Every finding on record at Pomeroy Living Sterling Skilled Rehabilitation

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program, resulting in the presence of gnats throughout the facility. This deficient practice had the potential to affect all residents, staff and visitors. Findings include:On 07/21/26 at 8:45 AM, an initial observation of the kitchen was conducted with Dietary Manager (DM) H. Upon entering the kitchen near the hand-washing sink, there was a roll-away trash bin uncovered and filled with garbage. There were swarms of gnats flying around the trash bin. A dietary staff member at the hand-washing sink was observed swatting the gnats away from their head. When queried at that time about the gnat issue, DM H stated that the pest control company had just been in on the previous day and had treated the drains, and that a wall mounted pest control unit had been installed. On 07/21/26 at 8:50 AM, gnats were observed in the main kitchen area. There was a buildup of debris and moisture observed on the floor underneath the tables located along the wall adjacent to the service hallway and underneath the ice machine. On 07/21/26 at 9:00 AM, there were gnats observed in the dish machine area. There was moisture and organic material observed on the floor underneath the dish machine and drain board. On 07/21/2026 at 9:50 AM, the Administrator stated that they are aware of the gnat issue and that they do have an ongoing plan in place that includes deep cleaning. On 07/21/26 at 1:15 PM, R96 and R112 were observed in their room. There were gnats observed flying around the residents and their food. On 07/21/26 at approximately 2:15 PM, the right-hand public restroom located near the reception desk was observed with 11 gnats on the walls and ceiling of the restroom. On 07/22/26 at approximately 9:45 AM, the same restroom was observed with 17 gnats on the walls and ceiling areas. On 07/23/26 at 2:30 PM, three gnats were observed on the walls and ceiling of the same restroom. On 07/23/26 at 11:23 AM, R105 reported an ongoing issue with gnats in their room. A single gnat was observed flying around the room. R105 reported they used a small trap and a fan to help control and remove them. Review of the pest control service reports on 07/21/26 at 3:00 PM noted the following: 03/23/26 .Small fly activity was seen in the kitchen mostly on the legs of the dishwashing equipment which has a film of grease and grime that the flies are eating and needs to be wiped down and cleaned and the sanitation in the kitchen needs to improve . 06/22/26 Door gap/damage noted that allows pest access. Please repair to prevent pest entry. Door 4 in C hallway 300. Door gap/damage noted that allows pest access. Please repair to prevent pest entry. E door to courtyard near bistro. 07/20/26 Performed service for the fruit flies in the kitchen .They are not in or coming from the drains anymore as the drains are cleaned and bio foamed every service. The fruit flies are eating and laying eggs in the gunk that is building up on the walls, racks, legs of the tables and the undersides of tables, areas that do not get regularly cleaned but need to start being cleaned to help prevent this issue from getting worse or from happening again once its stopped. Even the exterior of garbage bins and cloth bins need to be regularly wiped down. The entire kitchen is in need of a deep clean and the dish racks need to be emptied so all the metal racks can be scrubbed and cleaned . On 07/21/26 at 3:15 PM, Door 4 in the C hallway and the door to the courtyard located near the bistro were observed with Maintenance Director I. Maintenance Director I confirmed that the gaps which were noted by the Pest Control company on the 06/22 service report were still present. According to the 2022 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .Eliminating harborage conditions.

Based on observation, interview, and record review, the facility failed to maintain the cleanliness of privacy curtains for two residents (R6 and R51) of two reviewed for clean privacy curtains. Findings include:R6 On 7/21/26 at 9:51 AM, R6 was observed lying in bed on their back. The privacy curtain around their bed was noted to have brown, red and dark black stains on them. R6 stated that they noticed the dirty curtain and told a housekeeper a few weeks ago, but nothing has been done. R6 stated they were unable to move the curtain, so they had to look at the stained curtain daily. A record review revealed R6 was admitted on [DATE] with the following medical diagnoses of Multiple Sclerosis and Chronic Kidney Disease. R6's Brief Interview of Mental Status assessment score was 15/15 indicating intact cognition and required maximum assistance for all activities of daily living. On 7/22/26 at 10:25 AM, during a tour of the unit with Unit Manager A they confirmed housekeeping and maintenance change the privacy curtains. On 7/22/26 at 2:30 PM, the Nursing Home Administrator (NHA) reported the expectation for privacy curtains is soiled curtains should be reported into the (name of remote maintenance system) and privacy curtains are to be inspected monthly, changed, and cleaned at least quarterly whether they appear soiled or not. R51 On 07/21/2026 at 1:50 PM, R51 was observed sitting in the hallway and asked about any concerns they've had in the facility and explained they wanted to show the surveyor something in their room. Once entering into the resident's room, R51 pointed out their privacy curtain that was visibly soiled with an unknown brown substance R51 believed to be bowel movement and had reported it to various staff members, but nothing had been done. R51 explained the stained privacy curtain had been there for a while and would like it cleaned because it bothers me when visitors come into the room. A review of R51's medical record revealed they were admitted into the facility on 3/23/25 with diagnoses which include Diabetes, Chronic Kidney Disease, and Anxiety. Further review revealed the resident was cognitively intact and required assistance for activities of daily living.

Based on observation, interview, and record review, the facility failed to assess and monitor the need for continued use of psychotropic medications for one resident (R10) of one reviewed unnecessary medications. Findings include:On 07/21/26 at 9:50 AM, 12:19 PM, and 3:20 PM, R10 was observed asleep sitting in their wheelchair in the dining room.On 7/22/26 at 8:38 AM and 10:45 AM, R10 was observed sitting in their wheelchair in the dining room, with their head down on the table on top of a piece of paper with they're eyes closed giving the appearance of sleep.On 7/22/26 at 2:30 PM, R10 was observed laying in their bed in the room asleep. On 7/23/26 at 10:31 AM, R10 was observed sitting in their wheelchair in the dining room. R10 was asleep and did not awake after calling their name out three times.A review of the Electronic Medical Record (EMR) revealed R10 was admitted on [DATE] with diagnoses included Dementia; Psychotic Disorder with Delusions, Schizoaffective Disorder and Bipolar. Further review revealed a Brief Interview for Mental Status score of 99 which indicated severely impaired cognition.Further review of the medical record revealed R10's active physician orders for the following medications: Risperdal (antipsychotic) 1 milligram (mg) three times a day; Clonazepam (for panic attacks) 0.5 mg tablet once a day; Melatonin (sleep aid) 3 mg once daily at bedtime; Hydrocodone 5 mg - acetaminophen 325 mg tablet (an opioid, pain medication) give every 12 hours; Lorazepam (Ativan - antianxiety) apply 1 milligram by topical route every 12 hours and as needed every 8 hours topical gel. Each listed medication has known side effects of drowsiness.Review of the EMR documented the last gradual dose reduction (GDR) was 11/11/25 and the last behavior note was 1/25/26. Review of the progress notes did not show any monitoring for drowsiness nor a recent GDR except for a progress note dated 7/21/26 10:38 am - Late entry 7/20/26: patient received sitting in the wheelchair in the day room sleeping, patient was hard to arouse. Review of the Medication Administration Record (MAR) for June (2026) revealed six times that R10 was asleep and did not receive their medication.Review of the MAR for July (2026) revealed nine times that R10 was asleep and did not receive their medication. On 7/23/26 at 10:15 AM, the Social Work Director (SWD) G was queried regarding R10's sleeping/drowsy and lack of behavior documentation. After a chart review, SWD G was unable to show documentation of any behaviors and stated medications were also monitored by hospice services.On 7/23/26 at 12:15 PM, Unit Manager D was queried regarding R10's sleeping and psychotropic medication use. Unit Manager D was unable to show documentation of any behaviors. On 7/23/26 at 2:05 PM, in an interview with the Director of Nursing (DON) they stated R10 has had behaviors in the past. The DON was asked about behavior notes, decreasing psychotropic medications and was unable to show documentation of assessment for a GDR.On 7/23/26 at 3:19 PM, in an interview with Nurse Practitioner (NP) H the use of psychotropic medications for R10 was discussed. NP H said review of medications is followed by hospice and there had been no recent concerns or request to review medications related to drowsiness. A review of recent physician notes did not note an assessment for a GDR of the psychotropic medications. A review of the facility's policy/procedure titled, Psychotropic Medication Assessment and Monitoring, dated December 2008 and updated 8/2011, revealed, The purpose of policy is to administer, and monitor the effects of, psychotropic medications. Gradual dose reductions will be attempted at least one time every six months after antipsychotic therapy has begun. A gradual dose reduction is not necessary if within the last six months the resident has had a gradual dose, the dose has been reduced to the lowest possible dose to control the symptoms, and the physician documents this information.

