Every finding on record at Oceana County Medical Care Facility

This citation pertains to intake #: 2996367Based on interview and record review, the facility failed to promptly identify a change in condition and act upon those changes for 1 resident (Resident #2) out of 3 residents reviewed for quality of care resulting in a delay in surgical intervention.Findings:Resident #2 (R2)Review of an admission Record revealed R2 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: severe cervical spinal stenosis (spinal canal narrowing in the neck).Review of R2's hospital After Visit Summary dated 3/4/26 revealed, Please contact (name omitted), neurosurgery, to arrange outpatient follow up of the abnormal cervical spine MRI which does show some pressure on the spinal cord. At the 3rd and 4th cervical vertebrae. You are at risk for severe spinal cord injury with continued falls or cervical spine injuries. You should be extremely careful when moving from a lying down to a sitting to a standing position and always use a walker and assistance. Continue your medications as directed. Return with any concerns. Schedule an appointment with (name omitted) MD as soon as possible for a visit Specialty: Neurological Surgery.Get help right away if: You have severe pain. You have numbness in a hand or foot.Review of R2's Incident Report dated 3/25/26 revealed, Daughter reported mother told sister that she fell a few days ago and her butt hurts. Assessed resident for bruises and found bruise to right upper buttock although resident reports pain to left upper buttock. When asked how this happened resident stated she fell. Resident Description: A few days ago, I was transferring from wheelchair to recliner got stuck on arm of recliner and when I went to pull myself over, I slid down to floor on my butt. I then got to my knees and got part way back into recliner when staff member assisted me to sitting in recliner. Resident does not know time of day or what exact day this occurred other than 3-4 days ago. The incident report did not include the identification of the staff member that assisted R2 from the floor or documentation that the fall had been immediately reported to R2's care team.During an interview on 7/15/2026 at 10:32 AM, Family Member (FM) G reported R2 was to have a neurosurgical consult completed as soon as possible once admitted to the facility. FM G reported that she reported it to the case manager (Unit Manager [UM] M) following R2's admission stating, I truly trusted her to follow-up. FM G reported that due to R2's high risk for spinal cord injury, she would have expected additional diagnostic testing to be completed to ensure R2's cervical spine had not been impacted by the unwitnessed fall.FM G reported R2 had a significant decline in her functional ability following her fall. FM G reported R2 had progressed to the point that on 3/16/26 the therapy team had discussed with them a home evaluation in preparation for discharge. By 3/26/26 the therapy team was discussing discharge from therapy services as she was unable to participate in therapy services and was completely dependent on all aspects of care. FM G reported concerns that R2's symptoms were not immediately acted upon with diagnostic testing and/or a hospital transfer despite the therapy team voicing their concerns with her rapid decline. FM G reported that R2 had to undergo immediate surgery to correct the damage and spent 3 weeks in the hospital before being discharged to a different facility.During an interview on 7/15/2026 at 11:47 AM, Occupational Therapist (OT) K reported that following R2's admission she was making really good progress further reporting that she had progressed to the point that a discharge home assessment was discussed. OT K reported that per her physical therapy notes, by 3/10/26 she had improved to only requiring supervision for walking a short distance, transferring, moderate assistance with stairs and minimal assistance and/or supervision for her ADL (Activities of Daily Living) care.OT K reported the neurosurgical consult should have been completed immediately upon admission based on the severity of her cervical spinal stenosis and reported that during the 3/24/26 Medicare meeting (which included the Interdisciplinary Team [IDT]) the therapy department members discussed her need for the consult. OT K stated I don't know why it never happened.OT K reported that R2 described a fall that she had sustained while at the facility which aligned with the deterioration of her functional abilities and her fine motor coordination as well as complaints of numbness in her arms.OT K reported R2's significant shift in her functional abilities began on 3/26/26 and reported R2's progressive decline in her functional abilities was talked about daily in the IDT meetings, but nobody acted upon the observed decline despite R2's therapy team voicing concern and urging for immediate follow-up.OT K reported she received an email from R2's clinical care coordinator (unit manager) on 3/31/26 asking if tense muscles could have been the cause of R2's numbness, tingling, and inability to use her arms with a request for manual therapy (hands on application of pressure, stretching, and joint movements to improve pain, mobility, and restore function). OT K reported she was deeply concerned and frustrated and explained that that manual therapy wouldn't assist at that point with such a significant change in her condition and she couldn't feed herself. She couldn't use her arm when previously she had no difficulty eating or swallowing.OT K stated, When PT (physical therapy) started coding her as dependent (for functional abilities) on the 29th she reiterated that R2 went from walking on the 25th to needing a maxi lift in a week.OT K reported that R2 required surgical intervention on her neck due to her symptoms and the deterioration of the condition of her cervical spine.Review of R2's therapy Summary of Daily Skilled Services revealed:3/22/26-increased imbalance.need for therapist intervention to maintain standing with several incidents with knee buckling and pt (patient) stating she was unsure why she is so weak.3/23/26-PT (physical therapy) and OT (occupational therapy) provided therapy to maximize pt functional tolerance due to increased tremors with functional movements with decreased safety and increased level of assistance required to maintain safety.3/24/26-decreased safety and increased ataxic (poor muscle coordination) gait pattern and knees buckling with increased need for assistance to maintain standing .PT and OT provided therapy to maximize pt functional tolerance due to decreased safety with gait and transfers needing increased level of assistance to maintain safety3/25/26-PT and OT provided therapy to maximize pt functional tolerance due to decreased safety with transfer and functional mobility needing increased cues and assistance for maximal safety.3/26/26-(patient experiencing) posterior lean needing frequent assist to maintain upright posture.with decreased UE (upper extremity) function stating she cant hold anything PT and OT provided therapy to maximize pt functional tolerance with pt presenting with increased ataxic movement and increased tremors with difficulty grabbing and placing hands, with decreased safety with transfers and increased need for assistance to maintain safety.3/27/26-Pt with demonstrating decreased performance with high fearfulness .PT and OT required for safety of pt and staff with pt having decreased control and unsafe impulsive movements.No note on 3/28/263/29/26-.ataxic gait pattern, anterior lean with knees buckling and decreased trunk control with use of UE's.3/30/26-.decreased safety with increased knee buckling and complaints of numbness in hands and unable to support self when knees do buckle.3/31/26-.pt needing increased cueing and encouragement with pt repeatedly stating my hands are numb and her inability to do anything.4/1/26-Pt continues to state, I can't do it! I can't, I can't, I can't!, often before attempt of tasks at hand. She demonstrates impulsive/ataxic motion throughout entirety of session, posing safety risks.Pt throughout session on this date displaying decreased participation stating, my hand is numb I can't do anything and I can't with all instruction and encouragement.Pt instructed on SeraLift and with pt demonstrating decreased safety, no assistance with BLE (bilateral lower extremities) and slumping into lift. PT with discussion with staff and with indicating Maxi Lift to be used due to behaviors and decline in function and safety .pt demonstrating significant decline.Review of a Communication with Physician note dated 3/25/26 revealed, Situation: Review of ED (emergency department) imaging/report for Cervical Spine MRI: per radiology.degenerative changes are apparent w/ (with) severe spinal canal narrowing.Per radiology: r/t (related to) the presence of cord signal changes suggest establish spinal cord injury. Patient likely deserves consult/evaluation by neurosurgery to discuss avoiding progression of disease & possible improvement of neurologic function. Recommendation: (name omitted), neurosurgery, would like for (R2) to be seen in his clinic for follow up, confirming that she is at risk for more significant cord injury with continued falls.Review of R2's Order Summary dated 3/25/26 revealed, okay to see Neurosurgery (name omitted) for a follow up in his clinic, confirming that resident is at risk for more significant cord injury with continued falls. (Confirming the neurosurgical consult had not been completed/ordered upon admission.)Review of R2's Electronic Medical Record revealed no documentation that a neurosurgical consult was initiated upon R2's admission to the facility until 3/25/26 (21 days after admission).Review of R2's Communication with Physician note dated 3/26/26 revealed, Situation: Resident with complaint of left shoulder pain that goes up into her neck. Also reports that both hands feel numb.Review of R2's Skilled Charting note dated 3/27/26 revealed, .Reports no pain at this time. Reports continued bilateral hands numbness.Review of R2's Post Fall Note dated 3/27/26 revealed, .Therapy reported resident to continue 2 assist for transfers.Review of R2's Post Fall Note dated 3/28/26 revealed, .No new injuries observed. Poor strength and balance with 2 assist transfer.Review of R2's Skilled Charting note dated 3/28/26 revealed, .Reports no pain at this time. Reports continued bilateral hands numbness.Review of R2's Skilled Charting note dated 3/29/26 revealed, .Reports no pain at this time. Reports continued bilateral hand numbness.Review of R2's Communication with Physician note dated 3/30/26 revealed, Situation: Resident with increase in tremors last few days to the point that she cannot feed herself breakfast last 3 days (cereal). Indicating a significant change in R2's physical ability x3 days.Review of R2's Skilled Charting note dated 3/30/26 revealed, .Complaint of not being able to feed self this AM. Informed that getting OOB (out of bed) may help. Resident sternly stated that is not the problem .Reports continued bilateral hand numbness.Review of R2's Condition Stability note dated 3/31/26 at 5:11 AM revealed, While toileting around 0430 (4:30 AM) resident said that she could not use her right hand to stand up with staff, staff did observe resident use hand to lift leg and adjust it, staff struggled to lift resident back to w/c (wheelchair). Resident was educated that a maxi lift maybe needed in future if resident is unable to help the 2 CNA's (Certified Nursing Assistants) with transfers.Review of R2's Communication with physician note dated 3/31/26 at 7:51 AM revealed, Would resident benefit from checking lab values.r/t (related to) her experiencing numbness in her arms, weakness, & loss of coordination?Review of R2's Communication with Family note dated 4/1/26 revealed, .Family reports that (R2's) RIGHT HAND is almost dead weight. She has poor appetite.last night, she could not eat it. She said it was too difficult to chew and swallow. This is not typical behavior for (R2). Family is concerned that she may have experienced a stroke or TIA (transient ischemic attack [stroke like symptoms]).Review of R2's Communication with Physician note written by UM M and dated 4/1/26 at 9:19 AM revealed, Situation: Notification to PCP (primary care physician) r/t significant change in condition for (R2) & request for urgent neurology &/or neurosurgery evaluation, advanced imaging (MRI or CT of Cervical Spine as previously recommended), & additional workup for acute neurologic change. (confirming a delay in diagnostic studies/treatment)REVIEW/HISTORY/BACKGROUND: (R2) was evaluated in the ER on [DATE], where a cervical spine MRI revealed no acute fracture; however, notable findings included severe spinal canal narrowing at C3-4 with associated cord signal changes consistent with compressive myelopathy, as well as multilevel foraminal narrowing. Neurosurgical consultation was recommended at that time to address risk of progression & potential improvement in neurologic function. A neurology consult remains pending.On 3/25/26, (R2) reported a fall (exact date/time unknown, estimated 3-4 days prior), with subsequent bruising to the right upper buttock & new pain to the left upper buttock.She was seen by FNP (nurse practitioner) on 3/26/26 & diagnosed with cervicalgia (neck pain), with orders for topical Biofreeze. Follow-up evaluation on 3/30/26 for cervicalgia with hand numbness prompted cervical spine X-ray on 3/31/26. Results were limited, with mild degenerative disc disease noted to C5-C6 & recommendation for further imaging (CT or MRI).Current Concerns(New/Progressive):* New onset weakness with marked functional decline* Increased tremors* Right hand described as dead weight with minimal to no functional use* Very limited use of left hand* Regression in therapy; no longer progressing toward goals* Decreased appetite with 3lb weight loss since admission* Elevated blood pressures, including 176/96 & 157/108 on 3/28/26.Recommendation: Given her known cervical spine pathology with cord signal changes, combined with this acute neurologic decline & loss of upper extremity function, there is concern for progression of cervical myelopathy &/or possible new neurologic event.Please advise on next steps. Considerations may include: Urgent neurology &/or neurosurgery evaluation, advanced imaging (MRI or CT of cervical spine as previously recommended), or additional workup of acute neurologic change.Please let us know how you would like to proceed or if new orders are indicated.Review of R2's Communication with Physician note dated 4/1/26 revealed the provider response, 1. Order MRI C-Spine (without contrast) Dx (diagnosis): C-Spine stenosis with worsening pain. 2. Refer to Spine surgeon (time for after MRI results are available).R2 was sent to the hospital on 4/1/26 at approximately 12:30 PM.Review of R2's Wellness Committee Meeting regarding R2's MRI results, diagnosis, and hospital stay revealed, (R2) has been admitted to (hospital name omitted); MRI cervical spine showed multilevel degenerative changes with severe spinal canal stenosis at C3-4, large central disc herniation, facet arthropathy (arthritis), ligamentum flavum thickening (enlargement of spinal ligaments that can narrow the spinal canal and compress nerves), and subtle spinal cord signal abnormality suspicious for myelopathy (collection of symptoms caused by spinal cord compression).Orthopedic spine surgery note: severe central stenosis and apparent spondylolisthesis (slipping of the vertebrae-early intervention can prevent severe long-term complication) at the C3-4 level. Recommending ACDF C3-4 (Anterior cervical discectomy and fusion [remove a damaged disc and stabilize the cervical spine to relieve nerve and/or spinal cord compression]).During an interview on 7/15/2026 at 4:57 PM, The Director of Nursing (DON) reported her first day as the DON at the facility was 3/16/26 so she was not aware of the order for R2's consult upon admission. The DON reported that she was new to the job as the DON but upon her hiring she noted R2 was discussed daily in the IDT meetings which included R2's therapy team and her unit manager (UM M). The DON reported that R2's referral should have been immediately forwarded to Office Staff (OS) N who scheduled all resident appointments upon admission by the admitting nurse or by UM M following her review of R2's admission documentation. The DON confirmed that there was no documentation that R2's neurosurgical consult had been scheduled until the note written by UM M on 3/25/26 following R2's new onset of numbness and decline in functional abilities. The DON reported she had substantial concerns with R2's precarious and fast significant symptoms.Documentation that R2's neurosurgical consult was scheduled at the time of her admission was not received prior to survey exit on 7/15/26 at 5:35 PM. The DON confirmed she was unable to locate documentation that it had been ordered/scheduled.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, (Nurses) are accountable to report any significant changes in your patient's condition in a timely manner to the health care provider and to document these changes in the patient's electronic health record (EHR). Timely and truthful documentation is important to provide communication necessary among health care team members. Documentation must be accurate. In the EHR, ensure that assessments are complete and consistent with those completed previously. Ensure that you conduct your own assessment rather than copying the previous assessment in the patient's medical record to ensure accuracy of information.Notify other team members in a timely manner when changes in condition are triggered within the record. [NAME] RN, MSN, PhD, FAAN, [NAME] A.; [NAME] RN, MSN, EdD, FAAN, [NAME] G.; Stockert RN, BSN, MS, PhD, [NAME] A.; Hall RN, BSN, MS, PhD, CNE, [NAME]. Fundamentals of Nursing - E-Book . Elsevier. Kindle Edition.

This citation pertains to intake #: 3046473Based on interview and record review, the facility failed to ensure facility staff immediately reported an allegation of verbal abuse to the abuse coordinator for 1 resident (Resident #1) reviewed for neglect.Findings:Resident #1 (R1)Review of an admission Record revealed R1 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: multiple sclerosis.Review of the Facility Reported Incident (FRI) revealed an incident which occurred on 5/30/26. On June 2, 2026 the facility received an allegation that a Certified Nursing Assistant (CNA) used inappropriate language toward a resident. Another CNA reported that the accused CNA directed profanity toward a resident during care. Based on the findings of the investigation, it was substantiated that the CNA used inappropriate and disrespectful language toward the resident.Review of Certified Nursing Assistant (CNA) D's Witness Statement dated 6/2/26 revealed, On Saturday May 30th around 8PM.(CNA C) was holding (R1) up, not forcefully, but she stated, 'you need to stay on your f***ing side (R1). We go through this every f***ing night'.There have been other circumstances and situations similar to this from every hall on station 1.Review of CNA H's Witness Statement dated 6/3/26 revealed, Q (question): Can you tell me a little about how the weekend went most specifically any time you worked with (CNA C)? Per (CNA H) 'I can tell you she's not very nice to the residents' .this has been reported in the past.During an interview on 7/14/2026 at 3:35 PM, the Director of Nursing (DON) confirmed that CNA D had waited for 3 days to report the witnessed verbal abuse of R1. The DON reported that the staff did not implement the facility's policy and procedure following the identification of the verbal abuse observed between CNA C and R1. The DON reported that not only had the facility staff not immediately reported the abuse observed on 5/30/26, but they knew that CNA C had been abusive to other residents previously and failed to report those incidents to the Abuse Prevention Coordinator.The DON reported that upon further investigation and interviews the facility staff reported that she was told that the facility staff quit reporting CNA C's inappropriate behaviors resident abuse to the Abuse Prevention Coordinator and/or management because they (management) never did anything (disciplinary action, termination, etc) following the submission of allegations. The DON stated CNA C's coworkers quit reporting incidents and it escalated to this (the verbal abuse of R1).During an interview on 7/15/2026 at 7:44 AM, the DON reported that the expectation of facility staff was to ensure that any observation, notification, or inclination of abuse was to be immediately reported to her (the Abuse Prevention Coordinator) or to the Nursing Home Administrator.Review of the State Operations Manual revealed, It is the responsibility of the facility to ensure that all staff are aware of reporting requirements and to support an environment in which covered individuals report a reasonable suspicion of a crime, and staff and others report all alleged violations of mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Protection of residents can be compromised or impeded if individuals are fearful of reporting, especially if the alleged abuse has been carried out by a staff member [See S483.12(b)(5)(i)]. During investigations, some staff have stated that he/she was aware, or had knowledge, that the incident had occurred, but did not report because he/she did not think it met the definition of abuse, neglect, mistreatment, exploitation, or misappropriation of resident property or a reasonable suspicion of a crime. Another example is when a nurse aide witnesses an act of abuse but fails to report the alleged violation; the failure to report does not support a conclusion that the abuse did not occur and the facility would not meet the reporting requirements.Review of the facility policy, Abuse, Neglect and Exploitation last reviewed/revised 6/16/26 revealed, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included the following:On 6/2/26 CNA C was immediately suspended pending an investigation. Her license was reported to the Michigan Nurse Aide Registry. CNA C was subsequently terminated on 6/4/26.On 6/2/26 R1 was assessed and found to have no negative outcomes or long-lasting effects from verbal abuse. R1 had scheduled follow-up meetings/assessments with the facility social worker to ensure she felt safe with no new negative outcomes identified.Beginning on 6/2/26 interviewable residents on the unit CNA C worked were assessed and interviewed related to abuse. No other residents were found to be affected by CNA C.Beginning on 6/2/26 all employees were required to complete education on abuse, neglect, exploitation and misappropriation of resident property. All new hires and Agency staff must demonstrate knowledge of all areas of the abuse policy and the prevention and reporting of abuse prior to working with residents. Existing staff will receive annual education through planned in-services as required and as needed. A modified education was implemented following the QAPI meeting to include dementia care, behavior management/deescalation, and caring for residents with cognitive declines.Beginning 6/2/26 the DON and ADON implemented increased rounding on the units to ensure all staff display professional behavior. Review of camera footage for 3rd shift resulted in areas for improvement on time management and prioritization.Between 6/3/26-6/5/26 the DON initiated a new program called the Best Friends Approach (a type of buddy system where staff members are paired with residents and round with them on the agreed upon date and time.) This was implemented to ensure that all residents residing in the facility were interviewed/and assessed regarding abuse that went unreported and/or uninvestigated as a result of the facility staff's failure to follow the abuse policy and procedure.The Best Friend Approach was implemented to be a permanent audit system to ensure prompt identification and reporting of any allegations of abuse, neglect, or violations of their rights. Unit Manager (UM) M's role was modified to a supervisory status to oversee and manage the Best Friend Approach program. UM M ensures the Best Friend Approach rounds are completed, grievances forms are completed following the identification of a concern, prompt resolution of the grievance, as well as tracking and trending the program outcomes. UM M supervisory status also includes the oversight and supervision of staff in order to assure that the facility policies are implemented and staff provide residents with professional, competent, and dignified care.On 6/8/26, the IDT morning meeting agenda was modified to include a review of any grievances and/or negative outcomes identified from the Best Friends Approach rounds.On 6/17/26 a QAPI meeting was held which included the topics of abuse, abuse reporting, resident rights, and resident safety. The outcome of the Best Friend Approach audits were included in the June QAPI meeting and will continue to be reviewed in future QAPI meetings to track and trend compliance with the Abuse Prevention Program.As of 6/22/26 all staff completed the required abuse prevention and reporting education both in person and with a post-test.The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake #s: 2996367, 3090866, 3090922, and 3093262Based on interview and record review, the facility failed to 1.) provide adequate supervision and ensure systems were in place to prevent the elopement of 2 residents (Resident #3 and #6) and 2.) operationalize the facility's fall policy for 1 resident (R2), out of 3 residents reviewed for accidents, safety, and supervision.Findings:Resident #3 (R3)Review of an admission Record revealed R3 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: major depressive disorder and anxiety.Review of a Complaint Investigation Report submitted to the State Agency and dated 7/9/26 revealed, Complainant states that on 7/7/26, (R3) exited from the main entrance without staff. Complainant states that the staff ran after (R3) once she started to go to the parking lot. Complainant states that the activities department was taking some residents on a bus ride and (R3) said that she was going to wait to get on the bus, but she should not have been outside unsupervised.Review of R3's Care Plan revealed a new intervention was initiated on 7/7/26 for ROAM ALERT: Right Ankle Exp: 12/2026. (ankle monitor that alarms near an exit).Review of R3's Wandering Risk Scale (elopement risk) dated 7/7/26 revealed that R3 was determined to be a high risk to wander. (R3 was previously assessed on 4/21/26 and deemed a low risk to wander.)Review of R3's Electronic Medical Record revealed no documentation related to R3 exiting the facility unsupervised or documentation related to a rationale for the initiation of a roam alert ankle monitor or a rationale for assessing R3's wandering risk or the significant change in her wandering risk.During an interview on 7/14/2026 at 11:29 AM, Licensed Practical Nurse (LPN) E confirmed there was no documentation related to R3's unsupervised exit from the facility. LPN E reported R3 was able to exit the facility through the front doors during shift change when a vendor entered the facility causing the doors to open (were locked from the inside but not from the outside). R3 made it past the sidewalk to the driveway (less than 25 feet from the entrance). LPN E reported that she did not believe facility staff ever lost sight of her, and she observed the incident at the time R3 had exited the second set of doors and quickly assisted R3 back into the facility. LPN E reported the parking lot where she exited was busy with many visitors driving fast. Additionally, the facility was next to a high traffic roadway which placed the resident at risk as staff were not immediately available to assist her. LPN E reported that staff questioned R3's ankle monitor after the incident as there were no corroborating progress notes to explain the new intervention. LPN E reported the incident was immediately reported to management.During an interview on 7/14/2026 at 3:35 PM, the DON confirmed that R3 had left the facility through the front door without staff assistance/presence reporting that the root cause was due to a vendor that didn't follow facility policy. The DON reported that the vendors were to use the back doors to prevent the locked front doors from opening, allowing residents to exit the facility without supervision from staff. The DON reported they did implement a roam alert monitor due to her being independent with mobility, extremely hard of hearing, visitors and vendors using the front entrance, along with a slow decline in her cognitive ability reporting it was just precautionary.A copy of R3's Incident Report, root cause analysis, or investigation/witness statements related to R3's unsupervised exit from the facility was requested on 7/15/2026 at 1:24 PM via email to the Director of Nursing (DON).During an interview on 7/15/2026 at 4:00 PM, the DON confirmed there was no incident report or progress note completed related to R3 exiting the facility on 7/7/26.Resident #6 (R6)Review of an admission Record revealed R6 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's Disease and dementia with mood disturbances.Review of R6's Care Plan initiated on 10/28/25 revealed, WANDERING/At Risk for ELOPEMENT r/t: Alzheimer's dementia, impaired cognition.Review of R6's Wandering Risk Scales revealed that beginning on 11/21/25 R6 was high risk to wander.Review of R6's Electronic Medical Record revealed the following:4/22/2026 Behavior Note-Resident had to be redirected more than 2x this shift for advancing to main exit door of facility and setting off alarm. Staff stated she was at threshold of door while lab techs were leaving building.6/8/2026 Behavior Note-noted wandering halls, attempting to go through doors at the end of the garden to the memory care unit.6/8/2026 Behavior Note-.Increased confusion.Review of the Facility Reported Incident dated 6/25/26 revealed, .the resident exited the facility unsupervised through a fire exit door. Another resident reported observing the exit to staff, and staff responded immediately upon notification. The resident was promptly located outdoors in the facility's enclosed courtyard, which is secured by a chain-link fence.Review of Registered Nurse (RN) O's Witness Statement dated 6/25/26 revealed, Was in (a different) residents room assisting (with) a self-transfer. Heard alarm going off to panel noted 7 end of Garden hallway. Found nurse to obtain keys to turn alarm off. Down to door-no residents in site. (Resident #7) came to doorway to let (nurse know) there's a lady out there in a w/c (wheelchair). (RN O) noted door not latched, shut off alarm, no resident in area, (RN O) exited south doors to exit bldg (building). Note resident in w/c slowly strolling along side walk.During an observation and interview on 7/15/2026 at 2:02 PM, the DON and Maintenance Director (MD) B it was observed that the enclosed courtyard had to gates there were latched but were not locked. MD B reported that the fire doors and the door that R3 exited did not have the roam alert alarms, however, the fire door did have a functioning alarm that sounded once opened. The DON reported that at the time of the incident, the fire door was alarming which required a key to disarm. The DON reported that RN O should not have just shut the alarm off when she noticed the fire door was unlatched and alarming and should have ensured that no resident had exited the building prior to just shutting the alarm off per facility policy.Review of the facility policy, Elopements and Wandering Residents/Code Yellow last reviewed/revised 5/30/25 revealed, Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary.h. Adequate supervision will be provided to help prevent accidents or elopements.8. Procedure Post-Elopement-A nurse will perform a physical assessment, document, and report findings to physician.g. Documentation in the medical record will include: findings from nursing and social service assessments, physician/family notification, care plan discussions, and consultant notes as applicable.Resident #2 (R2)Review of an admission Record revealed R2 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: severe cervical spinal stenosis (spinal canal narrowing in the neck).Review of R2's hospital After Visit Summary dated 3/4/26 revealed, Please contact (name omitted), neurosurgery, to arrange outpatient follow up of the abnormal cervical spine MRI which does show some pressure on the spinal cord. At the 3rd and 4th cervical vertebrae. You are at risk for severe spinal cord injury with continued falls or cervical spine injuries.Review of R2's Communication with Physician dated 03/25/26 at 07:21 AM revealed, .(neurosurgical practitioner name omitted) neurosurgery, would like for *R2) to be seen in his clinic for follow up, confirming that she is at risk for more significant cord injury with continued falls.Review of R2's Incident Report dated 3/25/26 at 1:50 PM revealed, Daughter reported mother told sister that she fell a few days ago and her butt hurts. Assessed resident for bruises and found bruise to right upper buttock although resident reports pain to left upper buttock. When asked how this happened resident stated she fell. Resident Description: A few days ago, I was transferring from wheelchair to recliner got stuck on arm of recliner and when I went to pull myself over,I slid down to floor on my butt. I then got to my knees and got part way back into recliner when staff member assisted me to sitting in recliner. Resident does not know time of day or what exact day this occurred other than 3-4 days ago. The incident report did not reflect a witness statement from the staff member that assisted R2 back to her recliner or notification to the management team or R2's emergency contact #1, #2, or #3.During an interview on 7/15/2026 at 10:32 AM, Family Member (FM) G reported that she was R2's Emergency Contact #1/Substitute Decision Maker. FM G reported that due to R2's high risk for spinal cord injury, she would have expected additional diagnostic testing to be completed to ensure R2's cervical spine had not been impacted by the fall. FM G reported that she was never notified of R2's fall and therefore was unable to be involved in and/or request any additional testing to ensure R2 did not suffer any further damage to her cervical spinal cord.Review of R2's Safety Note dated 3/26/26 revealed, Fall Committee reviewed fall dated 3/25/26 Recommendations- Resident reported she slipped down from recliner chair onto floorfew days ago. Non slip strips were placed on floor in front of recliner to enhance traction. Non slip grip was placed on recliner seat to reduce fall risk. Additional call light was attached to recliner for ease of use.Review of R2's Electronic Health Record revealed no documentation that a witness statement had been obtained or that a root cause analysis was completed.During an interview on 7/15/2026 at 1:57 PM, the Director of Nursing (DON) reported that the facility had a fall committee as well as a specific staff member that investigated all falls and determined the root cause analysis. The DON reported that Restorative Registered Nurse (RRN) L was the designated staff member and would have expected her to find out who may have assisted R2 off of the floor in order to identify the date the fall occurred and complete a comprehensive root cause analysis.Review of the facility policy, Fall Assessment and Prevention last reviewed/revised 7/11/25 revealed, .10. When any resident experiences a fall, the facility will:Assess the resident for injury.Implement Neurological assessment for unwitnessed falls or witnessed falls when resident has hit their headComplete a post-fall assessment.Complete an incident report.Notify physician and family.Review the resident's care plan and update as indicated.Complete a Post Fall huddle with staff working on the unit for additional information prior to the resident's fall to determine interventions that may be effective decrease resident's risk for future falls.Document all assessments and actions.Obtain witness statements.Place resident on q (every) shift charting for at least 6 shifts post fall.

