncontained on their bedside side dresser. Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included Amyotrophic Lateral Sclerosis (ALS- Lou Gehrigsdisease), heart disease, and sleep apnea. Review of the MDS dated [DATE] revealed the Resident was moderately cognitively intact and required extensive to total assistance to complete ADL's. Review of Resident #16's EMR revealed the Resident did not have a care plan pertaining to CPAP utilization but a HCP order was in place to clean and sanitize the CPAP tubing weekly. An interview was conducted with the Director of Nursing (DON) on 3/5/24 at 3:57 PM. When queried regarding Resident #12's observed oxygen delivery rate and the order, the DON verified oxygen delivery rate and orders should match. When queried regarding facility policy/procedure related to CPAP storage, the DON replied, Should be stored in a bag after cleaned like oxygen tubing. When asked if oxygen tubing should be stored in a bag when not in use, the DON confirmed it should be. The DON was informed of observations of Resident #16's oxygen tubing and CPAP mask and indicated they would address the concerns. Facility policy/procedure related to oxygen and respiratory equipment storage was requested at this time but not received by the conclusion of the survey.

Based on interview and record review, the facility failed to implement and operationalize policies and procedures for psychotropic medication management for two residents (Resident #6 and Resident #16) of five residents reviewed, resulting in a lack of a 14-day evaluation and stop date for as needed (PRN) psychotropic medications, lack of documentation of consent for use, and the potential for unnecessary psychoactive medication utilization and adverse reactions. Findings include: Resident #6: Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included dementia with mood disturbance, dementia, left hemiplegia and hemiparesis (one sided paralysis) following cerebral infarction (stroke), and weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required substantial/maximum assistance for toileting hygiene and transferring. Review of Resident #6's current medication orders revealed the following psychotropic medications: - Valium (psychotropic anti-anxiety medication) tablet 2 mg (milligram) . oral . Once A Day on the 26th of the Month - PRN (as needed) . A consent for Valium was not noted in Resident #6's the Electronic Medical Record (EMR). Review of Resident #6's care plans revealed a care plan entitled, Psychotropic Drug Use .is at risk for adverse consequence from receiving psychotropic medication: Lexapro (medication used to treat anxiety and depression) (Start: 5/24/22; Edited: 12/12/23). Per Resident #6's EMR, Lexapro was discontinued on 1/8/24. The Resident did not have a care plan in place pertaining to use of psychotropic anti-anxiety medications. Resident #16: Record review revealed Resident #16 was admitted to the facility on [DATE] with diagnoses which included Amyotrophic Lateral Sclerosis (ALS- Lou Gehrigsdisease), anxiety, dysphagia (difficulty swallowing), and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired, displayed no behaviors, and required moderate to total assistance to complete all ADL's. Review of Resident #16's EMR revealed the Resident was receiving Hospice services. Further review of Resident #16's EMR revealed the Resident was receiving the following psychotropic medications: - Ativan (antianxiety medication) 0.5 mg tablet Q (every) 4 hours PRN. Note: The PRN medication order did not have a stop date. - Seroquel (antipsychotic medication) 25 mg tablet at Bedtime 25 mg - Sertraline (Zoloft - antidepressant medication) 200 mg daily No consents for psychotropic medications were noted in Resident #16's EMR. Review of Resident #16's care plan revealed a care plan entitled, Category: Psychotropic Drug Use. Resident is at risk for adverse consequence from receiving psychotropic medication: lorazepam (Ativan), sertraline, quetiapine (Seroquel) . (Start Date: 12/14/23) An interview and review of Resident #6's EMR was completed on 3/5/24 at 2:19 PM with the Director of Nursing (DON) and Social Services Registered Nurse (RN) Q. When queried regarding facility policy/procedure related to psychotropic medication use, RN Q specified a signed informed consent is obtained by the Resident and/or representative for each psychoactive medication. When queried regarding consents for Resident #16's psychoactive medications, RN Q reviewed the Resident's EMR and confirmed there were no consents for any of the psychoactive medications. RN Q was then asked if PRN psychoactive medications should have a 14-day stop and confirmed they should. When queried regarding Resident #16's PRN Ativan order not having a stop date, RN Q reviewed the EMR and verified there was no stop date on the order. When queried regarding Resident #6's current psychoactive medications, RN Q reviewed the Resident's EMR and stated, Valium. When asked about the Resident's care plan stating they received Lexapro, RN Q indicated the care plan must not have been discontinued and or updated when the medication had been discontinued. When asked if Resident #6 had a consent for Valium, RN Q reviewed the Resident's medical record and stated, No consent. When asked why Resident #6's PRN Valium did not have a 14-day stop date, RN Q reviewed the Resident's EMR and confirmed the medication did not have a 14-day stop date. The DON revealed the medication was administered monthly when the Resident's suprapubic urinary catheter (surgically created opening from the bladder to the abdomen to allow for the drainage of urine) was changed due to the catheter change being painful and traumatic for the Resident. When queried if the Resident always received the medication prior to the catheter change, the DON replied that they did. When asked why the medication was not scheduled and/or why a one-time order was not obtained rather than a PRN order with no stop date, an explanation was not provided. RN Q indicated they would address the lack of consent and PRN order. Review of facility policy/procedure entitled, Psychotropic Medication Policy and Procedure (Revised 3/16/23) revealed, Policy . Psychotropic medications include anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs . Procedures . 8. Orders for PRN psychotropic medications will be time limited (i.e., times two (2) weeks) and only for specific clearly documented circumstances . Nursing . 5. Will ensure that any PRN psychotropic medications have a time limit such as 14 days and then will have physician evaluate for continued need . Social Services . 4. Will obtain the informed consent for the medications use prior to administering, unless used in an emergency situation .