Based on observation, interview, and record review, the facility failed to assess and provide toenail care for one dependent resident (R104) of one reviewed for ancillary services. Findings include:On 07/21/2026 at 12:28 PM, R104 was observed lying in bed, and asked about their care in the facility. R104 explained it would be nice to have their toenails cut as they hadn't had them cut in a while. R104 was asked if the certified nursing assistants (CNAs) who provide showers cut their toenails and stated they would be afraid to have them (the CNA's) cut their toenails. A review of R104's medical record revealed they were admitted into the facility 9/22/25 with diagnoses which included Congestive Heart Failure, Anemia and Anxiety. Further review revealed the resident was cognitively intact and required assistance for activities of daily living. Further review of R104's care plan revealed the following: Focus: admission #1 - Self Care Deficit. I need help with activities of daily living. I require assist with transfers, mobility, toileting, dressing and grooming . Active Effective: 1/10/2024 . On 07/23/2026 at 9:57 AM, Unit Manager A was asked to observe the toenails of R104. Once the socks were removed, the toenails were observed as yellow, elongated, and measuring approximately half an inch past the ending of the toe. Unit Manager A acknowledged R104's need to have their toenails cut. R104 was asked how their feet felt, or if they were experiencing pain and explained the staff needs to be careful when placing socks on their feet. Unit Manager A was asked how residents are identified as needing their nails cut or provided with podiatry services, and explained that once observed, the CNAs notify the nurse, and podiatry services will be scheduled for the resident. On 07/23/2026 at 11:21 AM, documentation related to podiatry services were requested from the facility and was provided with a document acknowledged by R104 on 9/22/25 (a year and a half prior to the survey) they were declining podiatry services. On 07/23/2026 at 2:05 PM, the Director of Nursing (DON) was asked about R104's declination for podiatry services and re-evaluating the need for ancillary services and explained the facility does not revisit the form residents sign at admission, rather, the resident will need to make the request to receive ancillary services. Regarding R104's toenails, the DON acknowledged that although the resident had declined services, if nail care is observed as being needed, nursing staff should assess and provide the care need. A review of the facility's Fingernail care policy did not reveal procedures for toenail care.

Based on observation, interview, and record review, the facility failed to ensure timely repositioning was encouraged or provided for one resident (R11) of three observed for repositioning. Findings include:On 07/21/2026 at 9:49 AM, R11 was observed on their back in bed, with the head of the bed up around 45 degrees and dressed in a hospital style gown. The breakfast tray was on the over bed table across the bed with the breakfast partially eaten. R11 spoke with confusion and did not directly answer any question asked. A specialty (low air loss mattress alternating pressure mattress [APM]) was observed on the bed and active in the static non-alternating mode (this mode does not change the pressure points in the bed). No wedge, pillow or other devices were observed at the sides of the torso. On 07/22/26 at 8:30 AM and 9:49 AM, R11 was observed on their back in bed, with their eyeglasses on, their legs elevated on pillows, the head of the bed elevated around 30-45 degrees, and a specialty mattress was in place on the static setting. No devices or pillows were observed at the sides of the torso. A nursing progress note dated 07/21/26 indicated R11 had declined to eat breakfast that morning. On 07/22/2026 at 12:02 PM, R11 continued on their back in bed as before, two visitors were in the room standing at the bedside. A certified nursing assistant (CNA) was observed to enter the room and then exit; a position change was not offered or initiated. At 12:08 PM the visitors had left and R11's position was unchanged. The head of the bed was lower around 30-45 degrees. No devices or pillows at the side. On 07/22/2026 at 12:45 PM, 2:10 PM, and 4:32 PM, R11 was observed on their back in bed as before, dressed in a t-shirt, eyeglasses on, their head faced toward the left shoulder and side of bed. R11 was not observed out of bed on 07/22/26. On 07/22/2026 at 2:21 PM, Licensed Practical Nurse (LPN) B reported their role in care for R11 was to maintain their skin integrity, assist with repositioning and provide wound care as needed. On 07/22/2026 4:35 PM, CNA C was distributing water and reported R11 was able to feed themself, at times required meal assistance and encouragement for eating, but was dependent for all other care needs. On 07/23/2026 at 5:52 AM and 6:29 AM, R11 was observed on their back in bed, the head of the bed was up around 30-45 degrees, their eyeglasses on, their head turned toward the left shoulder, and the lower legs elevated. R11 had a t-shirt on as on 07/22/26. R11 The specialty mattress was active in the static mode. A pillow was at the left side of the bed toward the shoulder of R11 but not under the torso. The tray table was parallel along the right side of the bed with a white foam water cup and a protein shake on it. On 07/23/2026 at 7:16 AM, R11 continued in bed as before. At 7:18 AM, the CNA E entered the room of R11, called the resident's name and adjusted the tray table slightly. R11 was not offered to reposition and remained as before. On 07/23/26 at 9:12 AM, R11 was observed on their back in bed with the head of the bed up 45-60 degrees and a breakfast tray on the tray table across their abdomen. The CNA E entered the room and was briefly at the bed side and then exited the room. On 07/23/2026 at 10:46 AM, R11 was observed on their back in bed, with head of the bed up around 30-45 degrees, their eyeglasses on, their legs elevated and their head turned toward their left shoulder. Their arms were folded across the abdomen. On 07/23/2026 at 10:50 AM, CNA E reported they had worked with R11 for six months and R11 generally sleeps more than they did initially. CNA E reported R11 needed reminders to eat and required assistance and encouragement to reposition. It was noted that a pillow was not observed at the sides of R11 and CNA E reported R11 may refuse it or refuse to reposition. CNA E further noted R11 preferred the left facing direction as observed during the previous days. On 07/23/2026 at 11:11 AM, CNA E and LPN F entered the room of R11 offered and encouraged R11 to reposition and R11 accepted. The loose pillow was placed under the left torso and R11 acknowledged it was comfortable. LPN F reported the pillow at the left side was not under R11 when they entered the room. On 07/23/2026 at 1:19 PM, LPN F (wound care manager) reported the specialty low air loss APM mattresses are generally set to alternating for most residents and was not sure why it was in static mode as R11's mattress had not been provided by the facility. LPN F reported they noted some progress notes which indicated R11 declined to be repositioned. A single note date 07/21/26 at 2:31 PM indicated R11 had declined to be repositioned and a single note on 07/22/26 at 11:23 AM indicated R11 had declined to change position by a hospice aide. On 07/23/2026 at 2:08 PM, the Director of Nursing (DON) reported an alternating pressure mattress and repositioning are primary interventions for a resident like R11 and staff should offer repositioning and reapproach as needed and if the resident continues to refuse care notification of the nurse would be appropriate. A review of the electronic medical record for R11 revealed, R11 was admitted into the facility on [DATE]. Diagnoses included Muscle Weakness, Mild Cognitive Impairment and Diabetes. A review of R11's active nursing care plan revealed: Potential for Impaired Skin Integrity: Etiology: I can't control my bowel and bladder. I don't always have feelings in my feet. I don't move around much. I have pain when move. My skin is very fragile. Encourage and assist me to turn and reposition myself as I can tolerate and as directed by my plan of care . Pressure reducing mattress to my bed. Nursing 2/6/26 Active, Administer my pain medication as ordered Nursing 12/18/25 Active; Encourage and assist me to turn and reposition myself as I can tolerate and as directed by my plan of care, Nursing 12/18/25 Active; Encourage and assist me to turn and reposition myself as I can tolerate and as directed by my plan of care. Nursing 2/6/26 Active; Float heels if resident allows Nursing 4/27/26 Active; Refuses to turn and repos (reposition). in bed and refuses heel boots I prefer to stay in bed at all times: Allow to express my reasons of non-compliance and alter plan of care, if reasonable, Medical, Nursing 3/13/26 Active; Continue to encourage me to be compliant with recommended plan of care throughout stay. All 3/13/26, Active; Encourage my family to participate in may (my) care. All 3/13/26 Active; Explain to me the possible affects of not following plan of care. All 3/13/26 Active; Notify Social Work to assess reasons for possible cause and effect of behavior. Add to behavior monitoring program if indicated. Medical, Nursing 3/13/26 Active, Offer me choices in plan of care to encourage compliance. All 3/13/26 Active . A review of the Minimum Data Set (MDS) assessment dated [DATE] documented R11 had a 12/15 Brief Interview for Mental Status Score which indicated moderate cognitive impairment. The MDS further documented impairment of the lower extremity on one side and R11 was dependent on staff for rolling left and right in bed, transfer from the bed, going from lying to sitting, hygiene, bathing, dressing, and mobility. A review of the facility policy titled, Pressure Ulcer Prevention Measures revised 08/31/21, revealed Policy: Residents at risk for the development of pressure ulcers receive interventions to reduce the risk of pressure ulcers . periodically reposition residents who are unable to shift their weight . limit the amount of time the head is elevated . use pressure redistribution .