This citation pertains to intake #: 3046473Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for one (R1) of four reviewed for abuse.Findings:Resident #1 (R1)Review of an admission Record revealed R1 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: multiple sclerosis.Review of the Facility Reported Incident (FRI) revealed an incident which occurred on 5/30/26. On June 2, 2026 the facility received an allegation that a Certified Nursing Assistant (CNA) used inappropriate language toward a resident. Another CNA reported that the accused CNA directed profanity toward a resident during care. Based on the findings of the investigation, it was substantiated that the CNA used inappropriate and disrespectful language toward the resident. This conduct is considered verbal abuse, as it was willful and had the potential to cause emotional distress to the resident. This conduct violates the residents right to be free from abuse and the right to be treated with dignity and respect, in accordance with facility policy and applicable federal regulations.Review of Certified Nursing Assistant (CNA) D's Witness Statement dated 6/2/26 revealed, On Saturday May 30th around 8PM, I asked (CNA C) if she would help me roll her (R1) for HS (evening cares). We went in, got all of the HS stuff out and lifted the bed. (R1) does have a difficult time with staying still/rolling due to medical related. I had (CNA C) go between the bed and the wall. I had (CNA C) roll (R1) towards her so her bottom half was facing me so I could wash her up. (R1) tried to roll on her back before I was ready for her so I told her to roll back on her side. (CNA C) was holding (R1) up, not forcefully, but she stated, 'you need to stay on your f***ing side (R1). We go through this every f***ing night.' I didn't know what to say so I just reassured (R1) that I was almost done and she could roll back shortly. There have been other circumstances and situations similar to this from every hall on station 1.Review of CNA H's Witness Statement dated 6/3/26 revealed: Q (question): Can you tell me a little about how the weekend went most specifically any time you worked with (CNA C)? Per (CNA H)- 'I can tell you she's not very nice to the residents' .When I delivered (resident name omitted) her dinner she seems upset. When I asked her what was going on she stated that (CNA C) was working and she didn't even want to look at her. I asked her why but she didn't say, I checked to see if she needed anything else and left her to her dinner. This was (CNA C's) section but I just took care of (resident) so she wouldn't have to be upset about (CNA C).Q: Have you heard or seen anything else regarding (CNA C) and her interactions with residents? Per (CNA H) 'Well there was one night when [NAME] as very frustrated in general she came into a room I was working, when we were outside the resident room she was giving report about the resident and put her fists up when talking about that resident. There was another time she yelled at (R1) to stop when (R1) was moving around, (R1) can't control her movements. She told (R1) if you don't stop, I'm going to call (R1's daughter)! You need to stop!'Q: Did you report this? Per (CNA H) 'Yes, this has been reported in the past.Review of CNA C's Employee File revealed she was hired in January of 2025. Disciplinary Action dated 9/25/25 revealed 2 written warnings. 1.) Unprofessional conduct towards another employee, supervisor ot the public i.e. using obscene or improper language or gestures, immoral conduct or indecency and 2.) Disorderly conduct, horseplay, threatening or interfering with another employee or supervisor.(CNA C) is using unprofessional conduct on the unit. She is impacting her coworkers performance. (CNA C) is using foul language in hallways and nurses stations. It is difficult for staff to locate her. (CNA C) walks past call lights without answering them.(CNA C) will remain professional at all times. She will not use foul language.She will complete her assigned assignments. Disciplinary Action dated 10/10/25 revealed a final written warning. Unprofessional conduct towards another employee, supervisor ot the public i.e. using obscene or improper language or gestures, immoral conduct or indecency(CNA C) is using unprofessional conduct on the unit. She is impacting her coworker's performance and resident care. Her conduct is causing problems on the unit with other CNAs and nurses. (CNA C) has a negative attitude and is engaging in negative conversations with coworkers regarding other coworkers. Termination of Employment dated 6/4/26 revealed, On 6/2/2026 it was reported to Nursing supervisors that (CNA C) was cursing at a resident during while performing care on 5/30/2026. This is a group 1:2 violation-Verbal Abuse-includes use of verbal or other communication to curse at, insult or degrade a resident; and Group 1:11-Violation of Resident Rights policy by employee. (CNA C's) actions violated the resident's right to be free from abuse.During an interview on 7/14/2026 at 3:35 PM, the Director of Nursing (DON) confirmed that CNA D had waited for 3 days to report the witnessed verbal abuse of R1. Reported that not only had the facility staff not immediately reported the abuse observed on 5/30/26, but they knew that CNA C had been abusive to other residents previously and failed to report those incidents to the Abuse Prevention Coordinator. The DON reported that upon further investigation and interviews the facility staff reported that she was told that the facility staff quit reporting CNA C's inappropriate behaviors resident abuse to the Abuse Prevention Coordinator and/or management because they (management) never did anything (disciplinary action, termination, etc) following the submission of allegations. The DON stated CNA C's coworkers quit reporting incidents and it escalated to this (the verbal abuse of R1). The DON reported that she reviewed CNA C's employee file following the substantiated verbal abuse of R1 and reported that CNA C should have been terminated following the Disciplinary Action dated 9/25/25, but unfortunately, she did not assume the role of DON until 3/16/26.During an interview on 7/15/2026 at 7:44 AM, The DON reported that following the identification of the abuse she immediately suspended CNA C pending an investigation and subsequently terminated her on 6/4/26. Additionally, the DON reported CNA C to the Michigan nurse aide registry to ensure appropriate follow up was completed.Review of the facility policy, Abuse, Neglect and Exploitation last reviewed/revised 6/16/26 revealed, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.III. Prevention of Abuse, Neglect and Exploitation-The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves.B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms.G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; and H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included the following:On 6/2/26 CNA C was immediately suspended pending an investigation. Her license was reported to the Michigan Nurse Aide Registry. CNA C was subsequently terminated on 6/4/26.On 6/2/26 R1 was assessed and found to have no negative outcomes or long-lasting effects from verbal abuse. R1 had scheduled follow-up meetings/assessments with the facility social worker to ensure she felt safe with no new negative outcomes identified.Beginning on 6/2/26 interviewable residents on the unit CNA C worked were assessed and interviewed related to abuse. No other residents were found to be affected by CNA C.Beginning on 6/2/26 all employees were required to complete education on abuse, neglect, exploitation and misappropriation of resident property. All new hires and Agency staff must demonstrate knowledge of all areas of the abuse policy and the prevention and reporting of abuse prior to working with residents. Existing staff will receive annual education through planned in-services as required and as needed. A modified education was implemented following the QAPI meeting to include dementia care, behavior management/deescalation, and caring for residents with cognitive declines.Beginning 6/2/26 the DON and ADON implemented increased rounding on the units to ensure all staff display professional behavior. Review of camera footage for 3rd shift resulted in areas for improvement on time management and prioritization.Between 6/3/26-6/5/26 the DON initiated a new program called the Best Friends Approach (a type of buddy system where staff members are paired with residents and round with them on the agreed upon date and time.) This was implemented to ensure that all residents residing in the facility were interviewed/and assessed regarding abuse that went unreported and/or uninvestigated as a result of the facility staff's failure to follow the abuse policy and procedure.The Best Friend Approach was implemented to be a permanent audit system to ensure prompt identification and reporting of any allegations of abuse, neglect, or violations of their rights. Unit Manager (UM) M's role was modified to a supervisory status to oversee and manage the Best Friend Approach program. UM M ensures the Best Friend Approach rounds are completed, grievances forms are completed following the identification of a concern, prompt resolution of the grievance, as well as tracking and trending the program outcomes. UM M supervisory status also includes the oversight and supervision of staff in order to assure that the facility policies are implemented and staff provide residents with professional, competent, and dignified care.On 6/8/26, the IDT morning meeting agenda was modified to include a review of any grievances and/or negative outcomes identified from the Best Friends Approach rounds.On 6/17/26 a QAPI meeting was held which included the topics of abuse, abuse reporting, resident rights, and resident safety. The outcome of the Best Friend Approach audits were included in the June QAPI meeting and will continue to be reviewed in future QAPI meetings to track and trend compliance with the Abuse Prevention Program.As of 6/22/26 all staff completed the required abuse prevention and reporting education both in person and with a post-test.The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake # 2685659Based on interview and record review, the facility failed to 1.) ensure medications were administered in accordance with physician orders and 2.) accurately document the administration of medications for 6 out of 7 residents (Resident #1, #3, #4, #5, #7, and #8), reviewed for the provision of nursing services during medication administration.Findings:Resident #1 (R1)Review of an admission Record revealed R1 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: history of kidney transplant.Review of R1's Order Summary revealed:11/6/25-11/26-25 Tacrolimus ER Oral Tablet Extended Release 24 Hour Give 2 mg by mouth one time a day (anti-rejection medication).11/27/25-discharge Tacrolimus ER Oral Tablet Extended Release 24 Hour Give 3 mg by mouth one time a day.Review of R1's Medication Error Incident Report dated 11/24/25 revealed, Residents, Tacrolimus ER Oral Tablet Extended Release 24 hour 1 MG, was not given as the nurse did not see the medication in the pill packet nor saw the name on the MAR (Medication Administration Record) on any of the medication bottle(s) within the medication cart. There were three open medications of the same medication in three different spots in the medication cart drawer. Nurse did not feel confident that the medications were the same and held the medication, due to all bottles being opened, and names of meds not matching on the MAR .Review of Licensed Practical Nurse (LPN) D's Disciplinary Action form dated 12/1/25 revealed, (LPN D) did not give a resident their Tacrolimus medication on four separate occasions. This resulted in the resident's Tacrolimus trough levels being below the normal range which could result in increased risk of transplant rejection .Review of the Facility Reported Incident (FRI) dated 11/25/25 revealed, .(LPN D) signed on the MAR that he administered the medication 11/19/25 & 11/20/25 however with him holding the medication on 11/24/25 (due to not finding the tablet in the med packs) he was questioned about the accuracy of the documented administration of the Tacrolimus (since he did not know that the Tacrolimus was dispensed in bottles when he couldn't find the medication on 11/24/25). The Tacrolimus level of [1.0] on 11/20/25 would directly correlate that he missed the dose on 11/19/25.The Facility substantiated that the Tacrolimus was not being given consistently with missed doses as described above impacting the Tacrolimus Levels.During an interview on 12/17/25 at 1:50 PM, the Director of Nursing (DON) reported that following the identification of the medication error for R1 a facility wide PIP (Performance Improvement Plan) was implemented to identify areas of weakness for licensed nurses and/or a system breakdown. The DON reported that med pass observations were ongoing and 1:1 education was completed when knowledge deficits or medication errors were identified. Additionally, education through the online education program was ongoing and a mandatory in person education/meeting was scheduled for January.Resident #3 (R3)Review of an admission Record revealed R3 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: quadriplegia.Review of R3's Order Summary dated 6/6/22 revealed, Valium Tablet 2 MG (diazePAM) *Controlled Drug* Give 2 mg by mouth four times a day for muscle spasticity related to OTHER MUSCLE SPASM. To be administered in the morning, midday, evening, and bedtime.Review of R3's Controlled Substance Log revealed that on 12/13/25 the bedtime dose of valium was not documented as removed from the medication card (which would indicate the valium was not administered to the resident).Review of R3's December Medication Administration Record revealed that on 12/13/25 the bedtime dose of valium was documented as administered.Review of R3's Electronic Medical Record revealed no documentation and/or order for the withholding of the bedtime dose of valium.Resident #4 (R4)Review of an admission Record revealed R4 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia with behavioral disturbances.Review of R4's Order Summary dated 8/1/25 revealed, LORazepam Concentrate 2 MG/ML *Controlled Drug* Give 0.25 ml by mouth every 12 hours for agitation AND Give 0.25 ml by mouth every 4 hours as needed for agitation for 14 Days. To be administered at 8:00 AM and 8:00 PM.Review of R4's Controlled Substance Log revealed that on 12/7/25 the 8:00 PM dose of ativan was not ot documented as removed from the medication card.Review of R4's December Medication Administration Record revealed that on 12/7/25 the 8:00 PM dose of ativan was documented as administered.Review of R4's Electronic Medical Record revealed no documentation and/or order for the withholding of the 8:00 PM dose of ativan.Resident #5 (R5)Review of an admission Record revealed R5 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: chronic pain.Review of R5's Order Summary dated 9/26/25 revealed, traMADol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 2 tablet by mouth at bedtime for knee pain administer with a snack, max 6 tablets in 24 hours.Review of R5's Controlled Substance Log revealed:On 11/26/25 1 tablet of tramadol was documented as removed from the medication card (and not the prescribed 2 tablets).On 11/27/25 1 tablet of tramadol was documented as removed from the medication card.On 11/30/251 tablet of tramadol was documented as removed from the medication card.On 12/1/25 there was no documentation that tramadol had been removed from the medication card. On 12/5/25 1 tablet of tramadol was documented as removed from the medication card.On 12/6/25 1 tablet of tramadol was documented as removed from the medication card.Review of R5's November and December Medication Administration Record revealed that 2 tablets of tramadol were documented as administered to R5 on 11/26/25, 11/27/25, 11/30/25, 12/1/25, 12/5/25, and 12/6/25.Review of R5's Electronic Medical Record revealed no documentation and/or order for the withholding of the 12/1/25 bedtime dose of tramadol or the decreased (half) dose of tramadol on 11/26/25, 11/27/25, 11/30/25, 12/5/25, and 12/6/25.Resident #7 (R7)Review of an admission Record revealed R7 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: orthostatic hypotension (a drop in blood pressure upon position change).Review of R7's Order Summary dated 9/12/25 revealed, Midodrine HCl Oral Tablet 5 MG (Midodrine HCl) Give 1 tablet by mouth before meals for orthostatic hypotension related to ORTHOSTATIC HYPOTENSION. Hold for systolic (top number of blood pressure) of greater than 110. To be administered at 6:45 AM, 11:30 AM, and 5:00 PM.Review of R7's December Medication Administration Record (MAR) and Blood Pressure Summary revealed:On 12/4/25 R7's blood pressure was not assessed prior to the 11:30 AM and 5:00 PM dose of midodrine and the midodrine was held. Additionally, R7's 6:45 AM blood pressure assessment (121/74) was utilized/documented for the 5:00 PM dose of midodrine on the MAR.On 12/6/25 R7's blood pressure was not assessed prior to the 6:45 AM or 11:30 AM dose of midodrine and the midodrine was held. On 12/7/25 R7's blood pressure was not assessed prior to the 11:30 AM dose of midodrine and the midodrine was held. On 12/9/25 R7's blood pressure was not assessed prior to the 5:00 PM dose of midodrine and the midodrine was administered. Additionally, R7's 11:30 AM blood pressure assessment (107/71) was utilized/documented for the 5:00 PM dose of midodrine on the MAR.On 12/10/25 R7's blood pressure was not assessed prior to the 11:30 AM dose of midodrine and the midodrine was held.On 12/11/25 R7's blood pressure was not assessed prior to the 11:30 AM dose of midodrine and the midodrine was held. On 12/16/25 R7's blood pressure was not assessed prior to the 11:30 AM dose of midodrine and the midodrine was held. Review of R7's Electronic Medical Record revealed no documentation for the rationale for administering and/or holding the midodrine without first obtaining a blood pressure assessment or a rationale for not following the ordered parameters.During an interview on 12/18/2025 at 9:07 AM, the DON reported that on 12/6/25 an orthostatic blood pressure assessment was completed for R7 (with no documented time) with the following results; 122/76 while down and 105/69 when up. The DON confirmed the results were not transcribed on the MAR for the midodrine administration.Resident #8 (R8)Review of an admission Record revealed R8 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: hypertension (high blood pressure).Review of R8's Order Summary dated 11/20/25 revealed, Lisinopril Tablet 2.5 MG Give 1 tablet by mouth one time a day for Hypertension Hold for Systolic <100.Review of R8's December Medication Administration Record and Blood Pressure Summary revealed:R8's blood pressure was not obtained on 12/3/25 and the blood pressure obtained on 12/2/25 (150/82) was utilized/documented on the MAR. R8's lisinopril was administered on 12/3/25.R8's blood pressure was not obtained on 12/10/25 and the blood pressure obtained on 12/9/25 (115/81) was utilized/documented on the MAR. R8's lisinopril was administered on 12/10/25.Review of R8's Electronic Medical Record revealed no documentation for the rationale for administering the lisinopril without first obtaining a blood pressure assessment.During an interview on 12/18/2025 at 9:07 AM, the DON and Assistant Director of Nursing confirmed the medication errors identified for R3, R4, R5, R7, and R8. The DON reported the expectation was for the licensed nurses to follow the standards of practice for medication administration and follow the professional standards of nursing practice as they were trained to do. The DON reported that the facility PIP and the mandatory in person education would be modified to include the additional sources of medication errors identified during the survey.Review of the facility policy Medication Administration last reviewed/revised 6/9/25 revealed, Medications are administered by licensed nurses as ordered by the physician and in accordance with professional standards of practice, in a manner to maintain safety and prevent contamination or infection.13. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters.18. Save the signed MAR (Medication Administration Record) after administered. For those medications requiring vital signs, record the vital signs onto the MAR.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, (Nurses) are also responsible for documenting any preassessment data required with certain medications such as a blood pressure measurement for antihypertensive medications or laboratory values, as in the case of warfarin, before giving the medication. After administering a medication, immediately document which medication was given on a patient's MAR per agency policy to verify that it was given as ordered. Inaccurate documentation, such as failing to document giving a medication or documenting an incorrect dose, leads to errors in subsequent decisions about patient care. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 643-644). Elsevier Health Sciences. Kindle Edition.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, The National Coordinating Council for Medication Error Reporting and Prevention (2021) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/or failing to administer a medication. Preventing medication errors is essential. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 639). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review the facility failed to ensure call lights were in reach of dependent residents for 1 resident (R85) of 1 resident reviewed for availability of call lights. Findings include: Review of an admission Record revealed R85 admitted to the facility on [DATE] with pertinent diagnoses which included diabetes, heart failure, and weakness.Review of a current ADL (activities of daily living) Care Plan intervention for R85, initiated 12/3/2024, revealed resident was dependent on staff assistance for transfers. Review of a current risk for falls Care Plan intervention, initiated 11/29/2024, directed staff to leave R85's call light in reach when he was in the room without staff.In an observation and interview on 7/15/2025 at 11:36 AM in R85's room, R85 was sitting in his bedside recliner with a blanket over his lap and his call light was sitting on his lower legs and out of his reach. R85 reported he did not know where is call light was located. R85 reported he was able to use his call light to request staff assistance but could not locate the call light as he was unable to see it.In an observation and interview on 7/16/2025 at 1:29 PM in R85's room, R85 was sitting in his bedside recliner and reported he did not know where his call light was. Both call lights were wrapped around the frame of his bed and out of his reach. R85 reported he was supposed to let staff assist him when he needed to get up but could not call for help without his call light. In an interview and observation on 7/16/2025 at 1:34 PM in R85's room, Certified Nursing Assistant (CNA) C reviewed R85's care plan and confirmed he required staff assistance to get out of his chair. CNA C reported R85's call light should have been left within reach when staff escorted him back to his room from the dining hall. In an interview on 7/16/2025 at 1:36 PM, CNA F reported she assisted R85 back to his recliner in his room after lunch and forgot to place his call light within reach when she left the room. CNA F reported R85's call light should be left within reach as he was able to use his call light and required assistance to get out of his recliner.