Based on observation, interview and record review, the facility failed to ensure clinical staff posting of licensed and un-licensed staff was completed daily and posted with accurate and complete data, resulting in the inability for residents and visitors to know what clinical staff were working on those days. Findings include: Record review of the facility 'Skilled Nursing Facility posting of Nurse Staffing Information' policy, dated 12/16/2023, revealed that the purpose was to provide beneficiaries, their families, and the public with access to nurse staffing information on a daily basis. It was the policy of the facility to post nursing staff information in accordance with provisions specified in section 941 of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). Procedure included: staffing form completed for each shift, updated census, and posted daily, printed in a size large enough to be easily read. and will be posted in a uniform manner in a clearly visible place. Observation on 03/04/24 at 10:43 AM of the staff report public posting located in the upper window shelf of the entry to the main dining room was dated 11/29/2023 and revealed a census of 23. The posting was covered by a box of gloves and at a height that most wheelchair-bound residents would not be able to see. The State Surveyor will monitor and re-check the next day for change of staffing posting. Observation and interview on 03/05/24 at 09:46 AM with the Director of Nursing (DON) of the public posting of Nurse Staffing Information revealed the form was still dated 11/29/2023 with a census of 23. The posting was still up in the clear view posting frame covered by a box of gloves. The DON stated that the posting is done by the night shift after the midnight census and at the end of the shift and must be done and posted by end of their shift. Record review on 03/05/24 at 09:55 AM with the Director of nursing (DON) of the posting forms located in a box on the second shelf next to the public posting frame revealed: No postings forms for the dates of 12/18/2023, 12/24/2023, 12/27/2023, 1/3/2024, 1/10/2024, 1/17/2024, 1/24/2024, 2/7/2024, 2/14/2024, 2/21/2024, and 3/3/2024. All were noted to not have public posting sheets or missing postings. The DON went to check with the Nursing Home Administrator for any other public posting pages and none were found.

This Citation pertains to Intake Number MI00140583. Based on observation, interview and record review, the facility failed to ensure necessary supervision for one resident (Resident #101), who was left in the dining room unsupervised with a hot cup of coffee, which did not have a lid on it. The resident spilled the hot coffee on her lower abdomen and upper thigh area, resulting in first and second degree burns, pain, wound care and prolonged healing time. Findings Include: Resident #101: Review of the Face Sheet, Minimum Data Set (resident assessment tool) dated 9/22/23, progress notes dated 10/20/23, physician's orders dated 10/20/23 through 11/16/23 and care plans dated 9/21/23, revealed that Resident #101 was [AGE] years-old, admitted to the facility on [DATE], had decreased cognition, (and thus was not able to be interviewed), dependent on staff for all Activities of Daily Living and required set-up with eating. The resident's diagnoses included, right-sided hemiplegia and weakness, hemorrhagic stroke, decreased expressive communication, Dementia, depression and anxiety. Review of the MDS dated [DATE], revealed a BIMS of 6 (cognitive evaluation with decreased cognition). The resident had a history of stroke with right-sided weakness. Review of the resident's facility restorative, mood, and communication care plans, dated 9/21/23, revealed that the resident had communication difficulties, Dementia and had a right-sided weakness due to a stroke. Review of the Incident Report, Investigation Report and staff statements, dated 10/20/23, revealed on 10/20/23 in the main dining room, Resident #101 was sitting at a table waiting for her breakfast. She was served hot coffee by staff without a lid on it (the lids provided did not fit the cups correctly). The resident started screaming and staff ran into dining room and found the resident had spilled her hot coffee on her lap (lower abdomen and upper thighs). Staff immediately pulled her clothing up off her skin and wheeled her to her room and assessed her. She had first and second degree burns on her thigh and dime size area on her abdomen. The Dietary Department did not temp the coffee on the morning of 10/20/23 (no documentation of temp taken on that date was available), brought it down and staff served it to the resident without a lid. The physician, Administrator and Family were all notified on 10/20/23 per facility policy. Review of the nursing notes, dated 10/20/23 at 11:42 AM, stated At approximately 0700 this writer (Nurse, RN D)heard a resident screaming very loudly. I attended to resident who was in main dining room at table directly in front of south window (by nurses station). I immediately yelled for help, and grabbed at her clothing, holding it away from her skin. We wheeled resident into her room, removed clothing, placed her into bed and I assessed immediate damages. I observed multiple large red raised areas to the skin on her thighs, extending from anterior, inner and posterior thighs. Small dime size red, raised area to right ABD. I applied cool wash clothes delivered by aides and placed ice packs covered in towels to area. This writer left room to notify physician and on-call Administrator. New orders per DR (Physician MD G) to give Ibuprofen 400 mg Q (every) 6 hours PRN (as needed), and apply lidocaine jelly topically for pain. Review of the facility Wound Management Report, dated 10/23/23, revealed length 15, width 13, exudate present= no, wound healing status= stable. Review of physician's orders, dated 10/20/23 through 11/14/23, revealed that the resident was receiving Tylenol 325 mg, Ibuprofen 600 mg and Tramadol (schedule IV pain medication) at the time of the survey (11/16/23). Observation of Resident #101 was done on 11/15/23 at 10:15 AM. The resident was in bed and when showed her burns, the State Surveyor observed that the abdomen was healed and she had approximately 10 cm in length on the right inner thigh and 6 cm in length scabbed burn on the left inner thigh. Both thighs were slight pink colored around the scabbed areas. The resident was not able to be interviewed due to decreased cognition. During an interview done on 11/15/23 at 10:15 AM, Wound Nurse, RN F said both wounds on the resident's thighs have scabbed over and are not infected. The resident's abdominal wound had healed. Wound Nurse F said he gave the pain mediation, Tramadol, prior to all dressing changes and it seemed to be working. They should have temped the coffee and had a lid on it. Review of the hospital progress notes, dated 10/22/23 through 11/6/23, revealed the resident had received second