This citation pertains to Intake 2647910Based on interview and record review, the facility failed to implement medication pass guidelines for safe medication administration for one resident (R701) of four residents reviewed for medication administration. Findings include:Review of Intake 2647910 revealed an allegation that R701, who was not diabetic and did not have physician orders to receive insulin, had been administered an injection of 12 units of insulin on 09/09/25.A review of the facility record revealed R701 was originally admitted to the facility on [DATE] and was most recently admitted on [DATE] with diagnoses including Dementia and Congestive Heart Failure. It was noted R701 did not have a diagnosis of Diabetes Mellitus. R701 was discharged from the facility on 09/18/25 per family request.On 10/22/25 at 11:57 AM, Unit Manager (UM) B was interviewed in their office. UM B reported they did recall the reported incident and indicated on 09/09/25 around lunch time Licensed Practical Nurse (LPN) A came to them and reported they had administered 12 units of Lispro/Humalog (a fast-acting insulin often used at mealtime to control blood sugar) to R701 in error after mistaking them for another resident. UM B reported they called R701's physician and were advised to complete blood sugar checks every 30 minutes and to monitor the resident for any signs/symptoms of hypoglycemia (low blood sugar).Further review of R701's facility record revealed no physician orders for insulin. A physician's progress note dated 09/10/25 authored by Medical Doctor (MD) D stated Patient is being seen due to an incident that occurred. [R701] was given 12 units of Humalog which was intended for another resident. [R701] did not have any reactions to the medication. When queried regarding any further documentation of the incident UM B produced a Medication Error Report that documented the incident had occurred on 09/09/25 at 11:50 AM and that the physician was notified at 11:55 AM. The report included additional information pertaining to resident monitoring and staff education. The report was signed by LPN A, the Director of Nursing (DON), the Medical Director, and the facility Administrator.On 10/22/25 at 2:03 PM, LPN A was interviewed via phone call and reported they did recall the incident of administering insulin to R701. They reported multiple residents had returned from outside appointments and were in the dining room prior to lunch. LPN A reported they saw R701 beginning to eat some fast food they must have brought in from outside and they thought R701 was a different resident who required a standard dose of 12 units of insulin at meals. LPN A reported they completed a blood sugar check then administered the insulin to R701. When asked if R701 questioned them or tried to stop them LPN A indicated R701 started to ask about the injection once it was being administered. LPN A reported once the resident questioned them, they checked further and realized the insulin had been given to the wrong resident. They reported they immediately reported the error to UM B. When queried how they would normally verify a resident's identity for medication administration they stated, The five rights . right patient, right drug, right dose, right route, right time. When asked to describe that process LPN A reported they would refer to the resident's electronic medical record (EMR) to view their picture, ask the resident their name and date of birth , and check their wrist band if one was present. LPN A acknowledged that in this situation they did not do any of those things prior to the administration of the insulin. Review of the facility policy Med Pass Guidelines dated 08/2011 revealed the Purpose statement To assure the most complete and accurate implementation of physician's medication orders and to optimize drug therapy for each resident by providing the administration of drugs in an accurate, safe, timely, and sanitary manner and to systematically distribute medications to residents in accordance with state and federal guidelines.

Based on observation, interview, and record review, the facility failed to provide a clean, comfortable, homelike environment in one room on [NAME] (H203). Findings include: On 5/12/25 at 10:20 AM, room H203 was observed with multiple, bright colored orange [NAME] on the floor next to a chair. On 5/13/25 at 8:39 AM, room H203 was observed again with the same orange [NAME] on the floor next to the chair. On 5/13/25 at 2:58 PM, room H203 remained in the same condition with the orange [NAME] in the same place in the resident's room on the floor. At this time the [NAME] appeared to be darker in color. On 5/14/25 at 2:29 PM, the House Keeping Manager was asked the facility's expectations with the cleaning of the resident's room. The manager explained the floors are a part of the routine/daily clearing. The housekeeper's procedure is to move furniture or items out of the way to ensure the floors are cleaned properly. A review of the facility's policy titled, Maintaining Resident Rooms Purpose dated 1/6/22 noted, Resident rooms are inspected and maintained on a periodic basis to ensure proper function . The policy did not reveal the procedure for daily cleaning.

Based on observation, interview, and record review, the facility failed to ensure one (R128) resident of eight residents reviewed for bathing, was provided with a choice of having a shower rather than a bed bath. Findings include: Review of the facility record for R128 revealed an admitted [DATE] with diagnoses including Rhabdomyolysis (skeletal muscle breakdown causing muscle pain and weakness) and Unstageable Left Hip and Right Heel Pressure Ulcers. R128's Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. On 05/13/25 at 12:50 PM, R128 was interviewed in their room. R128's hair appeared disheveled and oily. The resident was asked if they were receiving showers and they stated I'm dying for a shower, I haven't had one since I've been here. When questioned further R128 indicated they had been taken to the shower room and given a shower while laying on a shower bed a couple times and had otherwise received bed baths in their room. R128 was asked if they were given a choice of having a bed bath or a shower and they stated No, they just told me we were doing a bed bath so I didn't think I had an option. They don't wash my hair during the bed bath so its filthy. R128 indicated that on one occasion they did ask staff if they could be taken to the shower room rather than having a bed bath and stated they were told We can't take you off the unit, they don't want us to do that. Review of R128's facility bathing documentation indicated between 04/18/25 and 05/09/25 the resident had received three showers and four bed baths. Review of R128's Progress Notes revealed no documentation of the resident refusing a shower. On 05/14/25 at 12:36 PM, R128 was interviewed in their room and asked if they had ever refused a shower or asked to have a bed bath rather than a shower and they responded No, I never refused a shower. When asked if they were given a choice of shower or bed bath they stated No, I prefer showers, I wouldn't ever pick a bed bath over a shower. On 05/14/25 at 01:01 PM, Certified Nurse Assistant (CNA) A was interviewed via phone call and stated they did recall providing the resident with a bed bath on one occasion. The CNA reported the resident did not refuse a shower and they believed they had not offered a shower due to concern about the residents wounds however it was documented R128 had received a shower on the previous shower day. On 05/14/25 at 01:29 PM, CNA B was interviewed via phone. CNA B who documented having provided R128 with a bed bath reported they did not specifically recall the resident or the situation but stated On [resident's unit], if the resident has a shower in their bathroom I give them a shower and if not I give them a bed bath. I've never taken anyone off the unit to go to a shower room. On 05/14/25 at 01:55 PM, the facility Director of Nursing (DON) reported all the rooms on R128's unit have a shower in the bathroom. The DON stated the expectation is that resident's will be offered a choice of either a shower or bed bath on their scheduled shower day. Review of the facility Resident Guide with a revision date of 02/25 revealed the Resident Rights statements which include: - The right to reasonable accommodations of individual needs and preferences. - The right to participate in choices about food, activities, health care and other services based on needs, interests and the care plan.

Based on observation, interview, and record review, the facility failed to apply ace wraps per physician orders for one resident (R24) out of one reviewed for physician orders. Findings include: A review of the medical record revealed R24 admitted into the facility on [DATE] with the following medical diagnoses, Urinary Tract Infection and Mood Disturbance. A review of the minimum Data Set assessment revealed a Brief Interview for Mental Status score of 3/15 indicating an impaired cognition. R24 also required assistance with bed mobility and transfers. A review of physician orders revealed the following, Order: Ace wraps to bilateral extremities: On in morning, off at night. On 5/12/2025 at 10:30 AM, R24 was observed in their bed. R24 stated they needed to be pulled up in bed and were looking for their call light. R24 was not observed to be wearing any ace wraps to their bilateral extremities. On 5/14/2025 at 9:54 AM, R24 was observed in bed with no ace wraps on bilateral extremities. R24 reported they have never worn ace wraps and doesn't believe anyone has ever put anything on their legs. On 5/14/2025 at 11:05 AM, an interview was conducted with Unit Manager (UM) A. UM A indicated R24 was refusing to wear the ace wraps, and the order was supposed to be discontinued. Documentation pertaining to refusal of ace wraps was requested but not received by end of survey. On 5/14/2025 at 11:12 AM, an interview was conducted with the Director of Nursing (DON). The DON stated their expectations are if there is a physician's order, then it is followed. A request for a following a physician's order was requested and not received by the end of survey.

This citation pertains to Intake MI00150202. Based on observation, interview, and record review, the facility failed to knock and announce themself prior to entering a room for one sampled resident (R803) of three reviewed for falls, resulting in a fall with a head injury. Findings include: A review of an Intake noted on 1/28/25 at 3:30 AM, the Certified Nursing Assistant (CNA) did not announce their presence by knocking and opened the door and hit R803's walker which caused R803 to fall and hit their head on the furniture. On 2/18/25 at 2:09 PM, CNA A was asked about the incident. CNA A explained they were in the day room when they heard a call light start to ring, they went to the panel to see which room it was. CNA A confirmed she did not knock before she entered R803's room because, when a call light is ringing (activated) it indicates the resident is waiting for us to come in and help. CNA A explained that R803 had to be directly behind the door when she entered, because she heard the door hit the walker and looked behind the door and saw R803 on the floor. On 2/18/25 at 2:55 PM, the camera recording was reviewed with the Nursing Home Administrator (NHA) which revealed, R803's door was at the far end from the camera, R803's call light was on, CNA A was observed to enter the resident's room, CNA A's right hand was observed to move the door to open it. A knock to announce they're entrance could not be observed. A review of R803's medical record revealed, R803 was admitted to the facility on [DATE] with diagnosis of aftercare following joint replacement surgery. R803 was readmitted to the facility after the fall on 1/31/25. A review of R803's Minimum Data Set (MDS) assessment dated [DATE] indicated R803 with an intact cognition and with a functional abilities of partial/moderate assistance- Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort. Further review of R803's medical record noted, progress note, Resident put on call light approx. (approximately) 3:30am. CNA (CNA A) answered right away. When CNA (CNA A) opened door to resident room, resident was directly behind the door with walker. Door hit walker and resident fell backwards hitting head on the drawer near the ground. Hematoma noted to back of head. No LOC (loss of consciousness). Resident made statement, I didn't think you'd be here that quick. I always take myself. I didn't want to make a mess all over myself. NP (Nurse Practitioner) notified, orders to send resident out. 911 called. 1/28/25 at 4:14 AM. A review of R803's incident documentation noted, Situation, Background, Assessment, and Recommendation (SBAR) communication form and progress note indicated, 1/28/25 3:47 AM, Situation: fall, hit back of head. A review of the hospital documentation revealed, History of Present Illness: ., recent left femoral neck fracture s/p (status post) left total hip arthroplasty on 1/10/25 is [R803] s/p fall. [R803] states [they were] up in the bathroom at [their] SAR (subacute rehab), when the nurse tried to come in to help [them], causing the door to hit [them] and knock [them] over. [R803] reports [they] hit [their head but denies LOC . [R803] denies any worsened hip pain. [R803] reports mild pain to the back of [their] head where [they] hit it. [R803] denies dizziness, syncope, neck pain, chest pain, shortness of breath, abdominal pain, N/V (Nausea and Vomiting), numbness and tingling. [R803] has no other complaints or concerns at this time. Hospital physical therapy note documentation dated 1/29/25 10:50 AM noted, Pertinent History of Current Functional Problem: [R803] is currently residing at a subacute rehab, on Lovenox and aspirin for DVT (deep vein thrombosis) prophylaxis. The patient states that [they] had to go to the bathroom early in the morning. As [R803] was ambulation with [their] walker, a nursing assistant accidentally opened the door into the patient's walker, causing the patient to fall backwards and strike [their] head. [They] denies any loss of consciousness. [R803] was only reporting pain to the back of the head with the associated hematoma. [R803] is denying any pain or concern elsewhere. [R803] has ambulated since the fall. A review of R803's care plan noted, Problem: Falls. With interventions put in place my risks for functional decline will be minimized Goal: With interventions put in place my risks for functional decline will be minimized Interventions: Toileting: I might need assistance with toileting and cleaning myself. Focus: Fall risk effective date 1/16/25. Etiology: My gait is unsteady. I am not always aware of my limitations. As Evidenced By: I fall when I bend over or stand up quickly. I had fallen at home. Additional Detail: I am afraid of falling. I don't want to break anything. I want to walk by myself. I don't want to ask someone to help me get up and down, but I forget I'm weak/unsteady. Goals: My risks for injuries will be reduced with interventions put in place. 3/1/25. On 2/18/25 at 2:40 PM, the Unit Manager (UM B) was asked about the incident. UM B explained R803's call light was answered within one minute, R803 has a history of getting up alone without assistance. UM B further explained, R803 is not independent with care, they need one person for assistance. UM B was asked if CNA A was supposed to knock before entering the room with the call light on. UM B confrimed they should be knocking on the door (to let the resident know they are entering). A review of the facility's policy titled, Fall Management Guidelines and the Resident Rights did not address the above concern.