Based on observation and interview, the facility failed to maintain ventilation, resulting in odors and uncirculated air, affecting all residents in the AU Unit and residents living in the 200 Hallways. Findings include: During an observation of the AU Unit on 8/5/24 at approximately 11:00 AM, the air on the halls and in the resident rooms felt muggy, humid and stagnant. During the observation, some of the resident rooms were noted to have lingering bathroom odors. During a family interview on 8/5/24 at 11:11 AM, resident's room was noted to be stagnant and hot. R50's daughter revealed, this room is always this way, we dress for it. On 8/7/24 between 10:58 AM to approximately 11:25 AM, the following AU resident restrooms (103, 109, 117, 127, 131 and 135) were tested using a tissue. The restroom vents were not producing any suction. On 8/7/24 at approximately 11:27 AM, the Unisex Restroom (located closest to room [ROOM NUMBER]) was also checked using a tissue and no suction was observed from the vent. During the 8/7/24 tour of the AU Unit with Maintenance Personnel (MP) L the unit was observed to be stuffy, and stagnant. The resident rooms/restrooms were noted to be hot, stagnant and some had lingering odors. During an interview on 8/7/24 at 11:51 AM, Maintenance Director (MD) C was queried on the maintenance of the AU's ventilation system and stated we had a blower motor issue on that unit. We may be having an issue down there again. We will get someone to check on it. 37573 During an observation and an interview on 8/7/24 at 10:19 AM, Maintenance Director (MD) C and this surveyor walked to room [ROOM NUMBER], 207, 209, 215, 217, 235, 237 and verified the air return ducts in the rooms had little to no air pressure pulling out the shared bathrooms and above the sinks. Some bathrooms had a lingering bathroom smell. The large activity room on the corner of Elm did not have a good air return ventilation either. MD C reported he did not see any problems on the roof with the functioning of the ventilation. He did not have a preventative maintenance checklist.

Based on interview and record review, the facility failed to: 1) provide documentation that they communicated a resident's wishes for code status to their guardian/ responsible party/Durable Power of Attorney for Medical Care in a timely manner for 3 of 4 residents (R32, R64, and R76) and 2) maintain a copy of a resident's advanced directives in the resident's medical record for 2 of 4 residents (R32 and R64) reviewed for advanced directives, resulting in the potential for a resident's wishes not being honored. Findings include: Resident #32 (R32) A review of R32's Admission Record, dated 8/7/24, revealed R32 was an [AGE] year-old resident admitted to the facility on [DATE] and readmitted on [DATE]. In addition, R32's Admission Record revealed multiple diagnoses that included late onset Alzheimer's Disease, dementia, and bipolar disorder. R32's Admission Record also revealed that Responsible Party (RP) J was R32's Power of Attorney (POA) for medical care and finances. A review of R32's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 5/21/24, revealed R32 had a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 10 which revealed R32 was moderately cognitively intact. A review of R32's Medical and Financial Determination form, dated 8/11/23, revealed R32's physician and a licensed psychologist determined R32 was no longer capable of participating in medical treatment decisions affecting their own health or financial decisions. Therefore, R32's advanced directive for medical and financial decisions was activated and R32's power of attorney (POA) to make medical and financial decisions was to take effect on this date. A review of R32's medical record, dated 8/11/23 to 8/6/24, failed to reveal an advanced directive for medical decisions that would officially designate someone as R32's POA. A second review of R32's medical record, dated 8/11/23 to 8/6/24, revealed that RP J (the individual listed as R32's POA for health care on R32's Admission Record) was first made aware of R32's code status (what to do in the event R64's heart and/or breathing stopped- Full Code) in a Social Service Note on 9/26/24 (1.5 months after R32 was determined to be unable to make medical decisions). During an interview on 08/06/24 at 10:55 AM, the Director of Nursing (DON) was informed that the surveyor could not locate R32's advanced directives for medical decisions paperwork in R32's medical record. A copy of R32's advanced directives for medical decisions paperwork was requested from the DON, if they could locate it. During a second interview on 08/06/24 at 11:30 AM, the DON stated R32 was deemed incompetent (unable to make medical decisions). She stated the facility does not have any advanced directive for medical decisions paperwork in R32's medical record because RP J repeatedly refused to provide it to the facility. The DON suggested that the surveyor speak with Social Worker (SW) A for more information on the situation with RP J and his refusal to provide the facility with a copy of R32's advanced directives for medical decisions. During an interview on 08/07/24 at 09:02 AM, SW A stated she had tried to get the R32's advanced directives for medical decisions paperwork from RP J several times. SW A stated unfortunately I have not documented that in his medical record. SW A stated RP J has had some issues accepting that R32 had been determined to be unable to make medical decisions and this may be a reason why RP J has not provided the facility with a copy of R32's advanced directives for medical decisions paperwork, even though RP J had provided the facility with a copy of R32's advanced directives for financial decisions paperwork. She stated RP J had provided them R32's financial decisions advanced directives because there had possibly been some financial issues that needed to be addressed. SW A stated she understands that the facility needs R32's advanced directives for medical decisions paperwork to prove who his medical decision maker was because some residents have different people who make medical decisions and financial decisions. She stated she will try and contact RP J again today and see if he will send R32's medical decisions advanced directive paperwork. During an interview on 08/07/24 at 11:45 AM, SW A stated she spoke with RP J and he had still refused to send a copy of R32's advanced directives for medical decisions paperwork to the facility. She stated RP J had said he was aware the facility needed the paperwork, but he was not going to provide it to them. During a third interview on 08/07/24 at 12:27 PM, the DON stated she, the Nursing Home Administrator, and the Assistant Director of Nursing had a conference call with RP J. The DON stated RP J had said he was not aware that the advanced directives paperwork that he had previously submitted to the facility did not address medical decisions. RP J had stated he thought medical and financial decisions were both on the advanced directives paperwork that he had already provided to the facility. RP J had told the DON that he would contact his attorney for a copy of the documentation and have it sent to SW A. A copy of R32's advanced directives for medical decisions was requested from the DON when the facility receives it. As of the time of the completion of the survey and exit from the facility, the facility failed to provide a copy of R32's advanced directives for medical decisions to the surveyors. Resident #64 (R64) A review of R64's Admission Record, dated 8/7/24, revealed R64 was a [AGE] year-old resident admitted to the facility on [DATE] and readmitted on [DATE]. In addition, R64's Admission Record revealed multiple diagnoses that included late onset Alzheimer's Disease, dementia with agitation, dementia with behaviors, psychotic disorder, and hallucinations. R64's Admission Record also revealed that Responsible Party (RP) I was R64's Power of Attorney (POA) for medical care and finances. A review of R64's MDS, dated [DATE], revealed R64 had a BIMS score of 8 which revealed R64 was moderately cognitively intact. A review of R64's Medical and Financial Determination form, dated 3/11/24, revealed R64's physician and a licensed psychologist determined R64 was no longer capable of participating in medical treatment decisions affecting their own health or financial decisions. Therefore, R64's advanced directive for medical and financial decisions was activated and R64's power of attorney (POA) to make medical and financial decisions was to take effect on this date. A review of R64's medical record, dated 3/11/24 to 8/7/24, failed to reveal an advanced directive for medical decisions that would officially designate someone as R64's POA. A second review of R64's medical record, dated 3/11/24 to 8/7/24, failed to reveal that R64's wishes for code status were discussed with RP I (the individual listed as R64's POA for health care on R64's Admission Record). During an interview on 08/07/24 at 11:45 AM, SW A stated she was sure R64's POA (RP I) had signed a code status form. She stated she was also sure that R64 had advanced directive documentation in his medical record. SW A stated she would look for both of these items and send a copy to the surveyor. SW A stated if she could not locate R64's advanced directive documentation, then she would contact R64's lawyer's office for a copy of it. A review of R64's Designation of Patient Advocate document, dated 7/9/19, was received on 8/7/24 at 12:43 PM. R64's Designation of Patient Advocate document revealed that RP I would be the Patient Advocate (POA) in the event that R64 was determined to be unable to make medical decisions. A third review of R64's medical record, dated 3/11/24 to 8/7/24, revealed that RP I was made aware of R64's code status (DNR- Do Not Resuscitate) in a Social Service Note on 8/7/24 at 12:13 PM (approximately 5 months after R64 was determined to be unable to make medical decisions). In addition, R64's Designation of Patient Advocate document was noted to have been added to R64's medical record on 8/7/24. Resident #76 (R76) A review of R76's Admission Record, dated 8/7/24, revealed R76 was a [AGE] year-old resident admitted to the facility on [DATE] and readmitted on [DATE]. In addition, R76's Admission Record revealed multiple diagnoses that included dementia. A review of R76's MDS, dated [DATE], revealed a BIMS score of 12 which indicated R76 was moderately cognitively intact. A review of R76's Order Regarding Appointment of Guardian of Incapacitated Individual, dated 7/11/24, revealed Guardian (GRD) K was appointed as R76's guardian. A review of R76's Do Not Resuscitate Order, dated 4/3/24 and signed by R76, revealed she wanted to be a DNR in the event that her heart and breathing stopped. A review of R76's medical record, dated 7/11/24 to 8/6/24, failed to reveal that R76's wishes for code status were discussed with GRD K. During an interview on 8/6/24 at 10:54 AM, a copy of any documentation that R76's guardian (GRD K) was aware of R76's DNR wishes (e.g., progress note, care conference note, DNR order signed by GRD K, etc.) was requested from the DON. A review of R76's Communication- with Family/NOK (next of kin)/POA note, dated 8/6/24 at 4:27 PM, revealed GRD K was made aware of R76's wish to be a DNR (27 days after GRD K was appointed as R76's guardian). A review of the facility's Advanced Directives policy and procedure, dated 12/2016, revealed, It is the Policy of [Name of facility] to ask resident and/or resident representative at time of admission to facility if they have Advance Directives (medical Durable Power of Attorney, Five Wishes) or Guardianship . If resident has Advance Directive resident and/or resident representative will be asked to bring in form so that copy of Advance Directive can be scanned into [name of facility's electronic medical records program] . A review of the facility's Designation of Resident's Ability to Make Medical Decisions policy and procedure, dated 2/16/22, revealed, 4) If both physicians sign the Medical Determination form social worker will notify the person who has been designated as medical decision maker in the Durable Power of Attorney Form for Health Care or 5 Wishes form. 5) Medical Determination form will be scanned into [name of facility's electronic medical records program] under Medical Determination .

Based on interview and record review, the facility failed to address a psychotropic medication that was ordered on an as needed (PRN) basis for 1 (Resident #33), resulting in the potential for unnecessary medication. Findings include: Resident #33 (R33) Review of a Face sheet revealed R33 admitted to the facility on [DATE] with pertinent diagnoses of anxiety, congestive heart failure, and non-pressure chronic ulcers in bilateral lower limbs. Review of the Medication Administration/Physician orders for R33 revealed on 4/20/23 an order for Ativan (Lorazepam) 0.5 mg (milligrams) to be given every 8 hours as needed for anxiety and discontinued on 6/26/23. The Ativan was not given every day. Review of the Medication Administration/Physician orders for R33 revealed a new order on 6/26/23 for Ativan 0.5 mg every 8 hours as needed for anxiety for 14 days in addition to an order for Ativan 0.5 mg at bedtime for anxiety. Review of a Pharmacist's Note To Attending Physician/Prescriber dated 5/18/23 for R33 revealed PRN 14-day rule psychotropics: .(R33) has a PRN order for Ativan (Lorazepam 0.5 mg every 8 hours as needed since her readmission on 4/20/23. This medication has been used 30 x since her readmission. According to guidelines, if this PRN order is to extend beyond 14 days, the rationale must be documented in the resident's medical record and must also indicate the duration for the PRN order. If you feel no change is warranted, please indicate at the bottom of this form, or in your next progress note, to be compliant with current regulations. The physician documented at the bottom of the form: Agree. I extended X 14 days on (electronic medical record.) Review of the Quality Care/Care Conference Progress note for R33 dated 6/2/23 revealed Started on Ativan 0.5 mg (by mouth every) 8 hours PRN on 4/20/2023 - risk- possible S/E sedation, benefit - quality of life anxiety treatment. Review of a Care Plan for R33 revealed a focus for Anxiety initiated on 4/12/23 revealed the intervention to administer anti-anxiety medications as ordered by the physician. No person centered or meaningful alternative intervention documented. In an interview and record review on 6/29/23 at 12:13 PM, the Director of Nursing (DON) reported that the physician did agree to extending the PRN Ativan for 14 days in June on the pharmacy review documentation for R33. When referring to the regulation's requirements for PRN psychotropic medications, the DON reported the physician may have put information into the progress notes. Review of the progress notes and physician documentation revealed no more required documentation for Ativan for R33.

This citation pertains to intakes MI 628 and MI 504 Past non-compliance was accepted for this citation. Corrective actions identified below. Based on interview and record review, the facility failed to prevent abuse towards 2 residents (R1 and R2) reviewed for abuse, resulting in the residents being abused by a staff member. Findings include: Review of facility policy Abuse, Neglect and Exploitation with a last revised date of 8/31/2022 revealed: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Verbal abuse is defined as: the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Physical abuse is defined as: includ[ing], but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. R2 Review of face sheet and electronic medical record revealed R2 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 is not their own responsible party. Review of facility reported incident revealed on 10/2/22 at 11:05 AM, it was reported CNA (Certified Nursing Assistant) A was overheard swearing at R2. The facility investigation revealed CNA A admitted to yelling at R2 don't you ever f---ing punch me like that after he punched her in the ear during cares. R2 did not recall the incident. Review of personnel file for CNA A revealed she was hired approximately December of 2007 and did not appear to have a prior history of any abusive behavior. She was issued a Final Written Warning: Unprofessional Conduct i.e. using obscene or improper language or gestures, immoral conduct or indecency related to the incident with R2 on 10/2/22. Per review of the facility provided incident file, following the incident on 10/2/22 CNA A completed multiple reeducation course regarding topics such as abuse and neglect, dementia care, management of challenging resident behaviors, etc. Other facility staff who worked on the dementia unit were also provided with a memo to review regarding tips for providing care for R2 to diminish chance of violent physical outbursts. R1 Review of face sheet and electronic medical record revealed R1 admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 is not their own responsible party. Review of facility reported incident revealed on 11/3/22 at 8:37 AM CNA A was witnessed slapping R1 on the shoulder after he poked her in the chest area. R1 did not recall the incident and was not injured. CNA A did not deny that she slapped R1. CNA A's employment was immediately terminated and local police were called and completed an investigation. A review of video footage of the incident was completed on 11/21/22 at approximately 10:30 AM with the Director of Nursing (DON). CNA A was seen to be standing in the hallway with R1, they were speaking to each other when R1 reached out to touch her in the chest area. CNA A paused for a moment then drew her hand back and slapped R1 in the shoulder area. CNA A immediately hugged and appeared apologetic towards the resident and quickly stepped away. Review of the facility investigation during an abbreviated survey on 11/21/2021 reflected the facility implemented the following interventions that identified the non-compliance: Description of deficient practice: [CNA A] slapped [R1] on the right shoulder in response to [R1] poking [CNA A] on her breast. 1. Immediate action(s) taken for the resident(s) found to have been affected include: With respect to allegation of physical abuse towards [R1], the facility was compliant with its Abuse Prohibition policy and procedure with respect to reporting and investigation. The facility was also compliant with its policies and procedures for protecting residents as well as disciplinary action resulting in termination on 11/3/22 for [CNA A's] noncompliance. [R1] was assessed for mood / behavior changes with no psychosocial concerns post incident. A skin assessment was completed with no skin alterations noted. Resident denied pain or discomfort as a result of being slapped. [R1] was placed on continued monitoring for mood / behavior changes. No psychosocial concerns have been noted and resident has continued about his normal routines. 2. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents have the potential to be affected. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: The facility's abuse and neglect policy and procedure will be reviewed and revised, if appropriate, to ensure compliance with current regulations. On 11/3/22 The Alzheimer's Foundation was contacted for support in education opportunities in relation to Alzheimer's Disease and abuse prevention and an in-service education program was immediately initiated with the staff working on the Alzheimer's Unit by the Social Worker This education focused on scenario's for abuse and responses/reactions, 7 strategies to prevent burnout, and Alzheimer's and Dementia behaviors resources. All staff in-servicing on Abuse Prevention. Staff will not work after 11/16/22 until they have received the outlined education. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Director of Nursing Services, or designee, will conduct ten (10) random staff interviews regarding facility abuse/neglect policy weekly for four (4) weeks, then (10) random staff interview monthly for at least two additional months. Any concerns will be immediately addressed via individual employee education. A compilation of findings will be presented to the QAA Committee each month in consideration of the plan effectiveness. QAA Committee will determine the date to safely discontinue the interview program. The Director of Nursing will be responsible for compliance. Corrective action completion date: 11/16/22.