degree burns to bi-lateral thighs from hot coffee. The hospital progress notes stated, Pt (patient) has 1st and 2nd degree burn injuries from an accidental hot coffee spill on 10/20/23 to lower abdomen and to b/l (bi-lateral) anterior and medial thighs. She has less then 5% surface area affected and burns are not circumferential so low risk of compartment syndrome (fluid shift). Blisters are no longer present. Her pain is well controlled with Tylenol/Ibuprofen and topical lidocaine as prescribed. She is denying any pain at this time. During a phone interview done on 11/15/23 at 11:06 AM, Nurse RN G revealed she took the resident to her room, removed her clothing and put cool cloths and ice packs on the resident's burn areas and immediately called the physician for orders. Nurse G stated We should have had lids and temped the coffee and had clothing protectors and supervise. During an interview on 11/15/23 at 8:45 AM, Nurse, RN D stated I was sitting at the nurses' desk; I heard (the resident) screaming and pulling up the right leg. I told (Nurse G) to look at her. She called me and she had already had pants pulled away, we took her to her room, took off pants, put cold cloths and ice to the area. The area was red with no blisters at the time on the thighs and right lower abdominal area. The lids they had did not fit properly, we tried to push them down but they did not go, they did not temp either. The coffee should not have been served until breakfast. During an interview done on 11/15/23 at 8:31 AM, Nursing Assistant/CNA C stated I got to work, we got her up and put her in the dining room at the time, I put her in the dining room, I gave her the coffee (from the coffee pot across from the nursing station) and put it (the hot coffee) within reach on her left side. Lights were going off I answered them. I was in a resident's room and they said she was screaming. They already had her in her room and had taken care of her. We did have enough staff for the day. This could have been prevented if it was tempted (the coffee from the kitchen) correctly and if a lid was on it. There should have been someone in the ding room. During an interview on 11/15/23 at 9:00 AM, Dietary Manager E stated The tops that fit we use to have them, no one told me the tops didn't fit; I did go and get the proper ones. Dietary Manager E said the kitchen did not temp the hot coffee before they delivered it on 10/20/23, and they should have. During an interview on 11/15/23 at 9:13 AM, Physician A stated She has second degree burns, most of the wounds are healed now; there is no signs of infection now. She will make a full recovery; it could have been prevented. During an interview on 11/15/23 at 10:00 AM, Social Worker B stated it could have been prevented if we would have implemented covers. During an interview on 11/15/23 at 11:18 AM, the Director of Nursing/DON stated temping the coffee, lids on and no assessment (hot liquids screening) should have been done prior to the incident. Review of the facility Burns, Nutritional and Infection care plans, dated 11/8/23 (after the burns), revealed due to the residents hot coffee burn she was at risk for infection, required a clothing protector (for foods and liquids), required a plastic mug with a lid for all hot liquids and was to be supervised with hot beverages. Review of the facility Wounds care plan, dated 11/15/23, revealed that Resident #101 received burns and was at risk for infection and required wound care. Review of the facility Hot Beverage Risk Screening tool, dated 10/27/23 (after the residents burn from coffee), revealed that the resident was at risk for hot beverage spills and burns due to cognition, Dementia, stroke, and right-sided weakness. The resident was referred to therapy services for continued screening. Review of the therapy Hot Beverage Screening Form, undated but completed after the resident's burn on 10/20/23, revealed that the resident presented with a posterior lean in wheelchair, poor safety awareness and flaccidity in right dominant side. Recommend to position resident upright in chair, clothing protector with backing and continue with one handle cup with lid. Review of the facility Hot Liquid Consumption policy, dated 4/2009 and up-dated 10/2023, stated Hot liquid temperatures will be taken by the Food and Nutrition Department on the Skilled Nursing Unit when delivered to ensure that hot liquids do not exceeds 150 degree. Temperatures will be recorded on coffee log that is located on the coffee cart in skilled by the Food and Nutrition Department. All residents will be assessed by nursing upon admission and quarterly with referrals to Occupational Therapy as needed based on the assessment. All residents consuming meals in their room must use a lid on when consume hot beverages to ensure safety.

Based on observation, interview and record review, the facility failed to ensure that food preparation and kitchen equipment were maintained in a sanitary manner and in good working condition, resulting in an increased potential for food borne illness with possible hospitalization and with the potential to affect the census of 21 residents who consume nutrition from the facility kitchen. Findings Include: During the initial tour of the facility small serving kitchen done on 2/16/23 starting at 8:40 a.m., accompanied by the facility Food Director C, the following observations were made: -At 8:40 a.m., the following clean and ready for use kitchen equipment were found to be wet inside, the robot coupe (food processor), a silver pan, and four coffee cups. Increased moisture has a potential for bacterial growth. During an interview done on 2/16/23 at 8:43 a.m., Food Director C said these items should have been dried completely prior to being stacked. -At 9:00 a.m., the kitchen freezer was noted to have frost/ice build-up on the right and left bottom of the door, and on the inside of the door. During an interview done on 2/16/23 at 9:00 a.m., Food Director C stated It has been like that for a while, we have been working on it for about 6 months now. During an interview done on 2/16/23 at approximately 2:40 p.m., Maintenance Staff B stated We have been working on it (the kitchen freezer door) for a while now. -At 9:10 a.m., the cooled and ready for use panini maker was found to be heavily coated with grease and small cooked pieces of food on the inside, top and on the sides. During an interview done on 2/16/23 at 9:10 a.m., Food Director C stated It (the panini maker) gets cleaned once a month. Review of the facility Sanitation and Infection Control policy dated 12/17, revealed the kitchen had detailed daily and weekly cleaning procedures which were to be followed. Review of the U.S. Public Health Service 2009 Food Code, as adopted by the Michigan Food Law effective 2012, directs food equipment and environment shall be cleaned on a regular basis as needed (this includes dishes having to be dry prior to stacking for further use).