This citation pertains to Intake MI00147284. Based on interview and record review, the facility failed to implement interventions, assess and monitor one resident (R901) following a fall, out of three residents reviewed for falls. Findings include: A review of Intake: MI00147284 revealed the following, .Complainant states [they] received a call on 09/28/2024 at approximately 5:44PM from an unknown female 1st shift nurse informing [them] that she found the resident on the floor in [their] room .Complainant states 3 hours later, [they] got a call from a 2nd shift nurse (unknown female), informing [them] she found the resident unresponsive on the floor of her room .Complainant states [they] went to the facility on [DATE] and was told the residents chart shows that neuro-checks (Neurological exam used to assess a patient) were completed but they didn't take any fall precautions because they can't predict when or if the resident would fall again A review of R901's medical records revealed the resident was initially admitted into the facility on [DATE] with diagnoses that include Hepatic Encephalopathy, Hypokalemia, Diabetes, and Depression. Further review of the medical record revealed the resident was alert and oriented to person and place, and according to their fall assessment dated [DATE], the resident was high risk for falls. Further review of the R901's medical record revealed the resident also had a physician order for an blood thinner dated for 9/23/24, Enteric Coated Aspirin 81 mg (milligrams) tablet delayed release. Give 1 tablet by oral route one time day .Start date 9/23/24 . Further review of R901's medical record revealed the following progress notes: Entered By: [Licensed Practical Nurse (LPN) A] on 9/28/2024 8:17 pm, Type: Standard. Patient found on the floor on the right side laying, right hand on the back of her head. upon asking she denied falling from the bed. patient mentioned the she just rolled down from the bed while trying to wiping the floor. patient is alert and oriented times 2. patient had no injuries, no bleeding. patient vitals are b/p (blood pressure) 154/91, HR (heart rate) 83,osat (oxygen level) 93, RR (respirations)18. patient is in (on) aspirin. patient neuro checked had been done. [Physician] and the family member had been informed. patient bed is lower to the floor. call bell is within reach. patient had been monitor at all the time. Entered By: [LPN B] on 9/29/2024 12:38 am, Type: Standard. Writer received resident in bed after 730pm, writer was informed in shift-to-shift report that resident had a fall at 6:30pm. Per previous nurse resident was observed on the floor next to bed laying on her right side, first neuro check initiated at 6:30pm. Writer did walking rounds before starting med pass & observed resident in bed, with bed in lowest position. At approximately 9:10pm writer was called into resident room by caregiver. Resident was observed on the floor next to her bed laying on her left side. Writer immediately rolled resident over & begin assessment, upon rolling resident over writer noted bruising over right eye, resident arms flaccid, resident grunting in response to questions, resident eyes opened spontaneous to pain/ sternum rub. Writer took several sets of vital signs due to elevated blood pressure when vital signs performed, writer had a second nurse come into the room & take a manual blood pressure to confirm the previous elevated blood pressures. Last noted blood pressure (manual) 200/160, blood glucose 177, spo2 97% on room air, pulse 81, respirations 18. Staff member stayed with resident while writer called resident physician, voicemail left for physician to contact facility as soon as possible & called 911 to transport resident to hospital due to unwitnessed fall, bruise on face & is on blood thinner. Resident was transferred to hospital via 911, family aware of incident & transfer to hospital, in house manager also aware. On 10/2/24 at 1:02 PM, an interview was completed with LPN A regarding R901's first fall, and she explained when she entered the room, the resident was on the floor, lying on their right side, with their hand on the back of their head. LPN A explained the resident told her she was attempting to wipe something off the floor and slid down. LPN A explained she contacted to physician, and did not receive an answer or return call therefore, she assessed the resident, completed a neuro check, and handed the concern over to the next shift nurse. On 10/2/24 at 1:19 PM, an attempt to reach LPN B was to no avail. A review of the Unusual Occurrence Report for R901's first fall revealed the following, What did you do to try to prevent the incident from happening again? The call light on (in) reach. Star program + (plus) Neuro checks. This report was signed by LPN A, the Director of Nursing (DON), the Physician, and the Nursing Home Administrator (NHA) on 9/30/24. A review of R901's Neuro Flow Sheet revealed the resident's name and room number, and noted R901 had one neuro check completed between her first fall at 6:30pm, and her second fall at 9:10pm. The Neuro Flow Sheet further revealed a timeline of when to Check Resident with the following times: Initial Assessment, Every 1 Hour Times 2, Every 2 Hours Times 3, Every 4 Hours Times 4, and Every Shift Times 24 Hours. On 10/2/24 at 12:48 PM, an interview was completed with the (DON) regarding R901's fall. The DON was asked about the neuro checks for R901 following her initial fall, and acknowledged additional neuro checks should have been completed however, the investigation of R901's falls are still in progress. The DON was asked about the physician not contacting the nurses back following the resident falls, and acknowledged this is an issue they are working on. On 10/2/24 at 2:10 PM, the NHA was asked about R901's fall, and explained LPN A's supervisor advised her to initiate the neuro check as a baseline and the resident reported she did not hit her head. Regarding the physician not returning the nurses' calls, she explained they did their due diligence to reach the physician per policy. A review of the facility's Fall Management Guidelines revealed the following, .3. When a fall occurs, the nurse should assess the resident for injury, and provide the appropriate first aide based on standard of practice. If there is a suspected head injury, neuro checks should be completed and contact the physician for further instruction .9. The nursing staff will assess the resident over the next 72 hours, and document in the nurses' notes to identify any possible injuries, including pain that may not be evident following a fall