This citation has 2 DPS statements. DPS statement #1 is linked to intake # MI 288. DPS statement #1 Based on interview and record review, the facility failed to prevent multiple falls and serious injury for one resident (Resident #326), out of 6 residents reviewed for falls, resulting in an injured right shoulder, lacerations to the lip and head requiring sutures, and fractures of 4 cervical (neck) bones, including the first and second neck bones. Findings: Resident #326 (R326) Review of an Admission Record revealed R326 was an [AGE] years old male, originally admitted to the facility on [DATE], with pertinent diagnoses of Alzheimer's, brain cancer, agitation, [CONDITION(S)], and anxiety disorder. Review of a Brief Interview for Mental Status BIMS dated [DATE], reflected a score of 5 out of 15, indicating R326 had severe cognitive impairment. Review of a Care Plan Report for R326 revealed: FOCUS-the resident is at high risk for falls related to ambulatory elimination status, history of stroke, Alzheimer's disease, cognitive deficit, brain mass, history of falls, impulsiveness, and poor safety awareness, GOAL- will remain free from falls through nursing intervention and prevention as evidenced by no falls at any time through review date, INTERVENTIONS- Frequent checks and implement 1:1 as needed-date initiated [DATE], - 1:1 staff supervision at all times-date initiated [DATE]. Review of an Incident/Accident Report (IR), dated [DATE] at 5:00 AM, revealed R326 had an unwitnessed fall less than 24 hours after admission, was confused prior to the fall, and the fall resulted in a skin tear to one hand. Review of a Safety Note time stamped 12:59 PM, noted the following regarding R326: (a) pleasantly confused/upset and depressed about placement at facility .several self transfers. Review of a Condition Stability note dated [DATE] at 12:03 PM reflected: several self transfers, does not use call light. Review of a Condition Stability note dated [DATE] at 10:00 AM reflected the following for R326: resident refusing care from staff, self transferring multiple times, unable to redirect, does not remember why he is here, does not use gait belt or call light, and gets up and starts walking. Review of a Condition Stability: noted dated [DATE] at 10:25 AM reflected the following for R326: while self-transferring, resident ran into night stand. Review of a Post Fall Note dated [DATE] at 10:49 AM revealed (R326) denies any pain/discomfort, continues to self transfer. Review of a Condition Stability note dated [DATE] at 11:28 PM, revealed (R326) continues to self transfer greater than 35 times this shift, is very unsteady on feet, does not show any comprehension of basic instructions and will not follow them. Review of a Condition Stability note dated [DATE] at 5:26 AM, revealed (R326) self transferred several times this shift, is unsteady on his feet, was observed walking unsteadily in his room, does not use call light, and gets out of bed whenever he wants. Review of a Condition Stability note dated [DATE] at 12:23 PM, revealed (R326) continues to self transfer multiple times, does not use call light, does not remember why he is here, gets up and starts walking, does not use walker, unsteady gait, and is anxious and looking to go home. Review of a Condition Stability note dated [DATE] at 10:47 PM, revealed (R326) (a) was having anxiety, (b) sit to stand balance is fair, (c) does appear as if he is going to lose balance when self transferring, and did require being a 1:1 most of this shift. ( Documentation did not specify when the 1:1 was initiated and when it ended). Review of an Incident/Accident Report dated [DATE] at 3:00 AM revealed (a) R326 had an unwitnessed fall, (b) the mental status portion of the IR was not completed by staff, (c) predisposing factors were listed as gait imbalance and impaired memory, (d) R326 yelled out ouch my arm, I think I broke it, (e) resulted in an injury to the right elbow, and (f) R326 was not taken to the hospital. Review of a Condition Stability note dated [DATE] at 10:41 PM, revealed (R326) made many self transfers this shift which prompted having a staff person remain with resident at all times, has very impulsive behavior without any regard to safety, and has been awake for 48 hours with occasional short naps. Review of a Communication-with Physician note dated [DATE] reflected resident frequently self transfers, is unsteady, and is not sleeping well at night. Review of a Condition Stability note dated [DATE] at 4:29 PM, revealed (R326) made numerous self transfers, placed on 1:1 supervision for safety, and does not use call light. (Documentation does not specify when the 1:1 was initiated and when it ended). Review of a Condition Stability note dated [DATE] at 5:17 AM, revealed (R326) resident slept fairly well the first part of the shift. The 2nd half of the shift the resident was more awake and set off the laser alarm at least every hour. Staff went to assist him. Review of a Condition Stability note dated [DATE] at 12:30 PM, revealed (R326) self transferred multiple times this shift, does not use call light, staff anticipate needs, and has unsteady gait. Review of a Condition Stability note dated [DATE] at 4:19 PM, revealed (R326) was placed on 1:1 this shift for numerous self transfers and unsteady gait. (Documentation does not specify when the 1:1 was initiated and when it ended). Review of a Condition Stability note dated [DATE] at 9:19 PM, revealed (R326) self transferred twice in past 15 minutes. 1:1 supervision for safety again started. Review of a Condition Stability note dated [DATE] at 6:10 AM, revealed (R326) slept very minimally this shift, was basically a 1:1 all shift and when resident was in bed and the laser alarm was effective in notifying staff when resident self transfers. Review of a Condition Stability note dated [DATE] at 12:52 PM, revealed (R326) had several self transfers and was 1:1 at times. Review of a Condition Stability note dated [DATE] at 12:51 PM, revealed (R326) continued to self transfer, had unsteady gait, and does not use call light. Review of a Condition Stability note dated [DATE] at 7:38 PM, revealed (R326) continues with many attempts to self transfer out of wheelchair and reminded to use call light. Review of an Incident/Accident Report dated [DATE] at 3:20 AM revealed (a) R326 had an unwitnessed fall from a recliner, (b) the mental status portion of the IR was not completed by staff, (c) predisposing environmental factors listed furniture, and (d) the recommendation made to prevent further falls was to remove R326's recliner due to the resident being unable to operate it safely. Review of a Condition Stability notes dated [DATE] at 1:38 PM and 8:51 PM, revealed (R326) continues to self transfer, has unsteady gait, and does not use call light. Review of all Progress Notes for R326 from [DATE] to [DATE] revealed staff initiated 1:1 supervision during various shifts for intermittent and undocumented lengths of time. Review of a Physician History and Physical, dated [DATE], revealed the following information and assessments related to R326: (a) does not have safety awareness and frequently self transfers, (b) has had falls at home, (c) has anxiety related to dementia and end-of-life, is being treated with [MEDICATION(S)] (benzodiazipine), and staff report the the anxiety is not well controlled, (d) has been experiencing urinary frequency especially at night and this contributes to the anxiety, restlessness, and self-transfers, (e) staff state resident continues to have restlessness, anxiety, frequent self-transfers, panic attacks, and crying episodes, (f) resident is a hospice patient and comfort is our goal for treatment (g) a review of systems found R326 positive for fatigue, hearing loss, visual disturbance, shortness of breath, back pain, gait problem, weakness, agitation, confusion, and decreased concentration, (h) needs assistance with activities of daily living and 24 hour supervision for safety, and (i) is a fall risk. Review of an Incident/Accident Report dated [DATE] revealed (a) R326 had a witnessed fall, (b) the mental status portion of the IR was not completed by staff, (c) predisposing factors were listed as confused, gait imbalance, and impaired memory, (d) R326 complained of right arm pain, (e) upon assessment resident noted with right shoulder out of place, and (f) right shoulder looked to be out of place and resident was unable to move it. Review of all Progress Notes for R326 from [DATE] to [DATE] revealed staff initiated 1:1 supervision at certain times for undocumented specific lengths of time. Review of a Post Fall Note dated [DATE] reflected resident continues to self transfer throughout day and night with no patterns. Resident does not use call light for staff assistance .is unsteady and unaware of safety needs. Review of an Incident/Accident Report dated [DATE] at 2:30 PM revealed (a) R326 had an unwitnessed fall, (b) the resident was found on the floor between the bed and the recliner, and (c) no immediate safety interventions were implemented. Review of an Incident/Accident Report dated [DATE] revealed (a) R326 had an unwitnessed fall, (b) the resident was found on the floor and kept saying I hit my head, and (c) no immediate safety interventions were implemented. Review of Communication with Physician progress note for R326, dated [DATE], reflected during self transfer resident fell out of chair to the ground, stating that he hit his head, unwitnessed, blood sugar was 432. Review of Communication with Family progress note for R326, dated [DATE], revealed family member/power of attorney notified of resident falling, was upset that the resident fell again and told staff this is the 6th fall in 2 months. Review of a lab report for R326, dated [DATE], revealed results for a urinalysis with culture and sensitivity. R326 was positive for a urinary tract infection ([CONDITION(S)]), colony count > 100,000, and the pathogen was [CONDITION(S)] oxytoca. On the bottom of the lab report was a hand written notation for [MEDICATION(S)] (an antibiotic) 300 mg (milligrams) one BID (twice daily) x 7 days. The notation had staff initials and was dated [DATE]. Review of an Electronic Medication Administration Record (Emar) for R326, dated [DATE] -[DATE], reflected an order for [MEDICATION(S)] ([MEDICATION(S)]) 300 mg 1 capsule every 12 hours for [CONDITION(S)] for 7 days. The medication was started the evening of [DATE]. Review of a Safety Note for R326, dated [DATE], reflected Fall committee reviewed falls dated [DATE]/21 and [DATE], recommendations-resident to receive 1:1 staff supervision at all times due to frequent self transfers, weakness, impaired cognition, and poor safety awareness. Review of an Incident/Accident Report for R326, dated [DATE] at 2:20 PM, revealed the resident fell while in the bathroom. The resident had been left unattended in the bathroom. Review of a Nursing Note dated [DATE], revealed the following information related to R326's fall: notified by CNA (certified nurse aide) that resident had fallen, resident was observed on the ground with feet inside bathroom door and upper body outside of door on his stomach. resident noted with laceration to forehead, laceration to top lip, blood inside of mouth with laceration to inner lip. Skin tear to left hand. Resident complained of pain to neck and right ribs. Review of a hospital radiology report for R326, dated [DATE], revealed R326 had fractured his neck at C1, C2 ( a type 2 ondontoid fracture), C6, and C7 (4 of the 7 bones in the neck). During an interview on [DATE] at 1:40 PM, Family Member/DPOA V reported the following concerns with the care that R326 received while at the facility: (1) (R326) fell the day after admission, (2) had lot's of bruises, (3) was told that (R326) stopped breathing after one of the falls, (4) did not believe that the facility provided enough supervision, (5) had asked to have (R326) moved to the locked unit for increased supervision but was told there were no beds available, (6) when a bed on the locked unit did become available, (R326) was not moved to the unit for increased supervision, and (7) (R326) died 2 days after the last fall when he broke his neck. DPS #2 Based on observation, interview, and record review the facility failed to minimize the risk of scalding and [CONDITION(S)] by allowing domestic hot water to exceed 120°F. This resulted in an increased risk of injury among residents who reside in areas where hot water is supplied by the East Hall boiler. Findings Include: During a tour of the facility, starting at 1:30 PM on [DATE], it was observed that the following resident rooms in the F Hall were found to have temperatures above the maximum allowed temperature of 120°F for domestic use fixtures: F Hall pantry sink was 122°F, The hand sink in the spa room was 123.5°F, resident room 169 hand sink was 123°F, resident room 167 hand sink was 122.5°F, and resident room 158 was 120.5°F. It was noted that all fixtures tested had anti-scald valves attached, but were not sure if they were working properly. During an observation on [DATE] at 1:44 PM, the bathroom sink in room 160 reached 123°F degrees Fahrenheit. During an observation on [DATE] at 1:48 PM, the bathroom sink in room 237 reached 133°F degrees Fahrenheit, and the shower reached 132°F degrees Fahrenheit. An interview with Maintenance Director E, at 1:55 PM on [DATE], found that usually hot water temperatures are taken every day, but this month has been pretty busy and I am not sure they have been done every day, I will have to check with my staff. When asked how many hot water systems supply the building, Maintenance Director E stated there are three different hot water loops and was pretty sure the F hall was supplied with hot water from the East Hall boiler, but would have to check the buildings schematics. During a tour of the East Hall boiler, at 2:04 PM on [DATE], an interview with Maintenance Director E, found that the outgoing domestic hot water temperature, supplying the F Hall, was 125°F with a return temperature of 120°F. When asked how often these temperatures are checked, Maintenance Director E stated he takes weekly checks of the boiler temperatures. During an interview with Maintenance Director E, at 3:55 PM [DATE], it was found that staff didn't complete any domestic water temperature logs for the month of May. During an interview on [DATE] at 11:04 AM, Maintenance Director E reported that domestic water temperatures had not been monitored at all this year. The last water monitoring log provided was for [DATE]. During an observation on [DATE] at 11:08 AM, the bathroom shower in room 237 reached 134°F degrees Fahrenheit. During an observation on [DATE] at 11:25 AM, the bathroom shower in room 120 reached 129.4°F degrees Fahrenheit.

This citation pertains to intake M 7853 Based on observations and record review, the facility failed to supervise two residents with dementia who required supervision (Resident #14 and Resident #327), resulting in residents known to wander and with behaviors having a physical altercation when the resident approached another resident's room unsupervised and was slapped in the face. Findings: Resident #14 (R14) Review of a Face Sheet revealed R14 is an [AGE] year-old male who admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) revealed he is severely cognitively impaired and utilized a wheelchair, required supervision, and extensive assistance with cares. He has limited range of motion on one side of his body affecting his upper and lower extremities. Resident #327 (R327) Review of a Face Sheet revealed R327 was a [AGE] year-old female who admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS revealed she was severely cognitively impaired and ambulated with supervision. Review of the Facility Reported Incident (FRI) dated 2/1/21 revealed R14 reported he was looking to speak with the physician and knocked on R327's closed door. When she opened the door, she smacked R14 in the face. A Certified Nursing Assistant (CNA) was walking with another resident in the hall when she heard R14 call out owe, heard a door slam, and R14 said Will you help me? R14 told the CNA the lady slapped him, and he referred to the closed door. Review of the statements from staff working this day revealed five three of the five staff were with other residents, one staff was on break and the other was not present. Review of a Police Report dated 2/1/21 revealed the facility reported an incident between R14 and R327 to the police. The CNA reported she was walking down the hall with a resident when she heard the victim (R14) say ow and then heard (R327) slam the door shut. The CNA asked R14 what happened, and he told her She hit me. The CNA asked who hit him and R14 replied That lady in there. Then R327 opened the door and looked upset and angry. The CNA reported R14 did have a pink mark on his left cheek under his glasses and remained there for about one hour and was gone by the time the police arrived to the facility. The office approached R327 who did not recall what had happened and R14 was non verbal and did not speak. R14 Review of a few Nursing Progress note dated 1/27/21 for R14 revealed he was agitated and had behaviors. At 10:15 PM the resident was self-propelling in his wheelchair in the hallway exit seeking. The Social Worker brought the resident to the common area stating he was pulling on the door and attempting to get out. While in the common area he was attempting to run into others and rammed into the trash can. He was difficult to redirect. Review of an Incident Report dated 5/14/22 at 6:38 PM revealed R14 was sitting in the common area in his locked wheelchair when the nurse heard the resident screaming ouch. The nurse went to the resident and saw his fingers were pinned between the table and his left armchair. The nurse immediately pushed the table away and R14 said ouch again and three of his left fingers were red and blanchable. The resident then cussed at the nurse and said his hand hurt. R14 was not able to push the table off his fingers or push himself away from the table. Review of a Care Plan for R14 on 4/1/19 and last revised on 12/31/21 revealed the resident has behavior problems related to dementia with behavioral disturbances, [CONDITION(S)] (stroke) with left [CONDITION(S)] (paralysis on one side of the body) and left visual field impairment, may use foul language, bumps into things throughout the day. Does not attempt to avoid others. May threaten staff or yell/use foul language. May hit or kick at staff. Easily agitated. May grab for other residents or their wheelchairs. May enter other residents' rooms. May become aggressive with others if they attempt to remove him. History of kicking another resident when she attempted to remove him. Interventions included but not limited to: Anticipate and meet the resident's needs and attempt to redirect away from other resident rooms. A Care Plan intervention for locomotion on/off unit initiated on 3/4/19 and last revised on 1/28/20 requires R14 to be supervised while self-propelling in his wheelchair and staff are to monitor and direct the resident to avoid him hitting objects. Another Care Plan initiated on 11/23/21 revealed the resident is/has potential to be physically aggressive related to anger, dementia, and poor impulse control. R327 Review of a Nursing Progress Note dated 2/1/21 for R327 at 4:30 PM revealed R327 was place on distant 1:1 supervision after the incident on 2/1/21. Review of a Nursing Progress Note dated 2/1/21 for R327 revealed at 6:00 PM the resident had a fork and a knife in her hands and the CNAs were trying to maintain safety and get the knife and form from her. Once the utensils were taken, the resident was upset and failed her arms arms around and yelled. Review of a Care Plan initiated on 4/1/19 for R327 revealed she had a behavior problem and may become agitated with staff or other residents. She may swat at others and take things form other residents. She may become agitated and aggressive with others in her room and with wandering residents or staff. An intervention initiated on 1/10/20 revealed: Attempt to redirect away from male residents prior to contact but allow appropriate affection if already together to avoid agitations. Place staff between resident and male residents when possible. A Care Plan initiated on 1/3/20 and last revised 6/28/21 revealed R327 had the potential for sexual behaviors and seeks out male residents. Review of a Behavior Management Education provided to staff dated 5/31/21 revealed the Problem or Opportunity for Improvement focused on the Alzheimer's Unit needing a proactive verses a reactive approach, developing trusting relationships, improving the lives of the person with dementia and reducing challenging behaviors. The goal of the caregiver to become more person-centered and less task- oriented with focus on more the process instead of the outcome. During an observation on 5/23/22 at 1:23 PM on the Alzheimer's Unit (AU), nine residents observed sitting in the common area alone with no supervision. A female resident was in the hall asking another female resident questions about her home while they were both sitting in their wheelchairs. When the second resident could not answer, she started to get anxious and frowned. The first resident grabbed the arm of the second resident's wheelchair when a couple minutes later a staff member walked around the corner and engaged with the residents for a minute then left and walked down the hall. The first female resident grabbed the arm of the second resident's wheelchair and started wiggling it back and forth. Another female resident came up to the first female resident and pushed her wheelchair away and told her not to do that. At 1:29 PM a nurse came around the corner to ask the first female resident was yelling and asked if she had to use the bathroom and the resident said yes. . During an observation on 5/24/22 at 8:54 AM in the AU, five residents observed sitting in the main gathering room near the nurses' station with no activities and the television is off. During an observation on 5/24/22 at 9:03 AM in the AU, the nurse left the floor and announces she was going on break but not sure to whom she was talking. At this time there were seven residents in the man gathering room without supervision when one male resident in a wheelchair wandered the hall. There were no staff observed in the hallways. 05/24/22 09:03 AM, Nurse left floor to go on break with seven residents in main gathering room without supervision and one male Male Resident in WC wandering. No staff in hallways. At 9:08 AM a staff member entered the main gathering room and started redirecting residents who needed direction. At 9:09 AM, staff left the gathering room with five residents alone. At 9:17 AM, a staff member passed through the gathering room to assist another resident down the hall. At 9:19 AM, a staff member came to the gathering room trying to engage residents in a coloring activity.

Based on observation, interview and record, the facility failed to implement, provide person centered activities, follow the calendar, and properly document activities for 4 (Resident #5, Resident #14, Resident #27, and Resident #57) reviewed for activities, from a total sample of 18, resulting in residents with lower cognitive function related to dementia having the potential to be socially isolated, depressed, bored, wander and have behavioral outbursts. Resident #5 (R5) Review of a Face Sheet revealed R5 is an [AGE] year-old male who admitted on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed he is cognitively intact and require supervision when independently ambulating. During an observation and an interview on 5/23/22 at 10:12 AM, R5 was ambulating in his room stating he is leaving today. His packed his clothes up, and no sheets were on the bed. He walked around in his room and would sit in his chair and look out the window. During an observation and interview on 5/23/22 at 12:37 PM, R5 was in his room with his meal tray in front of him and refusing to eat. He was upset and told staff he has a court order to get out of here. Staff were trying to convince him to eat. Restorative Aide (RA) W reported he just recently transferred to this unit (AU) and not adjusting well. When he was on the other unit, he was involved in activities every day at 11:00 AM and would walk down to the activity himself. But now his schedule has changed over here and is not doing the activities. During an observation on 05/24/22 at 9:14 AM, R5 was sitting in his room in a chair sleeping. Several observations were made throughout this survey with R5 in his room isolated, upset, and would not leave his room. Review of a Care Plan for R5 revealed: Resident is At Risk for ELOPEMENT related to confusion, disorientation, new admission status. Date Initiated: 02/14/2022. Interventions: Provide structured activities: toileting, walking inside and outside, reorientation, strategies including signs, pictures, and memory boxes. Resident is long term care with no plans to discharge. Date Initiated: 02/20/2022 Assist resident with adjustment to new placement by offering activities of interest. Date Initiated: 02/20/2022. The resident has potential for decreased activity participation r/t change in routine, weakness Date Initiated: 02/15/2022 Revision on: 04/14/2022. Interventions: 1:1-Offer preference/interest. Focus on outdoor leisure in Courtyard in good weather and the opportunity to enjoy 'nature', watching birds, caring for plants, walking for exercise and enjoyment. Resident may also enjoy participating in artwork, painting, coloring. See Activity Preferences for further ideas. Date Initiated: 04/14/2022. Revision on: 05/11/2022. Notify recreation department if activity supplies needed for resident to utilize. Has cell phone in room and niece stated she brought in a color book and pencils (on top shelf of closet). Date Initiated: 02/15/2022. Revision on: 02/15/2022. Provide invitation to activities of interest. Speak up during visits, eliminate background noise, in groups sit close to source of sound. Read words/literature of interest out loud to resident upon resident's request and/or need. Date Initiated: 02/15/2022. Revision on: 05/16/2022. Review of the Activities list R5 participated in revealed he was more active on the other unit than he has been on the AU. Resident #14 (R14) Review of a Face Sheet revealed R14 is an [AGE] year-old male who admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) revealed he is severely cognitively impaired and utilized a wheelchair, required supervision, and extensive assistance with cares. He has limited range of motion on one side of his body affecting his upper and lower extremities. R14 During an observation on 5/23/22 at 11:11 AM, R14 was in bed sleeping. The resident was observed either sleeping or in lunchroom at mealtimes throughout this survey. Review of the Care Plan for R14 revealed: Potential for inadequate stimulation r/t short attention span, impaired motor skills, impaired vision, impaired hearing. Date Initiated: 03/24/2019. Revision on: 09/23/2021. Activity Preferences/Interests: having literature to read, keeping up with the news, and favorite topic is reading the newspaper. In the past going outside to get fresh air in good weather (50 degrees or above w/blanket and outer wear) was a preference. Also, pertinent ideas to incorporate in residents' day are animal topics/sensory (has a dog named Mocha), reminiscing, 'work' terminology, and/or pampering. Date Initiated: 03/24/2019. Revision on: 12/31/2021. Interventions: invite and escort to areas of interest, set-up for right field of vision, provide assistance with holding/manipulating items and resident is generally able to hold the newspaper without assistance, speak clearly/concisely, check for understanding and repeat prn due to hearing deficit. Communication techniques using 'work' terminology such as would you guide me?, thank you. Prior to activity topics ending, resident may depart and/or return, ensure resident is reintroduced to topic at times of return. Date Initiated: 03/24/2019. Revision on: 03/24/2019. Provide a program of activities that is of interest and accommodates residents' status. Date Initiated: 04/26/2019. Review of the Activities charting for R14 revealed no activities charted during this survey and minimal activities in the last 30 days. Resident #27 (R27) Review of a Face Sheet revealed R27 is an [AGE] year-old male who admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] revealed he is severely cognitively impaired and requires limited assistance of one for transfers. During an observation on 5/23/22 at 10:48 AM, R27 is in the common area in recliner near the nurse's station. No activities going on and not engaged. Review of the Care Plan for R27 revealed: The resident has potential for decreased activity participation due to dementia, hearing, and vision deficit, sleeping pattern. Date Initiated: 8/06/2021. Revision on: 02/11/2022. Interventions: One on one-a.m./early p.m. focus. Offer interest/preference; per wife resident really enjoyed reading and reading to resident is a good set-up. Offer social stroll. At times of good weather promote outdoor leisure. Other themes to incorporate may be fishing and hunting. Date Initiated: 08/11/2021. Revision on: 02/11/2022. Interests/Preferences: reading literature of interest (sections of the newspaper, especially sports), listening to Country Music, doing favorite hunting activity, going outside when the weather is good, and participating in religious services or practices. Date Initiated: 08/11/202. Interventions-Invite/escort to areas of interest. Promote activities in a.m./early p.m. Resident may appreciate a stroll. Provide cues/task segmentation prn. Literature read out loud to resident, may need assist with placement of objects. Place next to source of sound. Ensure to speak clearly/concisely, check for understanding and repeat prn (as needed). Date Initiated: 08/06/2021. Revision on: 02/11/2022. Provide visits to identify activity interests/preferences and to assist in engaging in them prn. Review of the Activities charting for R27 revealed no documentation to show what activities if any the resident engaged in most days from 4/26/22 to 5/24/22. On 5/24/22, the documentation showed he was actively engaged in 1:1 activity and does not specify what that activity was. On 5/23/22 shows no documentation of any activity that occurred. Resident #57 (R57) Review of a Face Sheet revealed R57 is a [AGE] year-old female originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 5/23/22 at 10:25 AM, R57 was in Community room A in her wheelchair. She had her lap tray down sitting near a table. No staff in the room. The resident next to her is doing a puzzle and she had some toy like figures in her hand. During an observation on 5/23/22 at 11:44 AM, R57 was in Community room A with three other residents in the room and no supervision. She was grabbing at the air at times. Residents were not engaged in any activities on this unit. Review of the Care Plan for R57 revealed: The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits, does not verbalize activity wants, requires set up to engage with activities of preference. Date Initiated: 03/24/2019. Revision on: 12/09/2019. Interventions included: One on one-Unless in group, promote physical exercise to resident's tolerance such as seat dancing, playing rhythm instruments, kick ball, etc. Date Initiated: 10/21/2020. Revision on: 04/06/2021. One on one-Promote activity interest/preference. Date Initiated: 03/24/2019 Revision on: 01/19/2021. Activity interests/preferences-The resident prefers activities which do not involve overly demanding cognitive tasks, engage with simple structured activities. Suggestions: soft sensory, visual and auditory sensory, cartoons, children's book, a sister states resident 'loves animals!', looking out window, Cartoons, sensory dolls, nail care (polish), MSU 'anything' especially football related, favorite topics which provide opportunities to listen to music of preference/sing, dance (nursery rhyme, Country), and being around groups of people/being around others, going outside when weather is good, and participating in religious services or practices. Date Initiated: 03/24/2019. Revision on: 09/15/2021. The resident prefers the following TV channels: those with cartoon/family theme, Country music. Date Initiated: 03/24/2019 Revision on: 06/07/2019. The resident prefers to socialize with: residents/staff in main Sitting Area of the Unit. Date Initiated: 03/24/2019. Revision on: 12/02/2019. Review of R57s Activity documentation for R57 revealed on 5/2, 5/20, and 5/23 and most activities were passive. Review of the topic/subjects documented as activities dated 4/26/22 to 5/24/22 revealed several days no specific activity was charted. During an observation and review of the Activities Calendar on 5/23/22 at 12:44 PM on the Alzheimer's Unit (AU) revealed the scheduled activities this day included pampering, aviary care and my music Monday. No engaging or group activities observed from the time of entry this day. During an observation on 5/23/22 at 1:17 PM, twelve residents were sitting in the common are and no activities going on currently. At 1:23 PM there were nine residents observed with two female residents engaging in conversation that led to one female resident grabbing the arm of the wheelchair of the other female resident and shaking it. A couple minutes later another female resident entered the conversation and told the resident shaking the wheelchair to not do that and rolled her wheelchair away from that resident. During an observation on 5/24/22 at 8:54 AM, five residents observed sitting in the main gathering room near the nurses' station with no engaging activities and the television is off. During an observation on 5/24/22 at 9:03 AM, seven residents were noticed in the main gathering room without supervision and one male resident was in a wheelchair wandering the halls with no staff around. Review of the Activities schedule for 5/24/22 revealed a.m. Catholic communion and exercise. At 1:45 PM is Bingo and Two-Bit Store. During an observation on 5/24/22 at 9:19 AM, a Certified Nursing Assistant (CNA) started looking for coloring books to engage the residents in the main gathering room. In an interview on 5/24/22 at 2:10 PM, Activities Aide (AA) V arrived at the AU and reported she worked yesterday and did the beauty shop for the residents on the other unit in the morning, then did some charting and went to lunch. That is why she was not able to do activities in the AU yesterday morning. When questioned about the afternoon activities on 5/23/22, AA V reported she went around the facility and cleaned the fish tanks and the bird cages and tries to fit in activities when she can. When asked what the Aviary activity was on the calendar, she reported it was the cleaning the bird cages and it is considered a sensory activity. and insisted the residents sat around and watched her. When asked what residents participated, what bird cage she cleaned, and when, she reported that the activity surely happened, but the residents did not stay the whole time and could not answer. She insisted she played the piano for about 1 hour in the afternoon between 1:30 -3:00 PM. When asked about activities for this morning (5/24/22) that included communion and exercise, she reported she had not yet done the exercise activity and reported she could not confirm communion but was certain it usually happens. At 1:45 PM, BINGO was the scheduled activity. During this survey between 5/23/22 and 5/25/22, several observations on the AU unit included several residents sitting in the common gathering room near the nurses' station with the television off or it was on with a big error message in the middle of the screen. Residents observed in their wheelchairs with their eyes closed or appeared bored. Review of the May 2022 Activities Calendar for the AU revealed Aviary as an activity nine times. Every Sunday only has televised mass and worship with a lay person. Pampering is an activity every Monday and exercise is listed thirteen times. No proof the activities completed as scheduled.