Based on observation, interview and record review, the facility failed to ensure the dignity of 1 resident (Resident #70) who was in contact and droplet isolation with the room door closed at all times, had access to a call light (call light within reach), of 12 residents reviewed for dignity, resulting in the likelihood for isolation with no way of calling for assistance from staff, decreased self-esteem, and falls with injury. Findings Include: Review of the facility Call Lights policy dated 6/5/22, reported call lights will be placed within the resident's reach at all times when in their rooms. Review of the facility Resident Right policy dated 8/09, reported Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Resident #70: Review of the Face Sheet, physician orders dated 1/31/23 through 2/16/23, and nursing progress notes dated 1/31/23 through 2/16/23, revealed Resident #70 was [AGE] years-old, alert, in contact and droplet isolation due to a communicable illness, required assist with Activities of daily Living and was admitted to the facility on [DATE]. The resident's diagnosis included, COVID +, cystitis, neuromuscular dysfunction of the bladder, chronic pain, chronic kidney disease, essential tremors, depression and with a history of pulmonary embolism. Review of the facility Lab test dated 2/16/23, revealed the resident was positive for COVID and was put in isolation with his room door closed. Review of the resident's Psychosocial Well-Being, Mood and Infection care plans all dated 2/13/23, revealed no documentation of an intervention to ensure the resident's call light being within reach. Review of the resident's facility Nursing Assistant/CNA care guide dated 1/31/23, reported place on contact and droplet precautions, move resident to COVID-19 designated rooms. Review of the care guide revealed no documentation of assuring the resident's call light was within reach. Review of the facility Infection Control Droplet Precautions and COVID policy's dated 4/6/22, revealed a resident in isolation due to droplet/COVID + precautions were to have their door closed. Observation was done on 2/16/23 at 11:29 a.m., of Resident #70 in his room with the door shut. The resident had recently been diagnosed with a communicable illness and put into isolation. The resident was sitting in an oversized chair next to the bed and the call light was observed hanging over the wall oxygen hook-up. The call light was hanging on the wall above the resident's head behind him. When this surveyor asked the resident if he knew where his call light was, he said, no. When the call light was pointed out to the resident, he was unable to reach it and said that made him feel that no one would come if he needed them. During an interview done on 2/16/23 at approximately 12:00 p.m., Infection Control Nurse RN, A stated the call light should not be hanging on the wall, it should be within reach, we will fix it immediately.

This citation pertains to Intake Number MI 616. Based on observation, interview and record review, the facility failed to implement appropriate interventions for one resident (Resident #4) of three residents reviewed for falls, resulting in Resident #4 falling and fracturing their left third finger and bruising their forehead. Findings include: On 9/27/19, at 9:00 AM, The administrator was asked to provide the incident and accident reports for Resident #4 from the months of (MONTH) to present including the Facility Reported Incident file folder. On 9/27/19, at 10:00 AM, Resident #4 was sitting in the dining room at a table alone pulling at their left hand splint. Resident #4's sweatshirt was wet around the neck. Resident #4 was non-verbal. Aide [NAME] walked up and stated, She just got her hair done. I will go change her shirt. On 9/27/19, at 11:10 AM, a record review of Resident #4's electronic medical record revealed an original admission on 12/16/13 with [DIAGNOSES REDACTED]. Resident required extensive assistance with Activities of Daily Living (ADL) and had severely impaired cognition. A review of Resident #4's physician orders [REDACTED]. A review of Resident #4's Fall reports and Fall Care Plan revealed the following: Date of fall: 06/19/19 . Time 11:10 AM . Was this fall observed . No . was check marked . Getting out of bed . Yes . was check marked with . other: self transferring . Resident observed sitting on floor Self transferred and sat down 1 sock on and 1 foot bare . written on the report. There was no new intervention added to the Problem Start Date: 01/25/2016 Category Falls . for this fall. When did the event occur? 07/24/2019 12:52 PM . Was the fall observed . No . Resident observed sitting on floor mat (buttocks) next to bed. Gripper socks in place, bed in lowest position, pull tab alarm and personal alarm in place not sounding . There was no new intervention added to the fall care plan for this fall. Date of fall: 9-2-19 . Time 09:15 AM . Was this fall observed . No . was check marked . Getting out of bed . Yes . Was check marked. CNA (aide) responded to room for sounding alarm observed resident sitting on floor mat leaning against bed. Pull tab alarm sounding resident free of pain. Resident gripper sock in place. Resident unable to verbalize what or why. Staff assisted to restroom no void and dry . There was no new added intervention to the fall care plan for this fall. Date of fall: 9-13-19 . Time 19:45 PM (7:45 PM) . Was this fall observed . No . was check marked . Getting up from a chair . Yes . was check marked. Resident yelling and staff witnessed resident on back supporting self up with arms. Resident stated she was reaching for little boy. Resident had c/o (complaints of) pain in L (left) hip, upon assessment resident did not have c/o pain with ROM (range of motion), palpation, and ambulation. Redness noted on L lower back . This fall occurred in Resident's room. There was no new intervention added to the fall care plan for this fall. Date Recorded: 09/22/2019 22:33 (10:33 PM) . Observation Details: FALL Location of fall Resident Room . was check marked. What was resident doing just prior to fall getting out of bed Was fall witnessed? No . was check marked. Does Resident exhibit or complain of pain related to the fall? L wrist . and . moderate Pain Distressing , Miserable . was check marked. The intervention Approach Date: 09/23/2019 Continue pool noodle to edge of bed frame as before. Resident's left side of bed, to prevent back from hitting or sliding against frame Created: 09/22/2019 . A review of an x-ray collection 09-23-2019 0204 (2:04 AM) XR Hand 2 Views . Findings: Extensive [MEDICAL CONDITION] changes. Cortical thinning and osseous demineralization consistent with osteopenia . Nondisplaced oblique fracture midshaft third metacarpal . Diffuse swelling throughout the fifth digit without underlying fracture . On 9/27/19, at 12:35 PM, the Director of Nursing (DON) was asked if Resident #4 uses their call light to alert staff and the DON stated, she hasn't in a long time. The DON was asked if there was any other alerting system they could use for Resident #4 and the DON stated, I think I can get my hands on the round squeezy one. I think there called the light touch. The DON was asked if there was anything other intervention the facility could put in place for Resident #4's safety and the DON stated, the son stated he wondered if the ombudsman could help figure something out. She sits with the nurses all the time. Other than one on one, I don't think there is anything else we can do. The DON was asked if she felt the light touch call light would work and the DON stated, I am going to try it today. The DON was asked who maintains that the safety alarms are functioning and the DON stated, The CNA's do it at the start of each shift, two times a day. The DON was asked to clarify what intervention was put in place after Resident #4's fall on 9-22-19 that resulted in a fracture to her finger and the DON stated, I don't think we put anything in place. I think she was in her bed and decided to go to the bathroom. Got up to walk and went down and probably went to catch herself. On 9/27/19 at 1:40 PM, Staff C was asked to clarify the documentation for Resident #4's 30 minute safety checks and Staff C stated, we chart every 30 minute just one time on the task list but on the paper copy we write it in every 30 minutes. The paper copy is attached to the wall in Resident #4's room. On 9/27/19, at 2:00 PM, The Administrator was interviewed regarding Resident #4's falls. The administrator was asked if there was any other intervention they could put in place for Resident #4's safety and the Administrator stated, I have my purchasing help me find a motion detector but with alert to caregiver. I ordered new alarms and sensors but I sent them back because they were too loud. Everything I've looked at would be so overwhelming to her. The transferring out of bed is new, it used to be both from the chair and the bed but now it seems to just be her bed. Short of staying in the room with her for 24 hours, everyone is always watching on her. On 9/27/19, at 2:45 PM, Aide D was asked where she charted Resident #4's 30 minute checks and Aide D stated, yes we chart it on the wall. A record review along with Aide D of Resident #4's 30 minute checks located on the wall in her room revealed that Staff D had already signed the document up to 6:00 PM and it was only 2:45 PM. Aide D stated, That's the way I do it but really I'm in here more than that. On 9/27/19, at 3:30 PM, the Administrator offered a printed copy of a motion sensor and stated, I'm still trying to figure out the logistics of it. This will be right by her bed. The Administrator was asked if she felt it would aide in Resident #4's safety and the Administrator stated, I'm thinking this will be the only other thing I can think of . On 9/27/19, at 3:50 PM, a record review of Resident #4's 30 minute documentation revealed numerous days and times that were not charted/left blank and revealed the following: Electronic Medical Record 30 minute checks: For the month of (MONTH) and July, 2019 only 5 days were charted on: (MONTH) 6th, 7th, 8th, 20th and 26th and (MONTH) 5th, 7th 9th, 26th and 30th ; For the month of August, 2019 only 10 days were charted on: (MONTH) 3rd, 4th, 7th, 14th, 15th, 22nd, 23rd, 24th, 28th and 30th ; For the month of September, 2019 only 9 days were charted on: (MONTH) 1st, 3rd, 4th, 10th 11th, 14th, 1th, 25th and 26th. Hand-written 30 minute checks: Only (MONTH) 1st through (MONTH) 19th, (MONTH) 18th through (MONTH) 31st, (MONTH) 1st through (MONTH) 14th and (MONTH) 12th through (MONTH) 27th were offered by the facility and had numerous blanks where staff did not chart that they checked on Resident #4. On 9/27/19, at 4:00 PM, The Administrator was asked why there were so many dates missing on the hand written 30 minute check documentation and the Administrator stated, once they're scanned they get thrown away and I'm not sure why there not there. The Administrator was asked why there were missing documentation in the electronic medical record for Resident #4's 30 minute checks and the Administrator stated, I am getting an upgrade but corporate said there was some sort of switch for that. I'm going to watch it every shift. On 9/27/19, at 4:10 PM, Aide [NAME] was asked if the facility was doing everything they could for Resident #4's safety and Nurse [NAME] stated, I think we do everything we can for her. Yes, she is getting more confused and she doesn't walk like she used to. She has definitely declined. I think her falls are mainly at night. She will sit with us at the desk during the day. Aide [NAME] was asked if Residents were ever checked on every 15 minutes and Aide [NAME] stated, We haven't done them in a couple years. On 9/27/19, at 4:35 PM, the DON was asked what Resident #4's root cause was for the frequent falling and the DON stated, the root cause yes, it is self-transfer. On 9/27,19, at 4:50 PM, a record review of facility policy Falls Management Policy and Procedure Reviewed Date: 9/09/19 revealed .Purpose: the Falls Management Process guides the staff through a structured risk assessment and planning process, is utilized to evaluate appropriate interventions to minimize the risk of falls and fall related injuries . The Skilled Nursing Facility promotes an environment as free from accident hazards as possible and provides residents with supervision and alternatives to minimize the risk of accidents .