This citation pertains to Intake MI00142742. Based on observation, interview, and record review, the facility failed to serve food in a palatable manner and preferred temperature for three residents (R65, R89, and R117) and three confidential group residents of twelve residents reviewed for food palatability, resulting in dissatisfaction during meals. Findings include: On 4/12/24 at 8:30 AM, a random breakfast tray was pulled from the [NAME] unit at the facility and temperature tested by Dietary manager (DM) B and the results were the following: Eggs: 101 Degrees Fahrenheit; Waffles: 100 Degrees Fahrenheit; Sausages: 103 Degrees Fahrenheit. DM B was interviewed regarding their expectations regarding hot food temperatures and stated, We try and get it to the units as quick as possible. Breakfast is tough. DM B acknowledged having food complaints from residents regarding cold food. DM B taste tested the test tray and indicated that it tasted, Fine. On 4/12/24 at 8:34 AM, the test tray was taste tested by the surveyor and the food tasted cold which negatively impacted the palatability of the food. 34851 R65 On 4/10/24 at 12:45 PM, R65's was asked about the food at the facility. R65 stated, explained they were not happy with dessert selection and how it was not real dessert. R65 continued and explained, they are being served five grapes, flavored gelatin, pineapple, when we use to get brownies or pie. R89 On 4/10/24 at 12:59 PM, R89 was asked about the food at the facility. R89 stated, I have been sick two times this week with diarrhea because of something I ate. A review of pictures from R89's phone noted, January 29th and 24th, 2024. One of the pictures noted a piece of meatloaf that was pink in the middle indication undercooked. R89 stated, I sent it back and the next one they brought was the same color. R117 On 4/10/24 at 1:10 PM, R117 was asked about the food and stated, The food is horrible. 49102 On 04/12/24 at 10:03 AM, a confidential group interview was held with six residents representing various areas of the facility, all of whom were alert and oriented and able to verbalize concerns without difficulty. When asked about the food, three residents reported concerns. Responses included: Food on trays are cold Food is like ice sometimes. Food often needs to be reheated and it is not good when it is cold. On 4/12/24 at 2:02 PM, the Administrator (NHA) was interviewed regarding their expectations for food temperatures when served to the residents on the units and stated, Food is [temperature checked] at the steam table so it is at the right temperature, then [covered] .temperature is an individual preference.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 4/10/24 between 8:45 AM-9:20 AM, during an initial tour of the kitchen, the following items were observed: There were 2 hand sinks in the kitchen with no paper towels available and the one hand sink that did have paper towels was blocked by a tall rack of dishware. According to the 2017 FDA Food Code section 6-301.12 Hand Drying Provision, Each handwashing sink or group of adjacent handwashing sinks shall be provided with: (A) Individual, disposable towels; According to the 2017 FDA Food Code section 5-205.11 Using a Handwashing Sink, 1. (A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use. Pf In the walk-in cooler, there was an opened 1 gallon container of honey mustard with a use-by date of 4/1, an opened, undated 1 gallon container of ranch dressing, an opened, undated 1 gallon container of raspberry vinaigrette dressing, and an opened, undated 1 gallon container of thousand island dressing. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. There was a dusty ceiling vent cover directly above a rack of clean dishware, and 2 dusty ceiling vent covers above the clean drainboard of the dish machine. According to the 2017 FDA Food Code section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition, (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. The connection at the wall for the hose sprayer was observed with a steady stream of leaking water. The drain line underneath the sanitizer bin of the 3 compartment sink was leaking water onto the floor underneath. During an interview on 4/10/24 at 9:10 AM, Physical Plant Manager G confirmed the dusty ceiling vent in the dish machine room, and stated it would be cleaned right away. Physical Plant Manager G also confirmed the leaking plumbing fixtures and stated they would be addressed as well. According to the 2017 FDA Food Code section 5-205.15 System Maintained in Good Repair, A plumbing system shall be: (A) Repaired according to law; P and(B) Maintained in good repair. There was an unlabeled chemical spray bottle, filled with a blue liquid at the 3 compartment sink. According to the 2017 FDA Food Code section 7-102.11 Common Name, Working containers used for storing POISONOUS OR TOXIC MATERIALS such as cleaners and SANITIZERS taken from bulk supplies shall be clearly and individually identified with the common name of the material.

Based on observation, interview, and record review, the facility failed to provide visual privacy during patient care and or obtain consent for care in a public area for one resident (R114) of one reviewed for personal privacy. Findings include: On 04/10/24 at 4:25 PM, R114 was asked questions about the their location, date, and situation and provided answers unrelated to the questions. On 04/11/24 at 1:50 PM, R114 was observed to be in the day area, with seven other residents. R114 was seated at a table with two other residents. R114 was dressed in long sleeves, pants, non slip socks and a baseball style cap. R114 was approached by a female who identified themselves as a physician (Staff C). The physician attempted to identify the resident to verify their name and the resident replied with a different name. The physician exited the day room and asked staff to confirm this was R114. On the way back to the resident the physician called the resident by name and R114 answered. A certified nurse assistant also entered and confirmed R114's identity to the physician. The physician (standing over the resident) then asked if R114 if they were hurting anywhere asked if there was anything they could do for R114. The physician then listened with a stethoscope to the upper back area above the top of the wheelchair in two places and on the chest in two places. The physician then touched each foot/ankle area. The physician then thanked the resident and exited the day area. The physician did not ask R114 for consent to be seen in a public setting and was not seen to complete hand hygiene. On 04/12/24 at 2:25 PM, the Director of Nursing (DON) reported privacy should always be provided during patient care. The DON also reported if consent was given then a resident could be seen in a public area but preferably it would be conducted in the resident's room. The DON was asked if R114 was able to give informed consent and reported R114 was not. A review of the record for R114 revealed, R114 was admitted into the facility on [DATE]. Diagnoses included Dementia with psychotic disturbance and Anxiety. The Minimum Data Set (MDS) assessment indicated severely impaired cognition with a 2/15 Brief Interview for Mental Status score and the need for set up for eating and partial to maximal assistance for other Activities of Daily Living. A review of the facility policy titled, Medical Staff Rules and Regulations undated, revealed, 1. The physician shall adhere to the rules and regulations for the standard of medical care as set forth by Federal State and/or other regulatory agencies. 2. The physician shall adhere to the policies of the healthcare center .

This citation refers to Intake MI00142742. Based on interview and record review, the facility failed to ensure a weight was obtained upon admission for one resident (R448) of two reviewed for nutrition, resulting in the potential for unidentified weight loss. Findings include: On 04/12/24 at 2:17 PM, a representative of R448 reported R448 had not been assisted to eat, not provided fluids consistently and had weight loss. The representative reported R448 was transferred to another facility related to care concerns. The representative reported R448 had weighed 150 pounds prior to hospitalization and was down to 130 pounds when received at the nursing home. R448 confirmed the concern for weight loss and meal assistance. A review of the record for R448 revealed: R448 was admitted in the facility on 01/28/24 and discharged to another facility on 01/31/24. Diagnoses included Dysphagia (difficulty swallowing), Need for assistance with personal care and Muscle weakness. A review if the care plan indicated: Feeding: I need the meal tray set up for me. I may need to be encouraged to eat my meal and drink all the fluids. A review of the results and vitals for R448 revealed no weight had been recorded. The facility reported a weight was attempted on 01/28/24 but the resident had refused. Documentation of this was not provided. A subsequent attempt at a weight was not documented or attempted. A review of the physician order dated 01/28/24 at 7:53 PM documented, Weight daily times two then weekly times four, then monthly. Documentation of a weight was requested on 04/12/24 at 2:58 PM but not received prior to survey exit. On 04/12/24 at 12:09 PM, the Registered Dietitian (RD) reported discussion with the spouse and resident about food preferences and R448's fluid restrictions related to low sodium levels and the impact the C collar (neck brace worn post neck surgery) had on the dietary intake of R448. The RD documented a weight in the hospital notes of 140 pounds. The RD did not have a weight for R448 while at the facility. On 04/12/24 at 2:25 PM, the Director of Nursing (DON) reported a weight is a part of what we do and should be obtained in the first 24 hours of admission and after that as determined by the plan of care. A review of the policy titled, Weight Management dated July 2021, revealed, Residents will be monitored for significant weight change on a regular basis .2. Weigh residents upon admission .

Based on observation, interview and record review, the facility failed to ensure medication dispensing pens were dated when opened in two of four medication carts resulting in the potential for the decreased efficacy of the medications. Findings include: On 04/12/24 at 8:24 AM, an open Ozempic pen in the [NAME] B medication cart was not dated. On 04/12/24 at 8:43 AM, in the medication cart for the [NAME] 100 unit, a lantus insulin pen and a Novolog insulin pen (for R10) were not dated when opened and a novolog (for R5) was dated 02/28/24. On 04/12/24 at 2:25 PM, the Director of Nursing (DON) reported insulin should be dated when opened and a sticker should be in place on the pen. 38207 On 4/12/24 at 1:59 PM, medication cart B on the Charlevoix unit of the facility was inspected and revealed that resident identifying information was not labled on one inhaler. Unidentified nurse D who was administering medications on the unit to residents, was interviewed regarding labeling of inhalers and stated, Some inhalers are labeled. A review of the manufacturer's prescribing information dated 10/2023 revealed, Store your pen in use for 56 days at room temperature . The Ozempic pen you are using should be disposed of (thrown away) after 56 days, even if it still has Ozempic left in it. Write the disposal date on your calendar . A review of the manufacturer's prescribing information for the Lantus pen dated 12/2020 revealed, Once you take your SoloStar out of cool storage, for use or as a spare, you can use it for up to 28 days. During this time it can be safely kept at room temperature up to 86 F (30 C). Do not use it after this time. A review of the manufacturer's prescribing information for the Novolog pen dated 02/2023 revealed, Store the PenFill cartridge you are currently using in the insulin delivery device at room temperature below 86 F (30 C) for up to 28 days. Do not refrigerate. The NovoLog PenFill cartridge you are using should be thrown away after 28 days, even if it still has insulin left in it A facility policy titled Medication Ordering And Receiving From Pharmacy IC9: Medication Labels June 2019 was reviewed and stated the following, Policy: Medications are labeled in accordance with federal and state regulations and standards of pharmacy practice .Procedures: A.For very small items such as inhalers .the product itself must be labeled with, at a minimum, the resident's name.