This citation refers to intake M 7335 Based on interview and record review, the facility failed to assess, document and report timely an injury of unknown origin for 1 (Resident #57), resulting in the potential for unrecognized abuse to continue, a delay in reporting to the Nursing Home Administrator and the State Agency timely, delaying an investigation and the protection from a potential abuser. Findings include: Resident #57 (R57) Review of a Face Sheet revealed R57 is a [AGE] year-old female originally admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Facility Reported Incident (FRI) dated 3/13/22 (Sunday) at approximately 3:40 PM revealed Certified Nursing Assistant (CNA) I and Registered Nurse (RN) J assisted R57 to the bathroom when they noticed a bruise outside her pubic bone and her thigh. The resident was pleasant and cooperative. CNA K called the Assistant Director of Nursing (ADON) to inform her of their findings. Review of written witness statements regarding the bruising on R57 revealed on 3/11/22 CNA T reported there were no concerns regarding the residents skin during the day shift. CNA U gave the resident a bath on 3/11/22 on the first shift and did not notice any bruising on the resident. The State Agency Staffing Certified Nursing Assistant (CNA) M who worked the evening of 3/11/22 provided a written statement she saw a bruise on R57s hairline and reported it the State Agency Staffing Licensed Practical Nurse (LPN) N. The State Agency LPN N provided a statement reporting she was made aware of the bruise, assessed it and noted it to be old in nature and assumed it had already been reported. LPN S said she worked with R57 on 3/11/22 and it was reported the resident had a bruise but did not see the bruise. On 3/12/22, CNA P reported she saw a bruise on R57s pubic during the last morning rounds when she and CNA Q reported it to LPN L. LPN L reported she was informed of the bruise on 3/12/22 but did not realize it was a new finding and thought she was just being updated to monitor the area since she had been off of work for a while. CNA I reported she noticed the bruising on R57 that Sunday (3/13/22) while cleaning the resident after toileting and called RN J into the room. The bruise on her pubis was dark purple and a little on her left inner thigh. Review of a Skin Observation Tool dated 3/13/22 revealed R57 had a bruise on her left medial calf not measured, a bruise on her anterior groin that measured 3.5 x 1.5 centimeters (cm), and a bruise on her left superior medial thigh that measured 1 x 0.5 cm. During an interview on 5/25/22 at approximately 4:15 PM, the ADON reported she was informed on Sunday (3/13/22) that R57 had bruising on her pelvic bone and inner thigh. Through her investigation, she was made aware that the 3rd shift CNA from the night of 3/11/22 reported she saw what looked like old bruising during a brief change on the resident that night to the oncoming day shift nurse (RN L) on 3/12/22. RN L had just returned from vacation and thought the CNA was just letting her know about the bruise to monitor it, not to report it. When asked what her expectations would be for the nurse to do at that time was to look in the medical records to see if there was any documentation or monitoring for a bruise already implemented and if not, the nurse should have reported it immediately and do a full body skin assessment and document it. The ADON reported she tried to reach out to the State Agency Staff and the supervisor would not allow them to talk to the State Agency Staff regarding the injury of unknown origin. The statements had to come from the Supervisor from the State Agency who was also at the facility during that time. The incident should have been reported immediately when it was discovered and then investigated. Review of a Policy titled Skin Assessments last revised 2/8/22 revealed: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and skin management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, return from therapeutic leave of absence greater than 24 hours, and weekly thereafter. Skin observation is completed routinely by CENA staff on bath days' abnormalities are reported to licensed or registered nurse. The assessment may also be performed after a change of condition or after any newly identified pressure injury. Review of a Policy titled Resident Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last revised 10/12/21 revealed: It is the policy of (the Facility) to maintain an environment free of abuse, neglect, mistreatment, or misappropriation of resident property. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Injuries of Unknown Source: An injury should be classified as an injury of unknown source when both of the following conditions are met. i. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and ii. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. h. Immediately: means as soon as possible, but ought not to exceed 24 hours after discovery of the incident, in the absence of a shorter State time frame requirement, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. i. Staff includes employees, the medical director, consultants, contractors, volunteers, caregivers providing care on behalf of the facility, and students enrolled in CENA training or from affiliated academic institutions. Identification: All employees of [Name of Facility] possess a duty to recognize indicators of potential abuse, neglect, and exploitation of residents and misappropriation of resident property. Lesser-known situation that may indicate potential abuse, neglect, or exploitation include, but are not limited to the following: . An injury that is suspicious because the source of the injury is not observed, or the extent or location of the injury is unusual. An injury that is suspicious because of the number of injuries, either at a single point in time or repetitive over a period of time. Investigation: When an allegation or suspected incident of abuse is reported, the Administrator or his/her designee will fully investigate with the assistance of the appropriate facility personnel or outside agencies. Investigation of injuries of Unknown Origin or Suspicious injuries must be immediately investigated to rule out abuse. Such injuries may include, but are not limited to, bruising of the inner thigh, chest, face, and breast; bruises of an unusual size; multiple unexplained bruises; and/or bruising in an area not typically vulnerable to trauma. IX. Reporting/Response: Allegations or suspected abuse, neglect, and exploitation of a residents and misappropriation of resident property should be immediately reported to the Nursing Home Administrator (NHA) and Director of Nursing (DON) during normal business hours. After hours, employees should immediately report to the Nurse-in-Charge, who will in turn notify the NHA and DON. A NHA or DON who becomes aware of an act prohibited by this policy shall immediately follow applicable regulations to report to the Michigan Department of Health & Human Services (MDHHS) / Department of Licensing & Regulatory Affairs ([NAME]), Bureau of Community & Health Systems (BCHS). All alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to other officials in accordance with Michigan law.

This citation pertains to intake MI 3746 Based on observation, interview and record review, the facility failed to ensure 1 resident (Resident #31) was free from abuse, resulting in the potential for mistreatment and psychosocial harm when a staff member verbally yelled at the resident about her behavior in front of other residents. Findings: Review of an Admission Record reflected Resident #31 (R31) admitted to the facility with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Care Plan area activities on 2/25/2022 reflected goal for R31 Maintain activity participation level as evidence by active participation in each group and 1:1 activity. Interventions included Engage in an activity of interest out of her room. Activity Preferences, very important; having books/newspapers/magazines to read (large print), listening to music she likes, being around animals such as pets, doing things with groups of people, doing favorite activity (coloring, jigsaw puzzles, word search), going outside in good weather, and participating in religious services and/or practices. Review of an Incident Report dated 2/28/22 Recreational Therapy Aide (RTA) G reported to Recreational Therapy Director (RTD) H witnessed RTA F Blew up at (Name of R31) during nail care. (Name of R31) stated you're yelling at me and the staff member stating, I'm not (Name of R31) verbalized that she was very upset stating, I don't appreciate people hollering at me. The report reflected initial actions taken, Name of DON and Name of Administrator were notified. (Name of RTA F) suspended pending investigation. Investigation in progress. During an interview with RTA G on 5/24/22 at 12:10 PM, RTA G reported that on 4/28/22 she was working along with RTA F we had a room full of people, we were doing nail care then we had a tea social right after. We were both doing nails, (Name of RTA F) had stated to me, It must be nice having someone help you with activities. (RTA G revealed that earlier that day she had asked to get out early that night in order to coach soccer. Resulting in 2 events/activities being pushed back-to-back to get them in and 2 of us being put together to get it done. We usually do them by ourselves.) I was ignoring (Name of RTA F) at the opposite end of the table; I was working on another resident's nails. I saw (Name of R31), she had just got back from the bathroom she was excited and had a little bit of a raised voice, that's normal for her, kind of child-like she gets a little louder when she gets excited, likes to be the center of attention. She had her nails done; her tea hat was sitting on the table. I heard (Name of RTA F) get loud with (Name of R31), told her to stop yelling at me, (Name of R31). (Name of R31) was just about to cry and wanted to leave, I told her to stay, and other residents talked her into staying. RTA F finished the nails she was doing, when she told me she was not going to stay and deal with this. I stayed in the room with all the residents, and she went had a break, I reported the incident to (Name of RTD H). During an interview on 5/24/22 at 11:33 AM, Recreational Activities Director (RAD) H revealed, I was not in the room when it occurred. Two recreational aides were doing activities, I was told by (Name of RTA G) that another aide had blew up at (Name of Resident 31). I made sure that (Name of R31) and (Name of RTA F) were separated. RTA F was sent on a break, and then sent home. Checked on (Name of R31) she was upset but ok. The Administrator was in the building. I reported the incident to him right away, and then I reported to our DON. RAD H stated It was the first time I ever had a problem with one of my staff, (Name of RTA F) no longer works here. RAD H reflected it was because of the incident. RAD H further revealed that her and her staff have just had recent abuse training again because of this. During an interview on 05/24/22 at 09:15 AM, R31 stated, I was in activities and this lady starts hollering at me, I just had my nails done we were waiting for a tea party. She was yelling at another co-worker then she started yelling at me for no reason. I can't remember what she said, she was just hollering at me. I, don't why she yelled at me. I wanted to leave but they (My friends and the other aide) talked me into staying. (Name of RAD H) came and checked on me later that day, she is the activity director, and she knows I get upset easy. That girl has not been back since. On 05/25/22 at 08:26 AM, R31 revealed that her friend had witnessed the incident, she said I did nothing wrong. None of the other staff have ever been mean to me besides her. I was upset, I did not understand what I did wrong. Resident, wanted to know, Why was I yelled at? (During interview Resident 31 still showed signs of being upset over the incident. R31's voice was raised and would break as she talked, her shoulders made pronounced shrugging movements, lips were downturned, and she looked down as she talked.) During an interview on 05/25/22 at 08:57 AM, with Friend of R31 Z I remember one of the staff yelling at my friend (Name of R31), but I do not know what for, or why. I don't know why staff was yelling at her. (Name of R31) was really upset. Review of like resident statement reflected that Friend of R31 Z had been interviewed after the incident and the following was recorded: 1. How are the recreation staff treating you? - Okay 2. Do you have any issues with any recreational staff? - No Asked her if there was anything unusual at nail care, anyone getting loud. She mentioned there might have been some words, but she wasn't who it was and said it may have been a resident and another resident. I asked her this as (Name of Recreational Therapy Aide (RTA) AA) reported that (Name of Friend of R31 Z) said it was a little unnecessary (the next morning while (Name of R31) was talking about how (Name of RTA F yelled at her.) Review of statement dated by RTA F reflected, that on 4/28/22 she got yelled at while doing another residents nails by (Name of R31). I remember looking across at her as she began to raise her voice to me again. I asked (Name of R31) -Please do not yell at me. She yelled at me again saying I was not yelling. I said OK (Name of R31) you are correct, I am so sorry what can I do for you. This is a continuous thing with (Name of R31) if you do not respond instantly. Unfortunately I was talking to (Name of Another Resident) and did not catch what she had said exactly. I'm used to (Name of R31) yelling at me. So there are times when I am working with another resident that I don't hear exactly what she says to me. Although, I will add that I will always tell (Name of R31) I am here to make her as happy as I can. What can I do for you? What would you like? She does not know what she wants, she says that she is not happy. During an interview on 5/25/22 at approximately 12:30 PM, DON reflected that RTA F no longer works here because of Facilities code of conduct, poor customer service resulting from the incident with (Name of R31). Review of facility provided policy Abuse, Neglect, Mistreatment and Misappropriation of Resident Property with a last revised date of 10/12/21 revealed: It is the policy of (Name of Facility) to maintain an environment free of abuse, neglect, mistreatment or misappropriation of residents property. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Abuse is defined as: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Verbal abuse is defined as: the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental abuse is defined as: includes, but is not limited to humiliation, harassment, threats of punishment or deprivation. Mistreatment means inappropriate treatment or exploitation of a resident.

Based on interview and record review, the facility failed to implement a process to accurately track the vaccination status in 2 of 211 facility staff members (certified nursing assistant M and certified nursing assistant N), resulting in the potential for the spread of COVID-19 and/or serious illness to all facility residents. Findings include: A review of the facility's COVID-19 Vaccination Exemption Employee Tracking Log, undated (but provided to the surveyor on 3/1/22), revealed 2 of 108 employees (certified nursing assistant (CNA) M and CNA N) on the log had exemptions from receiving the COVID-19 vaccination or vaccination series. Both were listed as No under the Employee Exempt column. During an interview on 3/2/22 at 2:30 PM, the Director of Nursing (DON) stated they have been trying to get a hold of CNA M to see what their intentions are for getting the vaccine. She stated they were talking to CNA M, whose exemption was denied, until 2/3/22. At that point they have been sending her messages without any response. The DON stated CNA M is currently suspended per their policy and will be terminated in two weeks unless she gets her exemption approved or gets the COVID vaccine. During an interview on 3/2/22 at 2:30 PM, the DON CNA N is currently suspended because she has not had the COVID vaccine and has not applied for an exemption. She stated they have left messages for her and have not gotten a response back. The DON stated CNA N will be terminated in two weeks, or less, unless she gets the COVID vaccine or an exemption. A review of the facility's Employee COVID-19 Vaccinations Infection Control policy and procedure, revised 1/13/22, revealed, 5. The facility will ensure that all eligible employees (except for staff who have been granted exemptions to the vaccination requirements, or those staff for whom COVID-19 must be temporarily delayed, as recommended by the CDC (Centers for Disease Control), due to clinical precautions and considerations) are fully vaccinated for COVID-19 . 12. The facility will establish contingency plans in the event that staff have indicated that they will not get vaccinated and do not qualify for an exemption or staff who are not fully vaccinated due to an exemption or temporary delay in vaccination. Staff must complete the vaccination series or obtain an exemption by Feb. 28, 2022. Staff that fail to meet the criteria will be placed on administrative leave of absence for a period of 2 weeks and will be provided additional education regarding the COVID-19 vaccination. After 2 weeks the employee still to meet the criteria, employment will end.

Based on observation, interview, and record review, the facility failed to: 1) accurately maintain controlled substance records for 2 of 4 medication carts inspected ((D Hall and F Hall) and 2) failed to properly prepare and administer medications according to nursing standards of practice and facility policy for 3 of 7 residents (Resident #13, Resident #50, and Resident #53) observed during the medication administration task, resulting in controlled substance records not matching the amounts in the residents controlled substance medication cards, medications being pre-staged/ prepared far in advance of the administration of those medications, and medications being left at bedside for self-administration without a physician order [REDACTED]. Findings include: D Hall Medication Cart During a review of D hall Medication cart on 10/6/20 at 8:15 AM, this surveyor reviewed Resident #16's [MEDICATION NAME] (a narcotic pain mediation) Controlled Substance Proof of Use Form, this form indicated there were 183 tablets remaining in the medication cart. Upon observation at that same time, the [MEDICATION NAME] actual count was 182 tablets. Licensed Practical Nurse (LPN) F stated that she had given the missing tablet at around 7:20 AM (55 minutes prior) to Resident #16. LPN F then signed out the tablet on Resident #16's Controlled Substance Proof of Use Form. During this same observation, Resident #9's [MEDICATION NAME] (a controlled substance) Controlled Substance Proof of Use Form indicated 29 tablets remained in the medication cart. Upon observation of the [MEDICATION NAME] medication card, only 26 tablets remained in the medication cart. LPN F stated she had given the medication to Resident #9 around 7:00 AM (over an hour prior). LPN F then signed out the tablets on Resident #9's Controlled Substance Proof of Use Form. LPN F stated that she keeps the narcotic book in the locked medication room and typically signs out all of the administered controlled substances at a later time and indicated that there was no space to keep the narcotic book on her medication cart. LPN F reported that nurses are to sign out controlled substances at the time the nurse gives the medication. Review of facility policies Medication General Guidelines, revised 4/18, and Controlled Substance Administration and Accountability, dated 2/24/20, did not indicate when staff signs out medications-controlled substance or otherwise. According to Perry and Potter, dated 2014, Record medications immediately after administration (see agency policy). Include the drug name, dose, route, time, and your signature and an inventory record is used each time a narcotic is dispensed. Records are often kept electronically and provide an accurate ongoing account of the narcotics use, wasted, and remaining. Resident #13 A review of Resident #13's Admission Record, dated 10/7/20, revealed, Resident #13 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident #13's Admission Record revealed Resident #13 had multiple [DIAGNOSES REDACTED]. Resident #50 A review of Resident #50's Admission Record, dated 10/7/20, revealed Resident #50 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #53 A review of Resident #53's Admission Record, dated 10/7/20, revealed Resident #53 was an [AGE] year-old resident admitted to the facility on [DATE]. In addition, Resident #53's Admission Record revealed Resident #53 had multiple [DIAGNOSES REDACTED]. During an inspection of the F Hall medication cart (as defined by staff) with Registered Nurse (RN) B on 10/06/20 at 08:10 AM, a medication cup labeled with Resident #50's name was observed in the top drawer with pills/tablets in it. RN B stated she already prepared Resident #50's medications that he receives after breakfast and was going to give them to him when he was done eating. RN B stated the medication cup contained contained [MEDICATION NAME] 20 mg (milligrams) (a water pill), [MEDICATION NAME] 5 mg (a medication for urine retention), [MEDICATION NAME] 25 mg (a heart/blood pressure medication), [MEDICATION NAME] 0.4 mg (a prostate medication), senna 8.6 mg (a stool softener, and potassium 40 mEq (mill-equivalents). During a review of F Hall's Narcotic/Controlled Substance Log Book (as defined by staff) with RN B on 10/6/20 at 9:45 AM, the following interview and observations were made: - Resident #13's [MEDICATION NAME]/APAP 10/325 milligrams (mg) ([MEDICATION NAME] 10 mg and [MEDICATION NAME] 325 mg- [MEDICATION NAME]) Controlled Substance Proof of Use, dated 9/29/20, revealed LPN B signed she had removed one [MEDICATION NAME] tablet from Resident #13's medication card on 10/6/20 at 12N (12:00 PM- noon) (approximately 2 hours in the future) and there were a total of three tablets left in the blister pack of Resident #13's [MEDICATION NAME] medication card. A review of Resident #13's [MEDICATION NAME] medication card with LPN B at this time revealed there were four tablets in the blister pack of Resident #13's [MEDICATION NAME] medication card. - Resident #50's [MEDICATION NAME] 600 mg Controlled Substance Proof of Use, dated 9/30/20, revealed LPN B signed she had removed one [MEDICATION NAME] tablet from Resident #50's medication card on 10/6/20 at 12N (12:00 PM- noon) (approximately 2 hours in the future) and there were a total of twenty-three tablets left in the blister pack of Resident #50's [MEDICATION NAME] medication card. A review of Resident #50's [MEDICATION NAME] medication card with LPN B at this time revealed there were twenty-four tablets in the blister pack of Resident #50's [MEDICATION NAME] medication card. - RN B stated she had documented Resident #13's [MEDICATION NAME] and Resident #50's [MEDICATION NAME] as being removed from their respective medication cards early because she was just sitting at the desk and had time to do it. During a medication administration observation on 10/6/20 from 11:00 AM to 12:15 PM, with RN B the following observations and interviews were made: - RN B administered [MEDICATION NAME] 10/325 mg to Resident #13 (the tablet that had been signed out over 2 hours prior) after removing it from the [MEDICATION NAME] medication card blister pack. - RN B administered [MEDICATION NAME] 600 mg to Resident #50 (the tablet that had been signed out over 2 hours prior) after removing it from the [MEDICATION NAME] medication card blister pack. - RN B placed Resident #53's [MEDICATION NAME] 0.4 mg and [MEDICATION NAME] 80 mg (a medication for gas) in a medication cup, took the medications into Resident #53's room, placed the medication cup on Resident #53's bedside table, told Resident #53 to take them, and turned around and left the medication cup with the [MEDICATION NAME] and [MEDICATION NAME] in them without making sure Resident #53 took them. - RN B stated she documented Resident # 13's [MEDICATION NAME] and Resident #50's [MEDICATION NAME] early in the narcotic count book because If I know they're going to take their pills. I'll sign them out when I sit down to chart. If I don't know if they'll take them, I wait until it's time to given them before I sign them out. RN B confirmed she had documented Resident #13's [MEDICATION NAME] and Resident #50's [MEDICATION NAME] on their respective Controlled Substance Proof of Use sheets prior to the observation at 9:45 AM. - RN B stated she could leave Resident #53's medications in his room without watching him take them because Resident #53 had been evaluated to self-administer medications. During an interview on 10/07/20 at 10:00 AM, the Director of Nursing (DON) stated the expectation for narcotic sign out (Controlled Substance Proof of Use) sheets is the nurses sign out the narcotics around the time they prepare them or administer them. The DON stated it is not acceptable to sign them out hours before or after the narcotic/controlled substance is administered. The DON also stated nurses should not be preparing medications ahead of time and storing the medications in a medication cup in their medication carts. A review of Resident #53's physician order, dated 3/13/20, revealed, LOCK BOX at bedside for self administration of [MEDICATION NAME], Sodium tablets and Aspercreme. every shift for Self administration of med/treatments. During an interview on 10/07/20 at 03:30 PM, Assistant Director of Nursing (ADON) A stated Resident #53 only has an order to self-administer [MEDICATION NAME], Sodium tablets, and Aspercreme. She stated all other medications should not be left at the bedside. ADON A stated she would expect RN B to have watched Resident #53 take his [MEDICATION NAME] before she left the room. A review of the facility's Medication General Guidelines Policy and Procedure, reviewed/revised 4/2018, revealed, 1. All medications are to be given as ordered by the physician . 11. No drugs are to be left at resident's bedside unless a specific order from the physician. (Please discourage). Nurse must stay with the resident until medication have been swallowed. A review of Clinical Nursing Skills and Techniques (Perry and Potter), dated 2014, revealed, Record medications immediately after administration (see agency policy). Include the drug name, dose, route, time, and your signature and an inventory record is used each time a narcotic is dispensed. Records are often kept electronically and provide an accurate ongoing account of the narcotics use, wasted, and remaining. A review of the facility's Controlled Substance Administration and Accountability policy and procedure, dated 2/24/20, did not reveal when staff are supposed to sign out controlled substance medications.