THIS CITATION PERTAINS TO MI 702. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO SUPERVISE 1 (RESIDENT #500) OF 5 SAMPLED RESIDENTS, FROM A TOTAL SAMPLE OF 5 RESIDENTS, WHO HAD IMPAIRED BALANCE AND COORDINATION, RECENT BRAIN SURGERY DUE TO BALANCE PROBLEMS AND WAS AT HIGH RISK FOR FALLS, RESULTING IN A FALL WITH MULTIPLE SUBDURAL HEMATOMA'S (BRAIN BLEEDS), hospitalization AND SUBSEQUENT DEATH. FINDINGS INCLUDE: THE RESIDENT WAS NOT AT THE FACILITY AT THE TIME OF THE INVESTIGATION ([DATE] THROUGH [DATE]). REVIEW OF THE FACE SHEET, MINIMUM DATA SET (MDS, RESIDENT ASSESSMENT TOOL) DATED [DATE], PHYSICIAN ORDERS, NURSES NOTES DATED [DATE] THROUGH [DATE] AND HOSPITAL RECORDS DATED [DATE], REVEALED THE RESIDENT OF CONCERN WAS admitted to the facility on [DATE] FOR REHAB AND WAS READY FOR DISCHARGE HOME ON [DATE]. THE RESIDENTS [DIAGNOSES REDACTED]. REVIEW OF THE BOWEL AND BLADDER assessment dated [DATE], REVEALED THE RESIDENT HAD A MEMORY PROBLEM. REVIEW OF THE FACILITY RESIDENT HISTORY DATED [DATE], REVEALED RESIDENT #500 HAD BALANCE AND COORDINATION PROBLEMS WITH INCREASED CONFUSION AND HAD A VENTRICULOPERITONEAL SHUNT (A TUBE PLACED TO DRAIN EXCESS FLUID FROM THE BRAIN) PLACED PRIOR TO ADMISSION TO THE FACILITY FOR REHABILITATION AND PLANNED TO RETURN HOME. REVIEW OF THE HOSPITAL TRANSFER DATED [DATE], REVEALED THE RESIDENT HAD FALL PRECAUTIONS IN PLACE, REQUIRED ASSIST WITH HER ACTIVITIES OF DAILY LIVING AND WAS ALERT TO PERSON AND PLACE. REVIEW OF THE FACILITY FALLS CARE PLAN DATED [DATE], REVEALED THE RESIDENT OF CONCERN WAS AT HIGH RISK FOR FALLS, HAD IMPAIRED BALANCE AND COORDINATION, WORE GLASSES, WAS TO HAVE A NIGHT LIGHT ON, BED IN LOWEST POSITION, CALL LIGHT WITHIN REACH, TOILETED EVERY 2 HOURS AND WAS INDEPENDENT FOR AMBULATION AND TRANSFERS ON THE UNIT USING A ROLLER WALKER. REVIEW OF THE NURSING ASSISTANT FLOW RECORD DATED [DATE] THROUGH [DATE], REVEALED THE RESIDENT WAS A SET-UP FOR EATING, HYGIENE AND DRESSING, WITH LIMITED STAFF ASSISTANCE FOR DRESSING. REVIEW OF THE NURSES NOTES (DATED [DATE]) AND THE INCIDENT REPORT (DATED [DATE]), REVEALED ON [DATE] AT 3:00 A.M., RESIDENT #500 fell IN HER ROOM WHILE PUTTING HER SOCKS AND SHOES ON. THE RESIDENTS BED AND CHAIR ALARMS HAD BEEN DISCONTINUED ON [DATE] BY THERAPY BECAUSE SHE WAS DOING WELL IN THERAPY ON DAYS AND SHE WAS GOING TO BE discharged HOME ON [DATE]. THE NURSES NOTES REVEALED "NURSE HEARD LOUD NOISE, RES (RESIDENT #500) LYING ON FLOOR NEAR BED AND BATHROOM DOOR. STATED SHE HIT BACK OF HEAD, LARGE RAISED AREA MID CROWN NO BLEEDING, SHE WAS GETTING HER SOCKS AND SHE'S ON TO GET UP TO USE THE BATHROOM". REVIEW OF THE emergency room NOTES DATED [DATE] AT 6:24 A.M., STATED "PT (PATIENT) TRANSFER FROM (FACILITY), PT HAD ISSUES WITH BALANCE AND COORDINATION WITH INCREASED CONFUSION. PT WAS admitted [DATE], HAD SUR. (SURGERY) SENT TO REHAB, PT WAS GOING TO BE discharged AND HAD A FALL". REVIEW OF THE HOSPITAL PHYSICIAN CONSULTATION (DATED [DATE]) STATED "DR HAD PLACED A VENTRICULOPERITONEAL SHUNT FOR NORMAL PRESSURE [DIAGNOSES REDACTED] FOR SEVERE BALANCE PROBLEMS, SHE HAD A FALL (ON [DATE], AT THE FACILITY) AND WITH THAT HAD DEVELOPED A SUBDURAL HEMATOMA. THERE WAS NEUROLOGIC PROGRESSION AND WORSENING. SHE HAD A FOLLOW-UP CT SCAN WHICH DEMONSTRATED THE HEMATOMA HAS PROGRESSED TO MASSIVE SIZE". THE RESIDENT WAS admitted TO THE HOSPITAL FOR "COMFORT CARE AND MEASURES". REVIEW OF THE HOSPITAL REPORT OF DEATH DATED [DATE], REVEALED THE RESIDENT OF CONCERN deceased on [DATE] AT 1:20 P.M. REVIEW OF THE HOSPITAL TRANSFER SUMMARY DATED [DATE] REVEALED THE RESIDENT OF CONCERN HAD "FALL PRECAUTIONS" IN PLACE, WAS ALERT TO PERSON AND PLACE AND REQUIRED ASSIST WITH ADL'S. ON [DATE] AT 8:10 A.M., THE SURVEYOR REQUESTED THE RESIDENTS HOSPITAL RECORD DATED [DATE] THROUGH [DATE], AND WAS INFORMED BY MEDICAL RECORDS STAFF THAT IT "WAS