Based upon observation, interview and record review, the facility failed to serve food at a palatable temperature for five (R16, R65, R89, R230, R231) of 24 sampled residents resulting in resident dissatisfaction with meals. Findings Include: On 1/23/23 at 10:36 AM, R16 reported the food is usually too cold and that this was the case with that days breakfast. On 1/25/23 at 11:25 PM, R16 reported that the breakfast was too cold today. Review of the facility record for R16 revealed an admitted [DATE] with diagnoses including right lower extremity fracture and muscle weakness. R16's Brief Interview of Mental Status (BIMs) score is 13 indicating intact cognitive functioning. R16 was able to articulate their concerns and preferences clearly. On 1/23/23 at 10:52 AM, R89 reported the food is often too cold and it comes later than their preferred time. On 1/24/23 at 9:20 AM, R89 reported that the lunch and dinner from 1/23/23 were both too cold. Review of the facility record for R89 revealed an admitted [DATE]. Minimum Data Set (MDS) assessment dated [DATE] indicated that active diagnoses which included malnutrition. R89's BIMs score is 15 indicating intact cognition. R89 was able to articulate their concerns and preferences clearly. On 1/25/23 at 2:00 PM, the facility Dietary Manager reported that their expectation regarding hot food palatability is that the food be hot enough to be pleasurable and to the resident's preference. 38207 Resident 65 (R65) On 1/23/23 at 9:00 AM, during an initial tour of the facility R65 was interviewed regarding food palatability at the facility and stated, The food is terrible. I live on cereal. My family brings me food. On 1/25/23 at 12:13 PM, a review of R 65' s' electronic medical record was conducted and revealed the following, R65 was admitted to the facility on [DATE] with diagnoses that included Heart failure and Chronic obstructive pulmonary disease (COPD). A review of R65's most recent minimum data set assessment dated [DATE] revealed that R65 had an intact cognition. On 1/24/23 at 8:30 AM, a random breakfast food tray on the [NAME] unit was temperature tested by Dietary manager (DM) A and the results were the following: Scrambled eggs: 100 Degrees Fahrenheit; Oatmeal: 135 Degrees Fahrenheit. DM A was interviewed regarding the temperature of the food and indicated that he would like to see the scrambled eggs at 140 Degrees Fahrenheit or above. DM A was asked to taste the food and declined, stating, No, I already tasted it in the kitchen. 34851 On 1/24/2023 at 1:28 PM, a confidential Resident Council meeting was held. There were six residents participating in the meeting. The residents were asked about the food served at the facility and all stated, It's always cold. The residents continued and explained, the eggs for breakfast are cold and that they taste awful cold. Residents stated that when eating in the dining room the reason for the cold food is that, the meal cart arrives and there is no staff to assist with passing the meals, the food trays sit and get cold. 32220 On 01/23/23 at 8:36 AM, the breakfast tray cart was rolled into the Charlevoix dining room. The thermostat indicated it was 74 degrees Fahrenheit on the unit. A CNA (certified nursing assistant) commented to therapy that there were only two of us today. A call was heard to come into the nurse station and was not answered. A voice was heard to ask if any one was there. On 01/23/23 at 8:46 AM, a second breakfast tray cart was rolled onto the Charlevoix unit. The doors to the cart were left open during delivery a single CNA was observed to deliver the meal trays. On 01/23/23 at 9:44 AM, R231 commented of of the food was like rubber and had asked for an alternate and had not yet received it. On 01/23/23 at 9:50 AM, R230 commented The food was cold this morning and the food is usually cold. R230 had also ordered a new tray and was waiting on the tray to arrive. On 01/23/23 at 12:38 PM, foam clamshells were observed to be used for lunch food items on the Charlevoix unit. On 01/23/23 at 12:53 PM, the Charlevoix food tray cart door was left open during tray delivery. On 01/23/23 at 1:02 PM all trays from the cart had been delivered. On 01/24/23 at 12:35 PM, tray delivery was observed on the Charlevoix unit. The tray cart doors were left open during delivery. One aide closed the door initially but the next left it open and it remained open for the rest of the tray deliveries. At 12:44 PM, all lunch meal trays from the cart were delivered. On 1/25/23 at 2:12 PM, a facility policy titled Food Temperatures Revised: 12/2014 was reviewed and stated the following, Policy: Foods will be maintained at proper temperature to insure food safety and acceptable palpability and resident satisfaction. Procedures: 1 .hot food served to the resident will be no less than 135 degrees Fahrenheit.

Based on observation, interview, and record review, the facility failed to maintain the kitchen in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 1/23/23 between 8:30 AM-9:15 AM, during an initial tour of the kitchen with Dietary Manager (DM) F, the following items were observed: The handwashing sink located next to the clean side of the dish machine was observed with no hand soap or paper towels, and there was no handwashing signage. According to the 2017 FDA Food Code section 6-301.14 Handwashing Signage, A sign or poster that notifies food employees to wash their hands shall be provided at all handwashing sinks used by food employees and shall be clearly visible to food employees. According to the 2017 FDA Food Code section 6-301.11 Handwashing Cleanser, Availability, Each handwashing sink or group of 2 adjacent handwashing sinks shall be provided with a supply of hand cleaning liquid, powder, or bar soap. According to the 2017 FDA Food Code section 6-301.12 Hand Drying Provision, Each handwashing sink or group of adjacent handwashing sinks shall be provided with: (A) Individual, disposable towels;. The ice scoop holder was observed with black debris on the interior surface. The exterior surface of the ice machine was observed to be soiled, and the front grill cover had a sticky substance on the surface. According to the Food & Drug administration (FDA) 2017 Model Food Code, Section 3-304.12 In-Use Utensils, Between-Use Storage, During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: .(E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not potentially hazardous (time/temperature control for safety food) . The inside bottom surface and the exterior surface of the True refrigerator/freezer were soiled with dried on food debris. According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In the True refrigerator, there was an opened, undated container of coconut non-dairy creamer, a half gallon of lactose free milk dated 01/08/23, and an opened, undated container of thickened cranberry cocktail. In the dry storage room, there were 2 tubs of beef base stored directly on the floor, and 3 boxes (stew, sliced peaches, and fudge icing) stored directly on the floor. When queried as to what day stock was received, DM F stated Tuesdays and Fridays (boxes were still on the floor 3 days after being received). According to the 2017 FDA Food Code section 3-305.11 Food Storage, 1. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: 1. (1) In a clean, dry location; 2. (2) Where it is not exposed to splash, dust, or other contamination; and 3. (3) At least 15 cm (6 inches) above the floor. Also in the dry storage room, there was a 6 quart plastic container of an unlabeled light brown granular substance, with a spoon stored inside. DM F stated it was brown sugar, and that it should be labeled and should not have the spoon stored inside. In the walk-in cooler, there was an 11 pound container of opened, undated coleslaw, with a manufacturer's use by date of 1/3/23, an undated box of blueberry muffins, an opened, undated gallon of ranch dressing, 2 opened, undated gallon containers of thousand island dressing, 2 opened, undated gallon containers of Italian dressing, a gallon container of mayonnaise with a use by date of 1/13, a 1 gallon container of slaw dressing opened 7/1/22, a gallon of lactose free milk with a manufacturer's best by date of 1/8/23, a tube of raw ground beef stored on the rack directly above a box of heavy whipping cream, and an opened, undated bag of cooked Italian sausage. According to the 2017 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. The flooring in the walk-in cooler was soiled with dried up liquid spills, trash and food debris underneath the racks. DM F stated that the floors were to be swept and mopped between shifts. The flooring underneath the steam table was soiled with black grime and a buildup of food debris. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A)Physical facilities shall be cleaned as often as necessary to keep them clean. The drainboard on the 2 compartment sink was heavily soiled with crumbs and debris, and there was an unlabeled bin of white powder, a box of taco shells that was open and uncovered, and 2 boxes of pastries, all stored on the soiled drainboard. The ceiling vent covers located above the clean side of the dish machine drainboard, were soiled with dust. DM F stated that the Maintenance is responsible for cleaning the vents. According to the 2017 FDA food Code section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition, (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. On 1/23/23 at 10:45 AM, an irreversible registering temperature indicator (paper thermometer to check the dishware surface temperature to ensure adequate sanitiziation) was sent through the dish machine. The test window did not change black, indicating that the surface temperature of the dishware was not reaching 160 degrees Fahrenheit. A second and third strip sent through the dish machine did not change. Staff stated they tested the dish machine this morning with a strip and that it had changed. Staff could not find the strip. Review of the dish machine log book revealed that the last documented test strip on the log was dated 11/21. A lunch cart was observed being transported to the Great Lakes dining room. The cart was a shelving unit with all sides open, and the trays on the cart were observed with uncovered slices of pie on each tray. According to the 2017 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination, FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. There were small black flies observed throughout the kitchen, near the handwashing sink, in the dish machine room, and near the 2 compartment sink. Review of the pest control service report dated December 2022 noted, .Upon kitchen inspection, heavy drain fly activity was observed. Kitchen sanitation needs to be improved. There is a lot of standing water, debris and grease build-up found around kitchen causing fly activity and providing breeding sites for them . 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .4. (D) Eliminating harborage conditions.