Based on observation and record review, the facility failed to maintain confidentiality of medical records for 1 of 18 residents (Resident #50), resulting in Resident #50's electronic Medication Administration Record [REDACTED]. Findings include: Resident #50 A review of Resident #50's Admission Record, dated 10/7/20, revealed Resident #50 was a [AGE] year-old resident admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During an observation on 10/06/20 at 08:00 AM, Registered Nurse (RN) B left the F Hall medication cart (as defined by staff) to answer a bed alarm in room [ROOM NUMBER]. RN B left the computer screen on top of the medication cart open on Resident #50's medication record. Resident #50's electronic Medication Administration Record [REDACTED]. Some of the information that was visible on Resident #50's e-MAR were Resident #50's name, Resident #50's room number, and the medications Resident #50 had due ([MEDICATION NAME] (a water pill), [MEDICATION NAME] (a medication for [MEDICAL CONDITION]), [MEDICATION NAME] (a heart/blood pressure medication), [MEDICATION NAME] (a medication for prostate problems), senna (a stool softener), and potassium). There were not any staff visible in the hallway or near the medication cart and the F Hall medication cart was not within RN B's view (this surveyor was standing next to, and walking around, the medication cart and could not see RN B in room [ROOM NUMBER]).

This citation pertains to intake MI 4 Based on observation, interview and record review, the facility failed to ensure resident equipment was in good working condition for 1 Resident, (R#70) of 24 residents reviewed for their wheelchairs and accessory equipment to be in good working order, from a total sample of 86 residents. This deficient practice resulted in the potential for possible injury due to lack of equipment maintenance. Findings include: Resident #70 According to a facility admission record dated 10/06/20 at 17:42 ET, Resident #70 (R#70) was admitted into the facility on [DATE] with cumulative Diagnoses: [REDACTED]. During an interview on 10/07/20 at 3:44 PM, Certified Nurse's Aide (CNA) S revealed that We only lock his brake when he transfers, he only has one break on his wheelchair and it's on his left side and he can't use his left side. CNA S further revealed that during transfers, we have to hold the chair (wheelchair) down during a maxi lift so we can ensure the chair is under him (Resident #70). During and interview on 10/07/20 at 04:34 PM, the Director of Nursing (DON) stated 'I don't know what's going on and let's go find out. after referencing that R#70's chair only locked on the left side. On 10/07/20 at 04:40 PM, observed with the DON that R#70's wheelchair had no spacer bar on right side. The absence of the spacer bar prevented the right wheel from locking in place. On 10/07/20 at 4:44 PM, observed DON write a repair order for R#70's wheelchair. On 10/07/20 at 4:53 PM, a request was made to the DON for wheelchair maintenance policy or manufacturers book for R#70's wheelchair. On 10/07/20 at 5:09 PM DON replied, I have reached out to maintenance, but I do not see anything in their policies on the computer. Only thing I see is work order policy. On 10/07/20 at 5:10 PM, DON replied that No manual that Maintenance has that he sees. No w/c maintenance policy. A review of Facility Reported Incident (FRI) dated 9/16/20 revealed that an incident occurred on 9/16/20 that involved Resident #70, his wheelchair and its locks. Review of the policy and procedure of WORK ORDERS Nursing Reviewed and Revised 1/06 reflected the following: POLICY: It is the policy of this facility to communicate to Maintenance Department, by use of triplicate work order to provide detailed description, and the location of need and to facilitate assignment and follow-up for the repair needed. PROCEDURE: 1. When an item is in need of repair or cleaning, write a work order on Work Order form, send white copy to Maintenance Department and retain yellow copy for Nursing employee to give to the Director of Nursing or post at the Nurses' station. 2. When the job is completed, the work order form will be completed and copy filed in the Maintenance Department. 3. All employees are responsible to fill out a work order if they see items in need of repair or cleaning.

Based on observation, interview, and record review, the facility failed to prevent a pressure sore for one dependent resident (Resident #11), resulting in the development of a stage 2 pressure sore, and the potential for this sore to worsen by not following the plan of care, and the potential for development of pressure sores for all dependent facility residents at risk for pressure sores. Findings include: Resident #11 was originally admitted to the facility 11/9/11 and has current [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] reflected Resident #11 was severely cognitively impaired, was totally dependent for physical transfers, required 2 staff for positioning in bed, and was at risk for the development of pressure sores. Review of the Electronic Medical Record EMR Progress Notes dated 2/26/19 at 2:20 PM, reflected the discovery of a stage 2 Pressure Ulcer located on the coccyx (tailbone) and measured 2.3 centimeters (cm) by 2.7 cm. and a square centimeter (sq. cm) area of 6.21 sq. cm. Review of the EMR (electronic medical record) Progress Notes, from 1/1/19 to 2/26/9, did not reflect any documentation that a body skin assessment had been completed for Resident #11. On 2/28/19 at 9:36 AM, an interview was conducted with Certified Nurse Aide (CNA) DD. CNA DD reported Resident #11 had been spending more time in his wheelchair over the previous three weeks. CNA DD reported after the Resident was placed in his wheelchair in the morning staff try to lay him back in bed at least one time a day. CNA DD reported the Door Plan reflected Resident #11 was to be repositioned every hour but that it was difficult to even reposition every two hours due to the staffing on the floor. CNA DD indicated that turning and repositioning of residents was a task to be done, but did not think documentation that it was actually done was a required task that had to be completed. On 2/27/19 at 11:19 AM, CNA L reported there was not enough staff on the Hall that Resident #11 lived on. CNA L reported the Hall had fourteen residents and nine of these residents required the use of a lift for transfer. CNA L reported lifts required two staff to operate and indicated there was not enough staff and time to meet the needs of the residents. On 2/27/19 at 10:44 AM, Licensed Practical Nurse (LPN) J reported Resident #11 developed a pressure sore on his coccyx the previous day because of not being taken out of his wheelchair regularly. LPN J reported since the pressure sore developed, Resident #11 was changed from a regular wheelchair to a Geri-type wheelchair. LPN J reported Resident #11 was to be transferred to the wheelchair in the morning for breakfast then back to bed afterward. LPN J reported, more recently, the Resident had not been laid down as often because of a recent change in staffing. On 2/28/19 at 12:30 PM, an interview was conducted with Registered Nurse (RN) P. RN P reported she was certified as a wound care nurse. RN P reported two days prior she had been informed of a new pressure sore discovered on Resident #11. RN P reported she assessed the Resident and determined a stage 2 open area had developed on the coccyx. RN P reported that it was discovered that the Roho wheelchair cushion was not properly inflated. RN P reported the Resident was changed to a reclining Geri-chair and a new Roho cushion was provided. RN P reported the skin Care Plan for Resident #11 had not been updated. On 2/28/19 at 2:15 PM, the Care Plans for Resident #11 were reviewed and revealed a facility document titled Care Plan, Skin Integrity, Impaired . The Care Plan Reflected a Goal of Will have skin intact as evidenced by no skin breakdown at any time. The Care Plan reflected, Approach (interventions) of: Nurse Aide -2/28/2012 - Monitor and assist to turn/reposition (every) one hour and (as needed), Nurse Aide - 4/27/17 - Use positioning pillows/wedges to relieve pressure off vulnerable areas- hips, heels, coccyx . Review of the Care Plan did not reflect any additions or changes to the plan of care for Resident #11 to address the treatment of [REDACTED]. The Care Plan did not reflect that skilled nursing staff was expected to perform regular skin assessments on dependent residents. During an interview conducted 2/28/19 at 2:36 PM, the Director of Nursing (DON) reported that nurses do not do regular skin assessments or document body audits, but will assess a resident's skin if alerted of a skin issue by a CNA. The DON indicated she would have expected a revision of the Skin Care Plan for Resident #11 the day it was discovered. The DON reported that she thought the pressure sore developed because the Roho cushion had deflated and not due to a staffing issue. The DON reported that repositioning of residents was not documented but that staff were expected to follow the Door Plan. The DON reported that because of the location of the pressure sore she knew it developed from the Resident being in a sitting position and not from being in a lying position. On 2/28/19 at 7:56 AM, Resident #11 was found to be in his Geri-chair in a seated position in the Main Dining Room. At 8:53 AM, the Resident was found in the same position in the Geri-chair in a common area in front of a television with a small pillow on his lap. At 10:09 AM, Resident #11 was observed in an activity in the Chapel with the pillow on his lap. At 11:34 AM, Resident #11 was observed in his Geri-chair in a common area with the small pillow on his lap. During this observation, a CNA approached the Resident and informed him she was going to toilet him then return him to the Geri-chair to be taken to the Dining Room for lunch. At no time during these observations was Resident #11 observed out of his chair or that he had been repositioned in his chair with pillows or other devices.

Based on observation, interviews, and record review, the facility failed to prevent a fall for 1 of 7 residents (Resident #7) reviewed for falls and failed to safely transport a resident in a wheelchair for 3 residents (Resident #27, Resident #29, and Resident #256), from a total sample of 23 residents, resulting in Resident #7 sustaining a fracture from a fall and the potential for injury for residents being pushed by staff in a wheelchair without foot pedals (Resident #27, Resident #29, and Resident #256). Findings include: This portion of the citation (Resident #7 only) refers to MI 473. Resident #7 A review of Resident #7's face sheet, dated 5/14/18, revealed Resident #7 was a [AGE] year old resident admitted to the facility on [DATE]. A review of Resident #7's [DIAGNOSES REDACTED].#7 had multiple [DIAGNOSES REDACTED]. A review of Resident #7's Minimum Data Set (MDS- a tool used for assessing a resident's care needs), dated 5/9/18, revealed Resident #7 had a Brief Interview for Mental Status (BIMS- a tool used to determine a resident's cognitive status) score of 6 which revealed Resident #7 was severely cognitively impaired. In addition, Resident #7's MDS revealed Resident #7 had sustained 2 or more falls that resulted in minor injury since last assessment period (during the prior 3 months). A review of Registered Nurse (RN) PP's written and signed statement, dated 5/10/18, revealed a quarterly review of Resident #7 's velcro alarming seatbelt was completed on 5/8/18 with recommendation to discontinue velcro alarming seat (belt). Resident (Resident #7) is no longer making self-transfer attempts and seeks out staff for needs. A review of Resident #7's nursing progress note, dated 5/10/18, revealed on 5/9/18 Resident #7 had been found (on the floor) approx (approximately) 1930 (7:30 PM) in his room. His head (Resident #7's) was facing the opposite direction of the bathroom door opening there was blood on the floor likely from the open skin tear on his left arm lateral side of the AC (antecubital- crook of arm) space. The resident (Resident #7) was complaining of pain from his hip stating it wasn't a sharp knife pain but more like a piercing bone that went all around as he (Resident #7) touched the lateral right lower abdomen to his lateral left lower abdomen. He (Resident #7) also stated he was having pain in his right shoulder . In his room the resident's (Resident #7) wheelchair had been locked and was knocked over so the seat of the wheelchair was facing up, the direction of the wheelchair was facing towards the resident's bed where the call light was attached to the side of the bed opposite of the wheelchair. When asking the resident (Resident #7) what he thought caused the fall he was trying to get up on his own, then stated that he was trying to get to the trouble cord in the bathroom, which later was discerned from the CNA (certified nursing assistant) staff that the resident refers to the red pull cord (bathroom call light) as the trouble cord . this nurse had called the FNP (family nurse practitioner) and had told her that d/t (due to) hip pain and an unwitnessed fall that send out (to the hospital) may be best call, in agreement with the FNP the transfer process was started . family was contacted @ (at) approx 2000 (8:00 PM) given the condition update, they requested that the resident (Resident #7) be sent to (name of hospital). A review of Resident #7's nursing progress note, dated 5/10/18, revealed Resident #7 was admitted to the hospital with [REDACTED]. On 5/29/18 at 2:30 PM, a phone voice mail message was left for CNA X requesting a call back related to Resident #7's incident on 5/9/18. As of the time of completion of the investigation and exit from the facility, CNA X failed to return the call. During an interview via phone on 5/29/18 at 2:50 PM, LPN (Licensed Practical Nurse) W stated, I worked a double (shift) that day. I worked from 5:30 AM to 10:00 PM. He (Resident #7) was being aggressive toward another resident. He was flashing back to World War Two and he thought the other resident was a German. We stopped a near miss (an incident that almost resulted in a resident to resident altercation) where they almost had a confrontation. We moved the other resident to the dementia unit. At the change of shift in the afternoon, I was getting report from the CNA's. I was told the day CNA the day before had not charted he (Resident #7) had self transferred after the seatbelt was removed. I believe if they (the CNA) would have charted he (Resident #7) would have charted he self transferred, we would have put the seatbelt back on. I told my CNA's to keep an close eye on him (Resident #7). They (the CNA's) told me he (Resident #7) attempted to self transfer at 4:30 PM (on 5/9/18). At around 6:50 or 7:00 PM, he (Resident #7) went in his room. No one knew he went in his room because the door was shut and his stop sign (a banner that is attached by velcro across the doorway to help deter a resident from entering a room) was up. He must have climbed under it to get in the room or took it down and then put it back before his door shut. The CNA, either (name of CNA OO) or (name of CNA X), went to check on him. They found him on the floor with his gripper socks (socks with sticky strips on the bottom) off and the wheelchair was tipped. He (Resident #7) was found half way between the bathroom and his bed. He was complaining of hip pain. We took a slide board and transferred him to his bed. We did range of motion on him moving his legs. He didn't complain of pain with the range of motion. He had no shortness of a limb or anything to indicate he broke his leg or hip. He did complain of pain to his hip, so we thought he might have fractured (the hip). He had dementia and did not usually complain of hip pain, even though he had some chronic pain. I called the doctor immediately. We had him (Resident #7) sent out to the ER. I wrote down everything write away. I had everyone fill out witness statements. I was told after the incident by (name of CNA X) he (Resident #7) had self transferred 2 or 3 more times between 4:30 PM and when he was found at around 7:00 PM. But she didn't tell me before this (the fall) happened. If I would have known he (Resident #7) was self transferring 4 or 5 times during the shift, I would have put him on temporary 1:1 (one-to-one where a staff member is directly observing a resident at all times) until we could get something on him like a seatbelt or an alarm. During an interview on 5/29/18 at 3:25 PM, CNA Y stated, Earlier in the day before 3:30 PM, he (Resident #7) had self transferred onto the toilet. He had his pants, shoes, socks, and brief off. He was pretty messy with stool. He had loose stools. Me and another aide, (name of CNA OO) went in to clean him up. We let the nurse, (name of LPN W), know that he (Resident #7) did self transfer. He (Resident #7) did have a velcro stop sign on his door, but it wasn't sticking. One of the tabs was off. (Name of LPN W) said to make sure we can see him (Resident #7) so he doesn't self transfer anymore that day. Then around 7:00 or 7:15 at night I was with another resident getting her ready for bed. When I came out of the room, I was going to drop the linen and garbage off. I didn't see (name of Resident #7). (Name of CNA OO) was at the dining room table with another resident. I don't know where (name of CNA X) was. (Name of CNA X) was his aide that day. I asked (name of CNA OO) where he (Resident #7) was. I think (name of CNA X) was near by with another resident because when I asked (name of CNA OO) where (name of Resident #7) was, she went to his room. She (CNA X) saw he had fallen. His feet were pointing toward the bathroom. We got the nurse and got him (Resident #7) checked out. He (Resident #7) said he was trying to get to his light in the bathroom to try to get help. I think he was trying to go to the bathroom by himself. He wasn't incontinent. He wasn't saying anything much about pain. He wasn't yelling or screaming in pain. He just said his hip hurt. The night before, he (Resident #7) stood up by his dresser after the alarm was taken off. A review of CNA X's written and signed statement, dated 5/11/18, revealed the following questions and answers: - Did (name of Resident #7) self-transfer during your shift prior to the fall (on 5/9/19)? - Yes - If yes, how many times and what was he doing that prompted the self transfer(s)? -Less than 10 times, but more than 5 self transfers. - Has (name of Resident #7) regularly attempted to self-transfer from his wheelchair prior to the day of his fall (5/9/18)? - He began self transferring once his seatbelt alarm was removed from his (wheel) chair. Resident #27 A review of Resident #27's face sheet, dated 5/24/18, revealed Resident #27 was an [AGE] year old resident admitted to the facility on [DATE]. A review of Resident #27's [DIAGNOSES REDACTED].#27 had multiple [DIAGNOSES REDACTED]. A review of Resident #27's Minimum Data Set (MDS- a tool used for assessing a resident's care needs), dated 3/13/18, revealed Resident #27 had a Brief Interview for Mental Status (BIMS- a tool used to determine a resident's cognitive status) score of 17 which revealed Resident #27 was severely cognitively impaired. In addition, Resident #27's MDS revealed Resident #27 was independent with locomotion off the unit (e.g. to the dining room). On 5/22/18 at 12:25 PM, CNA KK was observed pushing Resident #27 from behind without foot pedals from the hallway into the dining room. Resident #27 was attempting to move her feet on the floor to propel herself while CNA KK was pushing the wheelchair. CNA KK pushed Resident #27 approximately 20 to 30 feet into the dining room before looking up, looking at this Surveyor, and going from the back of Resident #27's wheelchair to the right side of Resident #27's wheelchair and continuing to push Resident #27's wheelchair (versus guiding the wheelchair) from the side. Resident #29 According to a facility face sheet dated printed 5/29/18 at 3:33 PM, Resident # 29 was an [AGE] year old female admitted to the facility on [DATE] with the Diagnoses: [REDACTED]. On 05/23/18 at 10:01 AM observed Resident # 29 being propelled by wheelchair down Dune Drive by her sister in law according to Certified Nurses Aide (CNA) Z. CNA Z stated she didn't know Resident #29's family was pushing her without the foot rests and she would fix it. Resident #256 According to a facility face sheet dated printed 5/29/18 at 3:33 PM, Resident #256 was an [AGE] year old male admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. On 05/24/18 at 12:10 PM, CNA J was observed to be propelling Resident # 256 from the Bistro small dining area down hallway to his room without foot rests. According to a facility policy titled, Foot Pedals dated 6/15/05 reflected, All Wheelchairs will have a set of foot pedals (rests or plates) .Bags will be attached to the back of each wheelchair to store foot pedals when not in use .Wheelchair foot pedals are to be on the wheelchair with resident's legs/feet on the pedals when a resident is being pushed by a staff member .ADON (assistant director of nursing) will be responsible for monitoring this system. According to Mosby's Textbook for Long-Term Care Nursing Assistants 7th edition, in the Wheelchair Safety Section, Make sure the person's feet are on the foot plates (wheelchair foot rests or pedals) before moving the chair. The person's feet must no touch or drag on the floor when the chair is moving. Never push a person in a wheelchair without feet resting on the footplates (foot rests or foot pedals).