LOST". REVIEW OF THE FACILITY FALL RISK ASSESSMENT (DATED [DATE] AND [DATE]-DAY OF FALL), REVEALED THE RESIDENT WAS SCORED AS A "#15", AT HIGH RISK FOR FALLS. REVIEW OF THE GRAB BAR USAGE ASSESSMENT (DATED [DATE]) AND RISK FACTORS FOR PRESSURE ULCERS (DATED [DATE]), REVEALED THE RESIDENT HAD DIFFICULTY WITH BALANCE, TRUNK CONTROL, DECREASED MOBILITY AND FUNCTIONAL ABILITY. REVIEW OF THE OCCUPATIONAL PLAN OF TREATMENT DATED [DATE] THROUGH [DATE], REVEALED THE RESIDENTS RIGHT UPPER EXTREMITY HAD "POOR" COORDINATION AND DECREASED RANGE OF MOTION AND STRENGTH. REVIEW OF THE OCCUPATIONAL THERAPY TREATMENT SUMMARY DATED [DATE] THROUGH [DATE] REVEALED THE RESIDENT REQUIRED A ROLLER WALKER FOR AMBULATION, SUPERVISION WITH LOWER EXTREMITY DRESSING AND TOILETING, REQUIRED MINIMAL ASSIST WITH STANDING AND BALANCE AND HAD A MODERATE PROBLEM WITH ACTIVITY TOLERANCE. REVIEW OF PHYSICAL THERAPY PLAN OF TREATMENT NOTES DATED [DATE], REVEALED THE RESIDENTS STANDING DYNAMIC WAS "POOR", GAIT WAS "UNSTEADY, SLOW" AND SHE HAD "IMPAIRED BALANCE" AND WAS AT "RISK OF FALLS". REVIEW OF THE REHABILITATION PLAN OF TREATMENT DATED [DATE], REVEALED THE RESIDENT COMPLAINED OF WEAKNESS, NEEDED ASSISTANCE FOR MOBILITY SKILLS, HAD EPISODES OF LOSING HER BALANCE, GAIT WAS UNSTEADY AND had a history of [REDACTED]. AN INTERVIEW WAS DONE ON [DATE] AT 11:50 A.M., WITH THE RESIDENTS PRIMARY PHYSICIAN #1. PRIMARY PHYSICIAN #1 SAID THE RESIDENTS SYMPTOMS (REGARDING BALANCE AND COORDINATION) "WILL NOT GO AWAY RIGHT AWAY". REVIEW OF THE PHYSICIAN ORDERS [REDACTED]. REVIEW OF PHYSICIAN ORDER [REDACTED].M.); RECOMMEND THE RESIDENT AMBULATE WITH A ROLLER WALKER IN FACILITY AND OUTSIDE THE FACILITY WITH ASSIST OF 1. REVIEW OF PHYSICIAN ORDER [REDACTED].M.), REVEALED THE BED AND CHAIR ALARMS WERE DISCONNECTED BY THE OT, THE RESIDENT WAS INDEPENDENT FOR AMBULATION AND WAS TO BE TRANSFERRED WITH ROLLER WALKER AND 1 STAND BY ASSIST WHEN OFF THE UNIT. REVIEW OF THE MEDICATION RECORD DATED ,[DATE], REVEALED THE RESIDENT RECEIVED 1 XANAX 0.25 MG (AT 8:00 P.M. FOR ANXIETY), 1 VICODIN ,[DATE] MG (AT 8:00 P.M., A NARCOTIC PAIN MEDICATION) AND 2 RESTORIL 15 MG (AT 8:00 P.M., SLEEPING MEDICATION) TABLETS PRIOR TO HER FALL. THE RESIDENT WAS ALSO ON PLAVIX AND ASPIRIN (BOTH THIN THE BLOOD, INCREASING SEVERITY OF BLEEDING). AN INTERVIEW WAS DONE ON [DATE] AT 1:10 P.M., WITH CNA (NURSING ASSISTANT) #1. CNA #1 STATED "WE WERE TAKING CARE OF A MAN WITH BEHAVIORS AND IT WAS CHAOTIC THAT NIGHT ([DATE]). THEY DC'D (DISCONTINUED) HER ALARMS; THEY DECIDED SHE WAS OK TO GET UP ON HER OWN. THE NURSE SAID SHE HAD GIVEN HER SLEEPING PILLS. SHE NORMALLY WANTED TO GET UP BETWEEN 2:00 A.M. AND 3:00 A.M. AND SHE WANTS TO GET DRESSED THEN. BEFORE THIS HAPPENED (THE FALL), SHE GOT UP AT 12:00 A.M. MIDNIGHT AND SHE WANTED TO GET DRESSED THEN. SHE GOT ANGRY WITH ME; SHE DID NOT WANT TO GET BACK IN BED. SOMETIMES WHEN SHE WALKED (AT NIGHT) SHE SWAYED TO ONE SIDE OR THE OTHER. WE COULDN'T BELIEVE SHE WAS GOING HOME ALONE, SHE NEEDED THE WALKER. SHE WAS UNSTEADY WHEN I TOOK HER TO THE BATHROOM EARLIER; I HAD TO HOLD ONTO HER. IF I WOULD HAVE BEEN ASKED IF HER ALARMS SHOULD HAVE BEEN TAKEN OFF, I WOULD OF SAID NO". REVIEW OF THE FACILITY WRITTEN STATEMENT (UN-DATED) REVEALED "EARLIER THAT NIGHT ([DATE]), (THE RESIDENT) AROUND 12 A.M. RANG TO ASK FOR ASSISTANCE TO THE BATHROOM. I ANSWERED THE LIGHT. AFTER USING THE BATHROOM, SHE WANTED TO GET DRESSED. SHE WAS ACTING VERY CONFUSED. I CONVINCED HER THAT IT WAS WAY TOO EARLY TO GET DRESSED". AN INTERVIEW WAS DONE ON [DATE] AT 11:40 A.M., WITH CNA #2. CNA #2 STATED "SHE (RESIDENT #500) HAD BEEN GETTING UP THROUGH THE NIGHT (ON [DATE], PRIOR TO HER FALL). I KEPT TELLING HER NOT TO GET UP. I SAW HER UP ONE TIME BEFORE (THE FALL) AND SHE WAS NOT USING HER WALKER. THE NURSE TOLD ME SHE WAS ON A LOT OF MEDS AT NIGHT AND TO WATCH HER. SHE