Based on observation, interview, and record review the facility failed to ensure the bedside table was in reach for one of one resident (R98) reviewed for hydration, resulting in water not being within reach of the resident. Findings include: On 1/24/23 at 9:55 AM, R98 was observed in their room in the bed. R98's daughter was also observed in the room. R98's face was observed with a bruise and when asked was the cause R98 and the daughter stated, R98 fell out of bed. During the interview R98 stated, They have this matt next to the bed and my table is over there (not within reach). R98's bed was observed with the left side against the wall and the right side open to the room. R98 has right side weakness and is unable to use their right side to reach for items. R98 stated, Sometimes I want water and I can't reach it and no one is to be found to help me. On 1/25/23 at 8:54 AM, R98 was observed in be asleep. R98's fall mattress was observed on the right/open side of the bed. The bedside table was observed behind R98, at the head of the bed near the right side. The beside table was observed with a container of water that was unopened and out of the resident's reach. A review of R98's medical record noted, R98 was admitted on [DATE] with diagnoses of Hemiplegia (weekness/paralysis of one side) and Cerebrovascular Accident (Stroke). R98's Minimum Data Set assessment noted, R98 with a moderately impaired cognition and required extensive assistance by staff for activities of daily living. On 1/25/23 at 2:28 PM, Unit Manager, Licensed Practical Nurse (LPN E) was asked about the accommodation for R98's bedside table and stated The intervention was suppose to have the table on the left side of [R98's] bed. LPN E was told about the observations of the table out of R98's reach and explained that it would be looked into. A review of the facility's policy titled, Hydration dated, October 2010, noted, Policy: It is the policy of this facility to assist residents to maintain adequate hydration whenever possible. Nutrition, Hydration interventions will be pursued until the resident and/or family have opted for comfort care measures only, and attempting more aggressive methods of hydration are contrary to the resident's Quality of Life, comfort, and requests. Procedure: 3. Standard Hydration Interventions will include the following practice measures to prevent the occurrence of dehydration: . D. Assure fresh bedside drinking water is available at all times, unless contraindicated. Assist residents to periodically take a drink throughout the day .

Based on observation, interview and record review the facility failed to implement fall interventions per the plan of care for one sampled resident (R1) out of two residents reviewed for care plan interventions resulting in, the potential for the resident to sustain another fall with injury. Findings include: On 01/23/23 at 10:10 AM, R1 was observed in their bed which was not in the lowest position. A fall mattress was observed lying against the wall away from the resident's bed. R1 was also observed to have a cast on their right arm. Attempts to interview R1 were to no avail as the resident appeared confused. A review of R1's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Dementia, Diabetes and Muscle Weakness. A review of R1's Quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition, and required bed mobility, transfers and bathing. Further review of R1's medical record revealed the following care plan: .Admission #3 - Fall Risk. Etiology: My gait is unsteady. I am not always aware of my limitations. As Evidenced By: I fall when I bend over or stand up quickly. I had fallen at home. Additional Detail: I am afraid of falling. I don't want to break anything. I want to walk by myself. I don't want to ask someone to help me get up and down, but I forget I'm weak /unsteady. Effective: 1/04/2023 .Interventions. Low bed. Effective: 1/04/2023. I need a mattress next to my bed to prevent an injury. Effective: 1/04/2023 . On 1/24/23 at 8:14 AM, 11:23 AM, and 3:36 PM, R1 was observed in bed without it being in the lowest position. The fall mattress was also observed lying against the wall away from the resident's bed. On 1/25/23 at 2:05 PM, the Director of Nursing (DON) was asked about her expectations for following the Plan of Care for a resident at risk for falls. The DON explained that her expectations are that interventions should be in place. A review of the facility's Comprehensive Plan of Care policy revealed the following, .FUNDAMENTAL INFORMATION. The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, psychosocial wellbeing Include intervention to attempt to manage risk factors .