This citation is in reference to MI 521. Based on interview and record review, the facility failed to safely and adequately supervise the bathing process for 1 out of 3 sampled residents (Resident #101), who was being bathed in a shower chair and subsequently fell out of the shower chair on [DATE] at 6:40 p.m., resulting in a sustained closed fracture at the vault of the skull including intracranial hemorrhage (subarachnoid, cerebral and subdural hematomas), a left femur fracture and cervical spine fracture. Resident #101 was placed in Immediate Jeopardy (IJ) to her health and safety and subsequently died as a result of the fall. The Immediate Jeopardy (IJ) was identified on [DATE] at approximately 12:15 p.m. The Immediate Jeopardy (IJ) began on [DATE] at approximately 6:40 p.m. when, according to the "Facility Investigation Report - 5 Working Days" (dated [DATE]) the following occurred: "On [DATE] at approximately 6:40 p.m., (Resident #101's name) fell out of the (manufacturer's name) bath chair. (Staff member "CC"), CNA (certified nursing aide) stated, 'While trying to dry resident's arm (Resident #101), she was tensing up her arms. I had to lift the bar to lift her arm and dry her. I reached to the left for the deodorant. When I stood upright resident was already leaning forward and fell out of the chair'. (Resident # 101's name) was transferred to (name of area hospital) where she was diagnosed with [REDACTED]. (Resident #101's name) returned to this facility at 11:45 p.m. [DATE] per family request for comfort measures...Roxanol was ordered for pain control. Upon return to this facility it was noted the resident's vital signs (VS) were unstable with low blood pressure readings. (Resident #101's name) was transferred to (name of another area hospital) on [DATE] at 1:40 a.m. (Resident #101's name) was treated for [REDACTED]. It was determined that (Resident #101's name) was not a candidate for surgical procedures. Family conferred with physicians and it was determined that (Resident #101's name) would return to this facility on (company name) Hospice Services for comfort measures only. (Resident #101's name) returned to this facility on [DATE] at 6:30 p.m. with all medications discontinued with exception of Roxanol (pain control), Ativan (anxiety) and Tylenol (temperature and pain control). (Resident #101's name) expired [DATE] at 5:55 a.m. During the investigative process for this incident it was noted that no resident assessments had been completed per (manufacturer's name) bath chair manual and the safety seatbelt was not being used on a consistent basis. No policy had been implemented for the (manufacturer's name) bath chair upon purchase/implementation". The facility Administrator (staff "AA") was notified of the Immediate Jeopardy (IJ) on [DATE] at 3:13 p.m., and a written plan for removal was requested. On [DATE] at approximately 4:00 p.m. the immediate jeopardy (IJ) was removed but not corrected when the correction plan was accepted. Although the Immediate Jeopardy (IJ) was removed, the facility's deficient practice was not corrected and remained at a harm level of an isolated incident pending completion of the following: purchasing a new bath chair, devloping a policy and internal protocol, training all staff in the use of a new bath chair and quality assurance audits to be done monthly, every three months and then quarterly. Findings include: According to Resident #101's Face Sheet (electronically printed on [DATE]), Resident #101was originally admitted to the facility on [DATE]. Record review of Resident #101's medical record documented Resident #101 was admitted with the following medical Diagnoses: [REDACTED]. Record review of Resident #101's Minimum Data Set (MDS), a resident assessment and care screening tool dated [DATE] documented Resident #101 was severely cognitively impaired, required two + (plus) staff persons to physically assist Resident #101 with bed mobility, transfers between surfaces such as bed and chairs, dressing, toilet use and personal hygiene, indicating resident #101 was completely dependant on the facility staff for all activities of daily living. Record review of Resident #101's individualized care plans (undated) documented Resident #101 had profound weakness, impaired mobility, delusional thinking with hallucinations and paranoia and is rarely to never understood with impaired communication. Resident #101 was also a high risk for impaired skin integrity. Record review of the "Facility Investigation Report - 5 Working Days" (dated [DATE]) the following occurred: "On [DATE] at approximately 6:40 p.m., (Resident #101's name) fell out of the (manufacturer's name) bath chair. (Staff member "CC"), CNA (certified nursing aide) stated, 'While trying to dry resident's arm (Resident #101), she was tensing up her arms. I had to lift the bar to lift her arm and dry her. I reached to the left for the deodorant. When I stood upright resident was already leaning forward and fell out of the chair'. (Resident # 101's name) was transferred to (name of area hospital) where she was diagnosed with [REDACTED]. (Resident #101's name) returned to this facility at 11:45 p.m. [DATE] per family request for comfort measures...Roxanol was ordered for pain control. Upon return to this facility it was noted the resident's vital signs (VS) were unstable with low blood pressure readings. (Resident #101's name) was transferred to (name of another area hospital) on [DATE] at 1:40 a.m. (Resident #101's name) was treated for [REDACTED]. It was determined that (Resident #101's name) was not a candidate for surgical procedures. Family conferred with physicians and it was determined that (Resident #101's name) would return to this facility on (company name) Hospice Services for comfort measures only. (Resident #101's name) returned to this facility on [DATE] at 6:30 p.m. with all medications discontinued with exception of Roxanol (pain control), Ativan (anxiety) and Tylenol (temperature and pain control)". Record review of Resident #101's Patient Discharge Instructions from the local area hospital dated [DATE] at 15:35 p.m. (3:35 p.m.) documented Resident #101 was discharged from the hospital with the following Diagnoses: [REDACTED]. Record review of Resident #101's monthly Physician order [REDACTED].#101 returned to this facility from the local area hospital. Treatments the facility were to monitor for Resident #101 included the following: monitor laceration to left forehead, monitor bruising over bilateral eye and bridge of nose, monitor scab left forearm, monitor scratch under left and right abdominal folds, monitor bruising/swollen right ring finger, monitor bruise right inner elbow, monitor bruise right forearm, monitor index fingers for redness, monitor bruises left hand, monitor left knee bruising, monitor bruising left inner elbow, monitor bruising left forearm and monitor bruise lower right lip. On [DATE] the facility Administrator (staff "AA") was interviewed in the conference room at approximately 9:10 a.m. During the interview staff "AA" summarized the incident involving Resident #101and stated during the investigation process of the incident, the facility discovered the following deficient practices: There were no written policies available concerning the use of the shower chair; per manufacturer guidelines the facility failed to appropriately asses each resident to evaluate the posture and sitting capabilities of the residents; and the availability and provision of safety straps were not consistently used by the bath house aides. Staff "AA" stated, "We (the facility) purchased this (the bath house equipment) in 2004, we've been using this for [AGE] years and hadn't had an accident. This was an avoidable situation, if she (staff "CC") hadn't lifted up the safety bar, she (Resident #101) wouldn't have fallen. It's unfortunate, yes". On [DATE] the facility's In-service Coordinator (staff "EE) was interviewed in the conference room at approximately 9:45 a.m. During the interview staff "EE" stated that upon hire all CENA's would get at least two days of training in the bath house, and provided a copy of staff "CC"'s written skills check off list. Staff "EE" stated everyone is trained not to lift the safety bar until the resident is ready for transfer and all staff are trained on the usage of the safety seat belt. However, all orientation was verbal and indicated there was no facility policy in place concerning the safety and usage of the hygiene bath chair. Staff "EE" also stated that the facility did not provide the CENA's with any written training on the bath chair, "But we do now". Staff "EE" also stated that every CENA has to up-date their skills annually, "We cover all the other lifts in the building, but we didn't re-educate the staff on proper usage of this chair, but we will now". On [DATE] Restorative Nurse (staff "II") was interviewed in the conference room at approximately 9:55 a.m.with staff member "AA" present. Staff "II" stated that after the incident occurred she assessed all residents within the facility to determine if the bath house chair was appropriate based on the assessment. Staff "II" stated that she determined at the time of the incident, 32 other residents residing in the facility had been using this bath hygiene chair and based on assessment should not be using this shower chair. Staff "II" stated currently these residents were receiving bed baths until the new shower chair arrives. Staff "AA" stated the facility ordered another bath chair for those residents who were unable to maintain their posture and produced a purchase order dated [DATE]. At the time of this survey's exit on [DATE] at approximately 1:00 p.m. the new bath house chair had not yet arrived but was expected to arrive on [DATE]. Staff "AA" also added that staff "CC" was terminated from the facility stating, "She (staff "CC") was neglectful in her duties, it was an avoidable accident. She (staff "CC") didn't think things through". Record review of the (manufacturer's name) Operating and Product Care instructions for the bathhouse hygiene chair indicated the following: - The (name of chair) should be used by appropriately trained caregivers in accordance with the directions outlined in the Operating and Procedures Care instructions. - We recommend that facilities establish regular assessment routines. Care givers should assess each resident according to the following criteria prior to use. 1) The resident's weight should not exceed 350 pounds. 2) The resident should be active or semi-active (i.e. able to sit upright unsupported on the side of the bed or toilet). 3) The resident should understand and respond to instructions to stay seated in an upright position. - If a resident does not meet these criteria an alternative lift should be used. - Warning! The safety belt must be used at all times to make sure the resident remains in a upright position in the middle of the seat. - Warning! Never leave the resident unattended at any time, particularly if the chair is in a raised position. Record review of the facility nurses notes by staff member ("HH") and Licensed Practical Nurse (LPN), staff "HH" documented, "I was called to the bath house after resident fell around 6:40 p.m. When I walked in resident was on back with CNA (staff "CC") holding her head up. I told CNA (staff "CC") to stay with resident...needed to send resident out due to a deep gash on forehead from height of fall. Resident responded when verbally stimulated. Wouldn't open eyes, but mumbled". Staff "HH" was interviewed by phone on [DATE] at approximately 12:30 p.m. During the interview staff "HH" stated that Resident #101 had poor mobility and was unable to maintain posture. Staff "HH" recalled that the safety bar of the bath hygiene chair had been in the upright position. "The safety bar is not supposed to be raised while the resident is in the chair until you are ready to transfer them". Staff "HH" could not recall if staff "CC" had used the safety belt during the bathing process stating, "I'm sure it wasn't since there wasn't a mention of the safety belt on the incident report". When asked Staff "HH" stated the height of the sitting platform of the bath hygiene chair was approximately 3 feet off the bath house floor, indicating that while Resident #101 was sitting in the bath chair, Resident #101's feet were unable to touch the floor of the bath house. Staff "JJ" (CENA) was interviewed on [DATE] at approximately 1:10 p.m. in the conferance room. Staff "JJ" stated that he was working next door of the bathhouse at the time Resident #101 fell , "I couldn't respond right away because I had another resident I was taking care of. When I got there (approximately 10 minutes later), Resident #101 was still laying on the floor. The nurse was trying to stop her (Resident #101) gash above the eye from bleeding. She (Resident #101) was concious, but she was crying and moaning from pain". On [DATE] at approximately 12:30 p.m. staff member "FF" was interviewed in the conference room. Staff "FF" who identified herself as a CENA stated the following: she received at least two days training in the bathhouse upon hire and added, "Absolutely you keep the safety bar down at all times". When asked staff "FF" stated, "It was always optional to use the safety belts, I was told we only use it (refferring to the safety straps) on special people, maybe 3 or 4 different residents". Staff "FF" added that once her training was completed in the bathhouse she had not provided a bath since because the facility had designated bath house aides. On [DATE] at approximately 1:10 p.m. staff member "JJ" was interviewed in the conference room. Staff "JJ" who identified himself as a CENA stated the following: he also received at least two days training in the bathhouse upon hire but had not provided a bath since. Staff "JJ" also indicated the facility had just recently started providing baths again on the second shift (the shift Resident #101 fell from the shower chair). Staff "JJ" also stated, "The rumor is the second shift got most of the lifts. They (the facility) didn't equally distribute the work load". When asked about the use of the safety belts staff "JJ" stated, "We didn't have any safety belts in the bath house when I trained, we may have had them, but we weren't using them. At that time I was told we have one or two residents who might need them. If I had to work in the bath house again I wouldn't know what to do, cause I got no clue". On [DATE] at approximately 2:45 p.m. staff member "KK" was interviewed in the conference room. Staff "KK" who identified herself as a CENA stated the following: she also received at least two days training in the bathhouse upon hire but had not provided a bath since her date of hire, ,[DATE]. When asked staff "KK" stated that during her two day orientation to the bath house she was told the safety straps, "were only for about three or four residents who could scoot or slide out the chair". On [DATE] at approximately 10:00 a.m. staff member "CC" was interviewed by telephone from the conference room. Staff "CC", who's employment from the facility had been terminated as a result of the incident involving Resident #101 stated the following: I started working at the facility on [DATE], I hadn't worked in the bath house since. I heard the facility had an opening for a bath house aide on second shift, so I applied. I had only been in the bath house 3 or 4 days before (name of Resident #101) fell . I had no training to refresh me and was never trained in safety belts. I don't even know what they look like and I couldn't tell you how to put one on". According to staff member "II" 32 other residents had been identified as using the bath house hygiene chair who would not have passed an assessment based on the Operating and Usage Care instructions, indicating that since the year 2004 (when the equipment was purchased) the facility only had 1 accident as the end result related to lack of training, policy and procedures. Resident #101's accident resulted in a fall with multiple injuries and according to the Certificate of Death, death was caused by a "subdural hematoma due to fall". Resident #101 expired on [DATE] at 5:55 a.m. On [DATE] at approximately 4:00 p.m. the immediate jeopardy (IJ) was removed but not corrected when the plan of correction was accpeted. The remedies included: - Two bath aides assigned per bath house to ensure resident safety. - Use of seatbelt as outlined in (manufacturer's name) bath chair manual implemented for all resident baths. - Ward conference regarding safe use of bath chair placed on all stations for CENA's and Licensed Nurses to review and sign. - All residents on Station 1 and Station 2 were assessed for appropriate use of (manufacturer's name) bath chair as outlined in the bath chair manual by Restorative Nurse (staff "II"). Care plans/door plans updated. - Policy on (manufacturer's name) Lift Hygiene Chair implemented. - Completion of mandatory inservice for (manufacturer's name) bath chair use for all CENA and Licensed Nurses. - After the facility receives the (manufacturer's name) new bath chair (currently on order), a policy will be written and implemented immediately, and all nursing staff will be educated/inserviced on the new bath chair prior to initiating use. - All new hire nursing staff will be educated on the usage of all bath chairs and lifts with the orientation process, and all nursing staff members will receive inservice on both bath chairs annually. - Each resident will be assessed upon admission, quarterly and with any significant change of condition to determine the appropriate hygiene bath chair. All new admissions would follow the facility' new internal protocol. - Quality assurance audits to be done monthly x 3 months, then quarterly to determine CENA and Licensed Nurse level of knowledge. Compliance to remain at 100%. - Validation by the State Agency of the facility's ability to maintain substantial compliance in regards to safety of the facility's bath house procedures with systemic changes made to ensure that this deficient practice will not occur again. ( )

This citation pertains to intake MI 038. Based on interview and record review, the facility failed to provide the necessary care and services to attain the highest practicable physical well being by not performing an adequate comprehensive assessment and not providing adequate treatment of [REDACTED].#105) from a total sample of 6 residents, resulting a delay in the treatment of [REDACTED]. Findings include: Review of Resident #105's medical record revealed an [AGE] year old female who was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Her Minimum Data Set ((MDS) dated [DATE] indicated she was moderately impaired with cognitive skills, and required limited assistance of two persons for transfers and toilet use. Resident #105's physical mobility care plan dated 10/12/09 indicated she was at risk for falls related to weakness/fatigue, potential for impaired balance, and memory deficits with interventions listed to include low bed with mats, bed pressure sensor alarm, 15 minute checks while in room. Resident #105's Impaired Communication care plan dated 10/04/11 indicated she was impaired with communication related to disorientation and confusion with interventions listed to include allowing resident sufficient time to reply in any manner that provides information to staff/family to ensure that needs are being met, and provide care in a relaxed, unhurried, non-judgmental manner. Facility incident report dated 6/13/12 at 9:10 pm indicated Resident #105 was observed on the floor in her room with a laceration to her right arm and complained of right leg pain. The incident report indicated that Resident #105 was assisted to the toilet at 9:00 pm, she was wearing gripper socks, her alarm sounded at 9:10 pm, staff responded and observed her on the floor in her room at 9:10 pm. Review of nurse's notes for Resident #105 revealed on 6/13/12 at 10:17 pm, Licensed Practical Nurse (LPN) #5 documented normal lung sounds, respirations and no [MEDICAL CONDITION], and at 10:21 pm LPN #5 charted a fall assessment for Resident #105 which indicated Resident #105 was a high risk for falls. On 6/13/12 at 10:28 pm, LPN #5 documented an incident where Resident #105 was observed on the floor in her room beside her bed at 9:10 pm, had a laceration on her right arm and complained of pain in her right leg. There were no witness listed in the incident documentation, no family or physician notification, and actions were "continue to observe". Nurse's note for Resident #105 dated 6/13/12 at 10:43 pm indicated LPN #6 gave Resident #105 Tylenol 500 mg tablet for pain at a level of 9 in her right leg, and at 11:53 pm LPN #6 documented Resident #105 had no further complaints. Nurse's note for Resident #105 dated 6/13/12 at 11:02 pm indicated a new physician's orders [REDACTED]. Nurse's notes dated 6/14/12 at 11:18 am indicated Resident #105 does scream out with moving of the right leg for positioning, mobile Xray was in to do the Xray at 8:45 am, and Resident #105 was given Tylenol for pain at 9:10 am. The nurse's note indicated Resident #105's daughter was notified of "the fall last evening at 6:35 am today" and that Resident #105's daughter was notified of the right leg and hip Xray showing a fracture. Nurse's notes dated 6/14/12 at 2:48 pm indicated Resident #105 was transferred to the hospital at 11:55 am. Review of Radiology report for Resident #105 dated 6/14/12 revealed an acute intertrochanteric femoral fracture ([MEDICAL CONDITION] in the upper leg, near the hip area), mildly comminuted (bone broken in several pieces). In an interview on 6/28/12 at 3:20 pm, LPN #5 stated on 6/13/12 around 9:00 pm she was called to Resident #105's room where she (LPN #5) observed Resident #105 on the floor, half on and half off her fall mat, in front of her bed, with her legs and body facing the bathroom door. LPN #5 stated Resident #105 was hysterical and screaming, "my leg". LPN #5 stated she attempted to get vital signs but could not and could only observe Resident #105 at that time because touching her would not have helped the situation. LPN #5 stated she did not do any other type of assessment at that time, and that she, Certified Nurse Aide (CNA) #8, and CNA #11 used a backboard to transfer Resident #105 into her bed where Resident #105 did calm down a little bit. LPN #5 stated Resident #105 was still yelling that her leg hurt, but she (LPN #5) did not see any bruising or swelling. LPN #5 stated she looked at the front part of of Resident #105's upper right leg. When the surveyor asked LPN #5 if she assessed Resident #105's right hip, groin, or if she check to see if Resident #105 was able to move her right leg or any other body parts, or of both legs looked the same, LPN #5 stated she did not. LPN #5 stated Resident #105 would not straighten her right leg and she was yelling in pain that her leg hurt. The surveyor asked LPN #5 what she did next and LPN #5 stated she left the room and continued with her regular duties because she had medications to give and an IV running. When the surveyor asked if Resident #105 was still yelling in pain when she (LPN #5) left the room, LPN #5 stated yes. LPN #5 stated she stayed over late that night to fill out the incident report on the computer, and the girls brought Resident #105 to the computer area in a wheelchair. LPN #5 stated Resident #105 was quieter, but still whimpering. When the surveyor asked LPN #5 if she called the physician or Resident #105's family regarding Resident #105's fall or her injury, LPN #5 stated no, that the physician and family aren't called at night unless it is an emergency. LPN #5 stated she did not think this incident with Resident #105 was an emergency. In an interview on 7/3/12 at 1:05 pm, CNA #11 stated shortly after 9:00 pm, she responded to Resident #105's bed alarm and observed Resident #105 on the floor, laying with her feet toward her bathroom door, with her right leg hooked under her left leg like the number 4. CNA #11 stated Resident #105 was hollering, "help" and "ouch" and "something's wrong with my leg". CNA #11 stated she went to to doorway of the room and hollered for LPN #5 to come and help, then got a pillow and put it under Resident #105's head. CNA #11 stated LPN #5, and CNA #8 came into the room and they got Resident #105's vital signs, the CNA #8 went for the lift. CNA #11 stated Resident #105 was screaming by then and was stating, "ow" "please don't touch my leg, something is wrong with it, I can't move it". CNA #11 stated that LPN #5 stated she was pretty sure Resident #105's leg wasn't broken because she screamed like that all the time. CNA #11 stated she told LPN #5 they couldn't use the lift and sent CNA #8 for the backboard. CNA #11 stated she heard LPN #5 ask Resident #105 at least 10 times if she could move her leg and each time Resident #105 stated no, she could not, over and over. CNA #11 stated Resident #105 was wearing a regular night gown, not a hospital gown, and LPN #5 never lifted her gown to look at Resident #105's leg, but did touch Resident #105's right leg and Resident #105 screamed. CNA #11 stated when Resident #105 was transferred on the backboard to her bed, she kept her leg bent, and once on her bed, she kept her leg bent. CNA #11 stated Resident #105 did have a very large skin tear on her elbow, and LPN #5 treated the skin tear, then told Resident #105 if "it still hurts in the morning we'll call and get an Xray". CNA #11 stated LPN #5 then left the room. CNA #11 stated when LPN #5 left the room, Resident #105 was still hollering that her leg hurt. In an interview on 7/3/12 at 3:00 pm, CNA #8 stated while working 2nd shift on 6/13/12 he heard CNA #11 holler for help, he went to Resident #105's room and observed Resident #105 on the floor screaming that her leg was hurting and her right leg was hooked under her left leg. CNA #8 stated that Resident #105 screamed "bloody murder" if anybody touched her right leg. CNA #8 also stated LPN #5 was in the room and he observed LPN #5 touch Resident #105's leg, and Resident #105 screamed. CNA #8 stated that LPN #5 told him and CNA #11 that Resident #105 "does this all the time, there's nothing wrong with her". CNA #8 stated he did not see LPN #5 assess Resident #105 except when she touched Resident #105's leg. CNA #8 stated he and CNA #11 made the decision to use a backboard and not a lift to transfer Resident #105 to the bed and Resident #105 never straightened her leg during the transfer, and continued to scream. CNA #8 stated he had cared for Resident #105 before and had never heard her scream like that. CNA #8 stated LPN #5 left Resident #105's room and continued passing her medications. In an interview on 6/28/12 at 2:30 pm, LPN # 6 stated when she came to work on 3rd shift, on 6/13/12, LPN #5 reported to her that Resident #105 had fallen out of bed. LPN #6 stated she left the unit to do paperwork at the beginning of her shift and when she returned, the CNA's(Certified Nurse Aides) brought Resident #105 to the desk and told her (LPN #6) that Resident #105 had pain in her leg. LPN #6 stated Resident #105 kept touching her right thigh, whimpering and stating, "right there". The surveyor asked LPN #6 if she assessed Resident #105's leg and LPN #6 stated she looked at it and palpated (touched) it. The surveyor asked where Resident #105 was and what she was wearing when LPN #6 assessed her, and LPN #6 stated Resident #105 was wearing a gown and a robe and was sitting in her wheelchair at the desk. When the surveyor asked LPN #6 if she could visualize Resident #105's entire leg and hip area during the assessment, LPN #6 stated she could see her thigh, which was where Resident #105 was pointing to. When the Surveyor asked LPN #6 if she could assess Resident #105's hip while she was sitting in the wheelchair, LPN #6 stated, "if someone complained of pain in their wrist, I wouldn't assess their shoulder". The surveyor then asked LPN #6 if she was able to assess if there was any change in the length or rotation of Resident #105's right leg while she was sitting in the wheelchair and LPN #6 stated the CNA's had propped Resident #105's leg on a pillow in her wheelchair, her foot had turned sideways off the pillow, and when she attempted to put Resident #105's foot back on the pillow, Resident #105 hollered, "ow, ow, ow". LPN #6 stated she gave Resident #105 Tylenol for pain and called the doctor to get an order for [REDACTED].#105 Tylenol she slept for several hours in her wheelchair at the nurse's area until the aides put her back to bed around 2:00 am. In an interview on 7/3/12 at 1:45 pm, Physician #4 stated the first contact she received from the facility regarding Resident #105's fall on 6/13/12 was around 11:00 pm. Physician #4 stated she believed the nurse who called her briefly stated that Resident #105 had fallen out of bed, looks like she hurt herself, and could she get an Xray, so Physician #4 stated she told the nurse who called to go ahead and get an Xray. The surveyor asked Physician #4 if the nurse who called her reported that Resident #105 was screaming or hollering in pain and Physician #4 stated no. The surveyor asked Physician #4 if the nurse who called her reported that Resident #105 screamed in pain when her right leg was touched or moved in any way and Physician #4 stated no. The surveyor asked Physician #4 if she felt the nurse who called her gave her enough information to allow her to make an informed decision about Resident #105 and Physician #4 stated no. Physician #4 stated if she believes a resident has a suspected fracture, or if a resident is in a lot of pain, she would transfer them right away. Review of the facility video surveillance on 6/28/12 at 3:10 pm, in the Director of Nursing's office with DON #1 present, revealed Resident #105 was brought to the nursing area at 10:35 pm, LPN #6 was observed on video looking at Resident #105 and giving her medication, but did not at any time lift her gown. From 10:39 pm to 2:00 am, CNA #14, CNA #15 and CNA#16 were observed sitting with Resident #105 from time to time, adjusting the pillow under her right leg, and talking with Resident #105, with Resident #105 awake and moving in her wheelchair the entire time. At 11:22 pm, LPN #6 was observed sitting at a table at the nurse's area reading a newspaper with Resident #105 sitting in her wheelchair near LPN #6, with restless movements observed in Resident #105. LPN #6 is observed walking around Resident #105 in the video on multiple occasions, while Resident #105 is awake and restlessly moving forward and backward with her upper body in her wheelchair at the nurse's area. Review of the facility video revealed LPN #6 did not enter Resident #105's room during the entire shift. Once Resident #105 was in bed, LPN #6 did not return to check on Resident #105 to assess her or her pain level. In an interview on 7/5/12 at 2:50 am, CNA #16 stated she assisted Resident #105 to the toilet on 3rd shift with CNA #14 after the 2nd shift aides had reported that Resident #105 had fallen out of bed earlier in the evening on 6/13/12. CNA #16 stated Resident #105 was holding her right leg funny, behind her left leg, and would not bear weight on it. CNA #16 stated Resident #105 said the word, "scared" during the transfer and, "ow" when she sat on the toilet, and pointed to her groin area. CNA #16 stated when they transferred Resident #105 back to her wheelchair Resident #105 pointed to her groin and said, "hurt, hurt", that Resident #105 was distressed and had her right leg curled back, so they used a pillow to try to make her comfortable, but Resident #105 hollered and said "ouch" again. CNA #16 stated she and CNA #14 brought Resident #105 to the nursing desk and reported to LPN #6 that Resident #105 was in a lot of pain. CNA #16 stated LPN #6 got Resident #105 some Tylenol and called the doctor and when LPN #6 hung up from the doctor LPN #6 said, "she didn't say if I should get the Xray now or in the morning". CNA #16 stated that she and the other CNA's told LPN #6 she should send Resident #105 out right then because she was in so much pain. CNA #16 stated Resident #105 was screaming in pain. CNA #16 stated LPN #6 didn't re-approach Resident #105 the rest of the night, but walked around her. CNA #16 stated she and the other CNA's repeatedly told LPN #6 that Resident #105 was in pain and later in the night they told LPN #6 they were going to transfer Resident #105 back to bed, but again, LPN #6 did not respond. CNA #16 stated she and two other CNA's transferred Resident #105 as carefully as they could back to bed and positioned her with blankets, and Resident #105 moaned and hollered in pain and called a family members name out, so she (CNA #16) sat with her for a while to comfort her. CNA #16 stated she did tell LPN #6 at one point that she should send Resident #105 to the hospital. In an interview on 6/28/12 at 2:00 pm, CNA #14 stated on 6/13/12 when she started her 3rd shift, she was told by the 2nd shift aides Resident #105 had fallen. CNA #14 stated early in her shift while assisting Resident #105 to the toilet, she observed Resident #105 to have her right leg behind her left leg, not bearing weight on her right leg, and to cry out in pain when she sat on the toilet and in her wheelchair, pointing to her groin. CNA #14 stated she and CNA #16 took Resident #105 to LPN #6 in her wheelchair and CNA #14 stated LPN #6 seemed, "disinterested". CNA #14 stated LPN #6 gave Resident #105 pain medicine but never put Resident #105 in bed and assessed her. CNA #14 stated LPN #6 had 3 aides telling her all night that Resident #105 was in a lot of pain and asking her to send Resident #105 to the hospital and that LPN #6 had no concern for Resident #105's well being. In an interview on 6/28/12 at 1:40 pm, CNA #15 stated she worked third shift the night Resident #105 was injured and that she had observed Resident #105 screaming and crying at the nurses area. CNA #15 stated all of the aides kept telling LPN #6 to send Resident #105 to the hospital because she was in so much pain. CNA #15 stated LPN #6 did give Resident #105 medicine for pain, but Resident #105 screamed and cried in pain all night, and she was hurting really bad. CNA #14 stated Resident #105 didn't just complain of pain at the nurse's area, she screamed and cried. CNA #14 stated LPN #6 called the doctor and then said the Xray wouldn't get done until tomorrow. In an interview on 6/28/12 at 12:50 pm, LPN #7 stated when she arrived for her first shift on 6/14/12 she went to Resident #105's room and did and assessment of Resident #105 and found her to be in a lot of pain, and when she attempted to touch Resident #105's right leg, Resident #105 yelled "ow, leave it alone". LPN #7 stated she gave Resident #105 something for pain, an Xray was done, she called Resident #105's daughter around 6:30 am, who was not aware of the fall yet, and the Xray results came back positive for a fracture. LPN #7 stated Resident #105 was transferred to the hospital for treatment of [REDACTED]. In an interview on 6/28/12 at 12:20 pm, the facility Director of Nursing (DON #1) stated she had terminated LPN #5 and LPN #6. DON #1 stated she terminated LPN #5 because she didn't do a complete assessment of Resident #105 after she fell and assumed that her yelling was just her past behaviors. DON #1 stated she terminated LPN #6 because she never assessed Resident #105 when the aides reported Resident #105 was having severe pain in her right leg after a fall and when Resident #105 was hollering in severe pain. DON #1 stated all three aides on third shift reported to her (DON #1) they had repeatedly told LPN #6 that something was wrong with Resident #105 and she needed to go to the hospital. DON #1 stated when LPN #6 received the order for an xray from Physician #4, the aides reported LPN #6 hung up the phone and stated Physician #4 didn't state when to get the xray, so LPN #6 took it upon herself to get the xray in the morning instead of calling Physician #4 back for clarification of the order. DON #1 stated LPN #6 didn't give Physician #4 all of the information. Review of Emergency Physician notes dated 6/14/12 revealed Resident #105 had significant pain in the emergency room with any movement of her right lower extremity (leg) and had a [DIAGNOSES REDACTED]. Review of hospital records revealed Resident #105 was admitted to the hospital on [DATE] and had surgical repair of a fractured right hip on 6/14/12. According to the Michigan Department of Community Health in the Process Guideline for Pain Management (February 13, 2004) "The physician/physician extender needs to be notified of residents with pain management concerns as soon as possible in order to intervene on the residents' behalf." According to Stanley M. and Deare G. P., in "Gerontological Nursing" (Philadelphia, PA, 1995), "The nurse has a valuable role in helping to manage the patients' pain. One of the simplest ways to do this is to believe the patient and to acknowledge that the pain is real. Support should be given to show that the nurse is trying to understand the pain (pg. 298, 299). Nursing assessment is the "deliberate and systematic collection of data" of the residents' health and functional status and is the first step in Nursing Process. The data obtained in the assessment is communicated to other care givers and health professionals and is used to diagnose the problem and plan and implement care (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). #