WOULD GET UP AT 3:00 A.M. TO 4:00 A.M. EVERY NIGHT, 11:30 P.M. TO 12:00 A.M. MIDNIGHT WAS THE LAST TIME I CHECKED ON HER. MY NEXT BED CHECK WOULD HAVE BEEN AT 1:00 A.M., BUT I WAS WITH ANOTHER RESIDENT. SHE USUALLY USED HER CALL LIGHT AND WALKER BUT THAT NIGHT SHE DIDN'T, IT COULD HAVE BEEN PREVENTED IF ALARMS WOULD NOT OF BEEN TAKEN OFF". REVIEW OF CNA #2'S FACILITY WRITTEN STATEMENT (UN-DATED) REVEALED "(RESIDENT #500) HAD BED (BEEN) UP GOT HER CLOTHES AND WAS GOING TO GET DRESSED AGAIN, I THEN PUT HER CLOTHES UP AND SAID I'LL DO YOU AT 4:00 A.M.". AN INTERVIEW WAS DONE ON [DATE] AT 1:55 P.M., WITH THE MDS COORDINATOR. THE MDS COORDINATOR STATED "IF I WOULD OF KNOWN SHE GOT UP AT NIGHT, I WOULD OF SAID (ON THE FALLS CARE PLAN) TO MONITOR HER BETWEEN 2:00 A.M. AND 3:00 A.M.". AN INTERVIEW WAS DONE ON [DATE] AT 10:30 A.M., WITH THE OCCUPATIONAL THERAPIST (OT) #1 AND THE PHYSICAL THERAPIST (PT) #1. OT #1 AND THE PT #1 REVEALED THEIR ASSESSMENTS OF THE RESIDENT WERE DONE DURING THE DAY AND IN THE THERAPY ROOM. THE THERAPIST'S SAID THEY HAD NOT TALKED TO THE THIRD SHIFT NURSING ASSISTANTS OR NURSE'S REGARDING THE RESIDENTS BALANCE OR COMPLIANCE WITH USING HER CALL LIGHT AND WALKER. OT #1 REVEALED THE NURSES 24 HOUR DAILY SHEETS SHOULD HAVE HAD DOCUMENTATION OF ANY ISSUES REGARDING HER BALANCE OR NIGHT TIME CONFUSION, HISTORY OF GETTING UP AT NIGHT OR COMPLIANCE CONCERNS REGARDING THE USE OF HER WALKER ON THEM BECAUSE THAT WAS THE ONLY INTERDISCIPLINARY COMMUNICATION TOOL. REVIEW OF THE NURSE'S 24 HOUR SHEETS DATED [DATE] THROUGH [DATE], REVEALED NO DOCUMENTATION OF CONCERNS OR COMMENTS REGARDING THE RESIDENTS AMBULATION, BALANCE, COMPLIANCE ISSUES WITH THE USE OF HER CALL LIGHT NIGHT, USING HER WALKER OR HER USUAL ROUTINE OF GETTING UP AT NIGHT AND WANTING TO GET DRESSED BETWEEN 2:00 A.M. AND 3:00 A.M. AN INTERVIEW WAS DONE ON [DATE] AT 1:55 P.M., WITH REHAB CNA #1. THE REHAB CNA STATED "SHE (RESIDENT #500) DIDN'T ALWAYS DO WHAT SHE WAS TOLD, USE HER WALKER". AN INTERVIEW WAS DONE ON [DATE] AT 12:45 P.M., WITH THE RESIDENT OF CONCERNS ROOMMATE (ON [DATE]). THE ROOMMATE STATED "SHE (RESIDENT #500) DIDN'T USE HER WALKER, I TOLD HER TO USE HER WALKER BUT SHE DIDN'T USE IT. THEY (STAFF) TOLD HER TO USE THE CALL LIGHT AT NIGHT BUT SHE NEVER USED THE CALL LIGHT AT NIGHT. SHE WAS PUTTING ON HER SHOES, WHEN SHE fell SHE CUT HER HEAD". REVIEW OF THE ROOMMATES COGNITIVE (DATED [DATE]) AND COMMUNICATION (DATED [DATE]) CARE PLANS REVEALED SHE WAS "COGNITIVELY INTACT". DURING INTERVIEW'S DONE ON [DATE] (AT 2:00 P.M. AND 2:30 P.M.) WITH CHARGE NURSE #1 AND CHARGE NURSE #2. NURSE #1 REVEALED THE RESIDENT WAS UP A COUPLE OF TIMES PRIOR TO HER FALL ON [DATE], CONFUSED AND TRYING TO GET DRESSED TO GO HOME AND STAFF WERE WITH ANOTHER RESIDENT MOST OF THE TIME DURING THE NIGHT (ON [DATE]) DUE TO HIS BEHAVIORS. BOTH CHARGE NURSES FELT THE RESIDENT WAS NOT SAFE AT NIGHT WITHOUT AN ALARM ON BECAUSE OF ALL THE MEDS SHE WAS ON, AND SAID NO ONE ASKED THEM REGARDING HER SAFETY AWARENESS PRIOR TO DISCONTINUING HER ALARMS. REVIEW OF THE NURSES MEDICARE DAILY NOTES DATED [DATE] ON THIRD SHIFT (7:00 P.M. TO 7:00 A.M.), REVEALED THE RESIDENT HAD A BED ALARM AND WAS LIMITED ASSIST OF 1 FOR BED MOBILITY AND TRANSFERS AND ON [DATE] THIRD SHIFT, SHE WAS EXTENSIVE ASSIST FOR TRANSFERS AND TOILETING. A PHONE INTERVIEW WAS DONE ON [DATE] AT 11:33 A.M., WITH PHARMACIST #1 AND SOCIAL WORKER #1. THE SOCIAL WORKER STATED "WE WERE WORRIED ABOUT HER MEDS, THE XANAX, RESTORIL AND VICODIN". THE PHARMACIST STATED "WE ALWAYS TRY TO DECREASE THE HYPNOTICS (SLEEPING MEDICATIONS)". THE PHARMACIST AND SOCIAL WORKER REVEALED THEY HAD A MEETING ON [DATE], AND REVIEWED THE RESIDENTS MEDICATIONS. REVIEW OF THE MANAGEMENT TEAM REVIEW MEETING NOTES DATED [DATE], REVEALED NO DOCUMENTATION OF RECOMMENDATIONS REGARDING THE RESIDENTS MEDICATIONS. ( )