This citation pertains to intake MI 038. Based on interview and record review, the facility failed to do a complete assessment after an unwitnessed fall, and accurately inform a physician of a residents condition, in 1 of 4 sampled residents (#105) from a total sample of 6 residents, resulting a delay in the treatment of [REDACTED]. Findings include: Review of Resident #105's medical record revealed an [AGE] year old female who was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Her Minimum Data Set ((MDS) dated [DATE] indicated she was moderately impaired with cognitive skills, and required limited assistance of two persons for transfers and toilet use. Resident #105's physical mobility care plan dated 10/12/09 indicated she was at risk for falls related to weakness/fatigue, potential for impaired balance, and memory deficits with interventions listed to include low bed with mats, bed pressure sensor alarm, 15 minute checks while in room. Facility incident report dated 6/13/12 at 9:10 pm indicated Resident #105 was observed on the floor in her room with a laceration to her right arm and complained of right leg pain. The incident report indicated that Resident #105 was assisted to the toilet at 9:00 pm, she was wearing gripper socks, her alarm sounded at 9:10 pm, staff responded and observed her on the floor in her room at 9:10 pm. Review of nurse's notes for Resident #105 revealed on 6/13/12 at 10:17 pm, Licensed Practical Nurse (LPN) #5 documented normal lung sounds, respirations and no [MEDICAL CONDITION], and at 10:21 pm LPN #5 charted a fall assessment for Resident #105 which indicated Resident #105 was a high risk for falls. On 6/13/12 at 10:28 pm, LPN #5 documented an incident where Resident #105 was observed on the floor in her room beside her bed at 9:10 pm, had a laceration on her right arm and complained of pain in her right leg. There were no witness listed in the incident documentation, no family or physician notification, and actions were "continue to observe". Nurse's note for Resident #105 dated 6/13/12 at 10:43 pm indicated LPN #6 gave Resident #105 Tylenol 500 mg tablet for pain at a level of 9 in her right leg, and at 11:53 pm LPN #6 documented Resident #105 had no further complaints. Nurse's note for Resident #105 dated 6/13/12 at 11:02 pm indicated a new physician's orders [REDACTED]. Nurse's notes dated 6/14/12 at 11:18 am indicated Resident #105 does scream out with moving of the right leg for positioning, mobile Xray was in to do the Xray at 8:45 am, and Resident #105 was given Tylenol for pain at 9:10 am. The nurse's note indicated Resident #105's daughter was notified of "the fall last evening at 6:35 am today" and that Resident #105's daughter was notified of the right leg and hip Xray showing a fracture. Nurse's notes dated 6/14/12 at 2:48 pm indicated Resident #105 was transferred to the hospital at 11:55 am. Review of Radiology report for Resident #105 dated 6/14/12 revealed an acute intertrochanteric femoral fracture ([MEDICAL CONDITION] in the upper leg, near the hip area), mildly comminuted (bone broken into pieces). In an interview on 6/28/12 at 3:20 pm, LPN #5 stated on 6/13/12 around 9:00 pm she was called to Resident #105's room where she (LPN #5) observed Resident #105 on the floor, half on and half off her fall mat, in front of her bed, with her legs and body facing the bathroom door. LPN #5 stated Resident #105 was hysterical and screaming, "my leg". LPN #5 stated she attempted to get vital signs but could not and could only observe Resident #105 at that time because touching her would not have helped the situation. LPN #5 stated she did not do any other type of assessment at that time, and that she, Certified Nurse Aide (CNA) #8, and CNA #11 used a backboard to transfer Resident #105 into her bed where Resident #105 did calm down a little bit. LPN #5 stated Resident #105 was still yelling that her leg hurt, but she (LPN #5) did not see any bruising or swelling. LPN #5 stated she looked at the front part of Resident #105's upper right leg. When the surveyor asked LPN #5 if she assessed Resident #105's right hip, groin, or if she check to see if Resident #105 was able to move her right leg or any other body parts, or if both legs looked the same, LPN #5 stated she did not. LPN #5 stated Resident #105 would not straighten her right leg and she was yelling in pain that her leg hurt. The surveyor asked LPN #5 what she did next and LPN #5 stated she left the room and continued with her regular duties because she had medications to give and an IV running. When the surveyor asked if Resident #105 was still yelling in pain when she (LPN #5) left the room, LPN #5 stated yes. LPN #5 stated she stayed over late that night to fill out the incident report on the computer, and the girls brought Resident #105 to the computer area in a wheelchair. LPN #5 stated Resident #105 was quieter, but still whimpering. When the surveyor asked LPN #5 if she called the physician or Resident #105's family regarding Resident #105's fall or her injury, LPN #5 stated no, that the physician and family aren't called at night unless it is an emergency. LPN #5 stated she did not think this incident with Resident #105 was an emergency. In an interview on 7/3/12 at 1:05 pm, CNA #11 stated shortly after 9:00 pm, she responded to Resident #105's bed alarm and observed Resident #105 on the floor, laying with her feet toward her bathroom door, with her right leg hooked under her left leg like the number 4. CNA #11 stated Resident #105 was hollering, "help" and "ouch" and "something's wrong with my leg". CNA #11 stated she went to to doorway of the room and hollered for LPN #5 to come and help, then got a pillow and put it under Resident #105's head. CNA #11 stated LPN #5, and CNA #8 came into the room and they got Resident #105's vital signs, CNA #8 went for the lift. CNA #11 stated Resident #105 was screaming by then and was stating, "ow" "please don't touch my leg, something is wrong with it, I can't move it". CNA #11 stated that LPN #5 stated she was pretty sure Resident #105's leg wasn't broken because she screamed like that all the time. CNA #11 stated she told LPN #5 they couldn't use the lift and sent CNA #8 for the backboard. CNA #11 stated she heard LPN #5 ask Resident #105 at least 10 times if she could move her leg and each time Resident #105 stated no, she could not, over and over. CNA #11 stated Resident #105 was wearing a regular night gown, not a hospital gown, and LPN #5 never lifted her gown to look at Resident #105's leg, but did touch Resident #105's right leg and Resident #105 screamed. CNA #11 stated when Resident #105 was transferred on the backboard to her bed, she kept her leg bent, and once on her bed, she kept her leg bent. CNA #11 stated Resident #105 did have a very large skin tear on her elbow, and LPN #5 treated the skin tear, then told Resident #105 if "it still hurts in the morning we'll call and get an Xray". CNA #11 stated LPN #5 then left the room. CNA #11 stated when LPN #5 left the room, Resident #105 was still hollering that her leg hurt. In an interview on 7/3/12 at 3:00 pm, CNA #8 stated while working 2nd shift on 6/13/12 he heard CNA #11 holler for help, he went to Resident #105's room and observed Resident #105 on the floor screaming that her leg was hurting and her right leg was hooked under her left leg. CNA #8 stated that Resident #105 screamed "bloody murder" if anybody touched her right leg. CNA #8 also stated LPN #5 was in the room and he observed LPN #5 touch Resident #105's leg, and Resident #105 screamed. CNA #8 stated that LPN #5 told him and CNA #11 that Resident #105 "does this all the time, there's nothing wrong with her". CNA #8 stated he did not see LPN #5 assess Resident #105 except when she touched Resident #105's leg. CNA #8 stated he and CNA #11 made the decision to use a backboard and not a lift to transfer Resident #105 to the bed and Resident #105 never straightened her leg during the transfer, and continued to scream. CNA #8 stated he had cared for Resident #105 before and had never heard her scream like that. CNA #8 stated LPN #5 left Resident #105's room and continued passing her medications. In an interview on 6/28/12 at 2:30 pm, LPN # 6 stated when she came to work on 3rd shift on 6/13/12, LPN #5 reported to her that Resident #105 had fallen out of bed. LPN #6 stated she left the unit to do paperwork at the beginning of her shift and when she returned the CNA's(Certified Nurse Aides) brought Resident #105 to the desk and told her (LPN #6) that Resident #105 had pain in her leg. LPN #6 stated Resident #105 kept touching her right thigh, whimpering and stating, "right there". The surveyor asked LPN #6 if she assessed Resident #105's leg and LPN #6 stated she looked at it and palpated it (touched). The surveyor asked where Resident #105 was and what she was wearing when LPN #6 assessed her, and LPN #6 stated Resident #105 was wearing a gown and a robe and was sitting in her wheelchair at the desk. When the surveyor asked LPN #6 if she could visualize Resident #105's entire leg and hip area during the assessment, LPN #6 stated she could see her thigh, which was where Resident #105 was pointing to. When the Surveyor asked LPN #6 if she could assess Resident #105's hip while she was sitting in the wheelchair, LPN #6 stated, "if someone complained of pain in their wrist, I wouldn't assess their shoulder". The surveyor then asked LPN #6 if she was able to assess if there was any change in the length or rotation of Resident #105's right leg while she was sitting in the wheelchair and LPN #6 stated the CNA's had propped Resident #105's leg on a pillow in her wheelchair, her foot had turned sideways off the pillow, and when she attempted to put Resident #105's foot back on the pillow, Resident #105 hollered, "ow, ow, ow". LPN #6 stated she gave Resident #105 Tylenol for pain and called the doctor to get an order for [REDACTED]. In an interview on 7/3/12 at 1:45 pm, Physician #4 stated the first contact she received from the facility regarding Resident #105's fall on 6/13/12 was around 11:00 pm. Physician #4 stated she believed the nurse who called her briefly stated that Resident #105 had fallen out of bed, looks like she hurt herself, and could she get an Xray, so Physician #4 stated she told the nurse who called to go ahead and get an Xray. The surveyor asked Physician #4 if the nurse who called her reported that Resident #105 was screaming or hollering in pain and Physician #4 stated no. The surveyor asked Physician #4 if the nurse who called her reported that Resident #105 screamed in pain when her right leg was touched or moved in any way and Physician #4 stated no. The surveyor asked Physician #4 if she felt the nurse who called her gave her enough information to allow her to make an informed decision about Resident #105 and Physician #4 stated no. Physician #4 stated if she believes a resident has a suspected fracture, or if a resident is in a lot of pain, she would transfer them right away. CNA #16 stated during the 3rd shift, she and CNA #14 brought Resident #105 to the nursing desk and reported to LPN #6 that Resident #105 was in a lot of pain in her right leg. CNA #16 stated LPN #6 got Resident #105 some Tylenol and called the doctor and when LPN #6 hung up from the doctor LPN #6 said, "she didn't say if I should get the Xray now or in the morning". CNA #16 stated that she and the other CNA's told LPN #6 she should send Resident #105 out right then because she was in so much pain. CNA #16 stated Resident #105 was screaming in pain. CNA #16 stated LPN #6 didn't re-approach Resident #105 the rest of the night, but walked around her. In an interview on 6/28/12 at 2:00 pm, CNA #14 stated on 6/13/12 when she started her 3rd shift, she was told by the 2nd shift aides Resident #105 had fallen. CNA #14 stated early in her shift while assisting Resident #105 to the toilet, she observed Resident #105 to have her right leg behind her left leg, not bearing weight on her right leg, and to cry out in pain when she sat on the toilet and in her wheelchair, pointing to her groin. CNA #14 stated she and CNA #16 took Resident #105 to LPN #6 in her wheelchair and CNA #14 stated LPN #6 seemed, "disinterested". CNA #14 stated LPN #6 gave Resident #105 pain medicine but never put Resident #105 in bed and assessed her. In an interview on 6/28/12 at 1:40 pm, CNA #15 stated she worked third shift the night Resident #105 was injured and that she had observed Resident #105 screaming and crying at the nurses area. CNA #15 stated all of the aides kept telling LPN #6 to send Resident #105 to the hospital because she was in so much pain. CNA #15 stated LPN #6 did give Resident #105 medicine for pain, but Resident #105 screamed and cried in pain all night, and she was hurting really bad. CNA #14 stated LPN #6 called the doctor and then said the Xray wouldn't get done until tomorrow. CNA #14 stated she did not see LPN #6 do an assessment of Resident #105. In an interview on 6/28/12 at 12:50 pm, LPN #7 stated when she arrived for her first shift on 6/14/12 she went to Resident #105's room and did and assessment of Resident #105 and found her to be in a lot of pain, and when she attempted to touch Resident #105's right leg, Resident #105 yelled "ow, leave it alone". LPN #7 stated she gave Resident #105 something for pain, an Xray was done, she called Resident #105's daughter around 6:30 am, who was not aware of the fall yet, and the Xray results came back positive for a fracture. LPN #7 stated Resident #105 was transferred to the hospital for treatment of [REDACTED]. Review of Emergency Physician notes dated 6/14/12 revealed Resident #105 had significant pain in the emergency room with any movement of her right lower extremity (leg) and had a [DIAGNOSES REDACTED]. Review of hospital records revealed Resident #105 was admitted to the hospital on [DATE] and had surgical repair of a fractured right hip on 6/14/12. Review of facility policy titled Incident/Accident Reports - Residents revealed if an incident or accident occurred on the 3 to 11 shift, the physician will be notified during the shift if it is an emergency, or if there is an injury or a previous injury that could be exacerbated by the incident. The policy also indicated that a resident's family or responsible party will be notified STAT if it is a serious incident, the shift that the incident occurs before 9:00 pm. Review of facility Termination of Employment form for LPN #5 dated 6/19/12, revealed LPN #5 was terminated with a reason listed as: Failure to provide thorough assessment of resident whom had fallen and complained of pain on 6/13/12 resulting in delay of treatment. Review of facility Termination of Employment form for LPN #6 dated 6/19/12, revealed LPN #5 was terminated with a reason listed as: Failure to provide thorough assessment of resident whom had fallen and complained of pain on 6/13/12 resulting in delay of treatment. According to "Medical-Surgical Nursing" (4th Edition, 2002), "Evaluation of the hip joint relies primarily on determination of its degree of mobility, because the joint is deep, and difficult to inspect or palpate. The client with hip pain usually experiences pain in the groin area, or the pain may radiate to the knee..." (pg. 1087). The text continues (pg. 1130) "clients often complain of moderate to severe pain at the site of the fracture or in an adjacent or distal area. For example, clients with a [MEDICAL CONDITION] may have groin pain or pain referred to the back of the knee. Pain is usually due to muscle spasm and [MEDICAL CONDITION], which result from the fracture..." According to Potter, P.A. and Perry A.G. in "Fundamentals of Nursing" (6th Edition, 2005), ROM is defined as "the maximum amount of movement available at a joint in one of the three planes of the body..." (pg. 1434). Referring to the nursing assessment process, (pg. 938), "assessing ROM is one of the first assessment techniques used to determine the degree of damage or injury to a joint. The nurse assesses ROM to collect data to answer questions about the joint stiffness, swelling, pain, limited movement, and unequal movement"; the text continues (pg. 758) "When putting each joint through its range of motion, the nurse makes a number of basic observations, noting pain, limited mobility, spastic movement, joint instability, stiffness and contracture". Nursing assessment is the "deliberate and systematic collection of data" of the residents' health and functional status and is the first step in Nursing Process. The data obtained in the assessment is communicated to other care givers and health professionals and is used to diagnose the problem and plan and implement care (Potter, P. A. & Perry, A. G. (2005) Fundamentals of Nursing (6th ed.). St. Louis: Mosby.). "Failure to recognize the significance of changes or to communicate them clearly and promptly to the attending practitioner could endanger the patient." (McMahon & Associates. Nursing Standards of Practice. HGExperts.com. Retrieved May 19, 2011, from <http://www.hgexperts.com/article>.) #