This Citation has Two Deficient Practice Statements. Deficient Practice Statement One: This Citation Pertains to Intake Number MI 391. Based on observation, interview, and record review, the facility failed to ensure functionality of Resident care equipment for one sampled resident (#231) of one resident reviewed for injuries of unknown origin, resulting in the malfunction of an EZ Lift (SARA mechanical lift used to lift and in short distance transfers), pain and a right leg fracture. Findings include: Record review on 7/22/19 revealed Resident #231 was transferred to the hospital on [DATE] and had not returned. Review of Resident #231's face sheet revealed the resident was originally admitted into the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required extensive to total assistance to perform Activities of Daily Living (ADLs). A review of Resident #231's care plans on 7/22/19 revealed a care plan entitled, Alteration in Mobility: Alteration in mobility R/T (Related To) generalized weakness, [MEDICAL CONDITION] (Effective 3/11/17) The care plan included the intervention, Transfer/Mobility Status: 2 PA (Person Assist) EZ Stand. A review of Resident #231's orders at this time revealed the following activity order dated 2/26/19, Activity . Transfer Status: Mechanical Lift: EZ stand x 2 for transfers and showering. Additional record review on 7/22/19 revealed Resident #231 was transferred to the hospital on [DATE] due to uncontrolled leg pain. Upon request, the facility provided an investigation pertaining to the injury of unknown origin for Resident #231. A review of the provided investigation on 7/22/19 indicated the resident was transferred from their wheelchair to bed on 6/15/19 around 9:00 PM and was complaining of leg pain. The investigation did not include an Incident and Accident Report. The investigation further revealed the resident continued to complain of severe pain despite having mobile X-Rays of their knees completed at the facility on 6/16/19 which did not show an acute injury. Resident #231 was transferred to the hospital on [DATE] due to the pain. Diagnostic studies at the hospital revealed the following: -Hospital X-Ray Report: 6/18/19 . Findings . There is a right medial tibial plateau fracture with mild depression . -Hospital CT Report: 6/18/19 . There is a comminuted [MEDICATION NAME] fracture (bone broke in several pieces, perpendicular to the long part of the bone) through the proximal metaphyseal region of the tibia (upper part) which is mildly impacted. There is also a [MEDICATION NAME] slightly oblique fracture (break at an angle through the bone) though the fibular head nearly nondisplaced . diffuse soft tissue swelling . Additional review of facility provided investigation documentation included eight handwritten Staff statements indicating the staff had cared for Resident #231 from 6/16/19 until 6/18/19 but revealed the staff members completing the forms did not transfer the resident for the dates the forms were completed. On 7/23/19 at 1:34 PM, an interview was conducted with Confidential Witness G and Confidential Witness H. When queried regarding Resident #231's whereabouts and ability to speak to them, Witness G stated, You don't know? (Resident #231) passed away. They went back to the facility on [DATE] and then got sent back to the hospital on [DATE]. They passed away on 7/11/19. When asked about Resident #231's leg, Witness G stated, (Resident #231) hurt their leg on 6/15/19- Saturday night. With further inquiry regarding the injury, Witness G stated, There was a problem getting (Resident #231) moved from the wheelchair to the bed. Staff were using the EZ stand and I think they ended up having to use the Hoyer lift (different type of mechanical lift). We met with the Administrator and they said the Hoyer did go into (Resident #231's) room when they watched the video and indicated the facility was completing an investigation related the fracture. With further inquiry, regarding the Resident's leg, Witness H stated, At 7:43 (PM) on Saturday (6/15/19) when I called, (Resident #231) was still in their chair and I called the nurse and asked them to make sure (Resident #231) was in bed by 9:00 (PM). I called back later, and the nurse said they were getting (Resident #231) in bed. Then I called back at 9:25 (PM) and the nurse said they were getting (Resident #231) into bed with the sling on the EZ stand. At 10:10 (PM), I talked to (Resident #231) and they said their leg was hurting. I asked what happened and (Resident #231) said 'I don't think they (staff) knew what they were doing (with the lift). (Resident #231) told me they felt something pull in their knee. Then I called and talked to the Nurse (Nurse D) and the Weekend Supervisor (Nurse J) and they told me they were having trouble with the sling and the knee pads on the EZ stand. Witness H then stated, On Sunday, (Resident #231) was in pain and not feeling well from it so they did not get (the Resident) out of bed. On Sunday, I spoke to the nurse and they put in an order for [REDACTED].#231) was in major pain and then on Tuesday, they were nauseous from the pain. (Resident #231) said they were in pain and they felt something pull in their knee. I talked to Unit Manager D and told them what happened. After that, (Unit Manager D) tried to elevate Resident #231's legs but couldn't because of the pain and then they (facility staff) said they were sending (Resident #231) to the hospital. When asked what happened at the hospital, Witness H stated, It showed a fracture. (Resident #231) was in the hospital from 6/18/19 to 6/28/19. With further inquiry, Witness H stated, (Resident #231) just said they felt something snap in their knee. I talked to the Administrator on 6/17/19. We had a meeting with the Administrator on 6/28/19 and they said they were still investigating but the findings were inconclusive. The head nurse (DON) was there (at the meeting) and they said the cameras showed the Nursing Assistants were in there (Resident #231's) room for like 50 minutes. They kept contradicting each other, it seemed like their stories did not match. When asked if the Resident had problems with their leg or knee prior to the incident, Witness G replied, (Resident #231) would get [MEDICAL CONDITION] from their heart failure and they had arthritis but that was it. Witness H then stated, All we really know is (Resident #231) did not have a fracture at 7:43 (PM on 6/15/19), something happened, they started having pain, and then they did (have a fracture). Witness G then revealed they maintained detailed written records of Resident #231's care and provided documentation. Review of documentation maintained and provided by Witness G on 7/23/19 revealed the following: -6/15/19: 9:45 PM: (Nurse C) said CNA having issue with EZ stand sling and rubber. (Resident #231's) knees were hurt in the process. Bed at 10:00-10:15 PM. Called (Nurse Supervisor J) who went in and put cream on (Resident #231's) knees . Talked to (Resident #231) and they were in pain . -6/16/19: 8:40 AM: Talked to (Resident #231) and they were moaning . hurt. (Resident #231) said something pulled in leg, wrenched knee on EZ Stand (on 6/15/19) . -6/16/19: 11:59 AM Talked to (Resident #231) who said they were in pain through the night . Not hungry for lunch . -6/17/19: 8:07 AM Left message for (Administrator) regarding (Resident #231's) care; knees injured . asked to follow up . Review of Resident #231's pain level documentation in the medical record on 7/23/19 revealed the Resident had no pain (0/10 on pain scale with 10 being the worst pain) from 6/9/19 to 6/14/19. The first documented pain level, following the transfer on 6/15/19 occurred on 6/16/19 at 2:52 AM and revealed a pain level of 6/10. From 6/16/19 until 6/29/19 the Resident's documented level of pain ranged from 0 to 10 on the pain scale. Review of Resident #231's progress note documentation revealed no nursing documentation on 6/15/19. Additional review revealed the following: -6/16/19 at 1:13 PM: SBAR Communication Form and Progress Note . Situation . Resident is c/o (complain of) knee pain and generalized body pain . Reported to Primary Care Clinician (Nurse Practitioner F) -6/16/19 at 4:39 PM: Writer received in report this morning that Resident Family made several calls throughout the night in regard to (Resident #231) being laid down last night. Resident also c/o pain in which staff applied [MEDICATION NAME] to bilateral knees. Later that morning resident continued to c/o pain. (Family) was called and resident was to stay in bed today. Resident was given schedule Tylenol for pain; [MEDICATION NAME] cream applied to knees. Writer called (Nurse Practitioner F) . expressed Family concerns to order X-rays . -6/17/19 at 10:37 AM: Resident continues to c/o pain in bil (bilateral) knees, Tylenol is scheduled . Bil legs rewrapped with ace wrap and elevated -6/17/19 at 11:27 AM: Spoke with Resident family, informed that Resident was still c/o pain and that [MEDICATION NAME] gel was applied. -6/18/19 at 11:31 AM: Resident continues have pain in bil (bilateral) knees, uncontrolled with pain meds. Ankles are more swollen that usually. BUN elevated. Ace wraps were removed due to constant moaning, no relief. Resident yells in pain when legs are touched. Spoke to Doctor, transfer resident to ER for eval. Family notified of transfer. Ambulance called. On 7/23/19 at 2:32 PM, an interview was conducted with Nurse Practitioner F and Unit Manager D. When queried regarding Resident #231, Nurse Practitioner F stated, I remember (the Resident) had a sore knee but I never dreamed it was a fracture. Unit Manager D then stated, I was shocked it was a fracture because (Resident #231) doesn't move that much. An interview was completed with Unit Manager D on 7/23/19 at 2:43 PM. When queried regarding Resident #231, Unit Manager D indicated they were not working when the incident occurred and stated, I was on vacation and just got back. With further inquiry, Unit Manager D stated, (Resident #231) would not have been easy to X -Ray because of their size. When asked, Unit Manager D indicated the Resident was a larger person. Review of the Resident's medical record with Unit Manager D at this time revealed the Resident was 66 inches tall and had weighed 340 pounds. When asked how the Resident was transferred, Unit Manager D replied, An EZ stand. An interview was attempted to be completed with Nursing Assistant A on 7/23/19 at 4:01 PM and 7/24/19 at 11:27 AM. On 7/23/19 at 4:05 PM, an interview was conducted with Nursing Assistant B. When queried if they had cared for Resident #231 on 6/15/19, Nursing Assistant B stated, I was a standby assist. Another Aide asked me if I could go in while they put (the Resident) in bed. When asked about the transfer, Nursing Assistant B stated, (Resident #231) kept sliding somehow when the machine (EZ lift) lifted. It made a popping sound and it broke. When asked what broke, Nursing Assistant B replied, The pad by the shin. When asked, Nursing Assistant B stated, It cracked. When queried what happened after the lift broke, Nursing Assistant B indicated they lowered the Resident back down and ended up having to get a different lift. When queried if the lower extremity strap on the lift was in place when the Resident was sliding, Nursing Assistant B replied, It was the part their shin goes up against that broke. When asked again about the strap being connected, Nursing Assistant B did not provide an explanation. When asked if the Resident complained of pain during or after the transfer, Nursing Assistant B replied, Yes. When asked about the EZ stand, Nursing Assistant B stated, We were told Maintenance fixed it but the next thing we know there is a new one. Observation of EZ Stand in the hall of the unit where Resident #231 had resided at the time of the incident occurred on 7/23/19 at 4:30 PM. The EZ Stand lift was noted to have a blue shin guard which appeared new compared to the lower extremity leg strap. A sling was placed over the arm of the EZ stand lift. An interview was conducted with Rehab Manager I on 7/23/19 at 4:41 PM. When queried regarding Resident #231's transfer recommendations, Manager I replied, (Resident #231) was an EZ lift. The EZ lift machine and operation was reviewed with Manager I at this time. When queried regarding the lower extremity leg strap, Manager I replied, Should always hook leg strap so legs don't move. When queried how a Resident's legs would slip if the leg strap was hooked, Manager I indicated Resident's legs should not move if their legs are placed and the strap is hooked correctly. Appropriate placement of sling and positioning on the lift was demonstrated at this time. On 7/23/19 at 5:45 PM, an interview was conducted with Nurse C. When queried if they cared for Resident #231 on 6/15/19, Nurse C indicated they were the assigned nurse for the Resident. When queried regarding any incidents that occurred, Nurse C indicated the Nursing Assistants had difficulty transferring the Resident from their wheelchair to bed. With further inquiry, Nurse C stated, They (Nursing Assistants) had the wrong sling and basically had to lower (Resident #231) to the floor. When asked for clarification regarding when the Resident was lowered to the floor, Nurse C replied, They (Nursing Assistants) said they did not have the right sling for the machine and had to lower (Resident #231) to the floor. When asked if they observed the Resident on the floor, Nurse C stated, No. I was answering the phone and trying to pass meds. They (Nursing Assistants) said they had it under control. With further inquiry regarding how the Resident was lowered to the floor if an EZ Stand lift was being used, when an EZ stand lift does not go to the floor, and how they got the Resident off of the floor without assistance, Nurse C stated, I don't understand it myself. I'm baffled by it to. I should have asked them more questions. With further inquiry related to the EZ Stand lift, Nurse C stated, The (Nursing Assistants) said it cracked on the legs. Then I saw a sign on it that said 'Broken, Do Not Use'. When asked about the lift cracking and if the malfunction could have caused Resident #231's injury, Nurse C' replied, It's the right area, definitely could have. I could see it. When queried if the Resident complained of pain following the transfer, Nurse C stated, Yes. (Resident #231) had chronic knee pain. (Resident #231) was always complaining about their knees anyway. When queried regarding treatment of [REDACTED].#231). When asked about completed Staff Statement Form indicating they worked with the Resident on 6/17/19 and facility investigation of the incident, Nurse C indicated they spoke to the Administrator regarding the incident and stated, (Administrator) pretty much asked me the same questions. Review of Resident #231's Incident and Accident reports on 7/24/19 did not reveal an Incident Report pertaining to the EZ Lift and/or the unusual occurrences that took place, as stated by facility staff when transferring Resident #231 on 6/15/19. Review of facility provided work orders and repair bills for EZ Lift mechanical lifts were reviewed on 7/24/19. A repair invoice, dated 6/20/19, indicated repair work was completed on facility EZ lift (Sara 3000) machines on this date totaling $3965.55. The invoice detailed multiple repairs including replacement of leg fixation kit, knee support plate kit, knee support (blue), handgrips, and castors on the EZ lifts. An interview was conducted with the Administrator (Assistant Administrator- Acting Administrator) and the Director of Nursing (DON) on 7/24/19 at 11:40 AM. When queried regarding the letter provided in the facility investigation which indicated cameras were reviewed and what information was obtained from the review, the Administrator replied, We tried to look back to see if we could see anything. We just saw staff members go in (Resident #231's room) to do transfers. There were issues due to pain and they had to use a different lift. When asked, the Administrator stated, They went in with an EZ Stand. When asked why the investigation did not contain a schedule of staff who worked at the time of the incident, the DON stated, I don't know. Is it in there. The DON reviewed the investigation documentation at this time and stated, No (it is not in there). Well, that is how I get the names in the first place. Schedules of staff who worked from 6/15/19 to 6/16/19 was requested at this time. When queried regarding the Staff Statement Forms and facility procedure for how the forms were completed, the DON replied, We just had staff fill them out. When asked why the dates on the form began on 6/16/19, when the incident occurred on 6/15/19, and why all forms indicated no staff had transferred the Resident, the DON and Administrator did not provide an explanation. When queried why Nursing Assistant A's Staff Statement form indicated the form was pertaining to the shift worked on 6/16/19 and not on 6/15/19 when the transfer occurred, the DON indicated Resident #231's fracture was not caused by the transfer. When queried how they were aware the fracture did not occur during the transfer when the Resident began complaining of increased pain following the transfer and staff statements of a malfunction with the lift including the lift cracking and having to lower the Resident, the DON did not provide an explanation. When queried further regarding the EZ lift malfunction and transfer of Resident #231 on 6/15/19, the DON indicated they were unaware of a problem with the EZ lift. The DON then stated, I remember now. I saw an EZ stand out of service and I asked maintenance to take a peek at it. When asked, the DON indicated they were not aware of what was wrong with the lift. A review of EZ lift work orders and repair bills was completed with the Administrator and DON at this time. When queried regarding a total of $3965.55 worth of repairs being completed on 6/20/19 and if it was reasonable that the repairs were related to the malfunction that occurred while staff were transferring Resident #231, the DON replied, Yes. The DON then indicated the repair company probably completed repairs on all facility lifts while at the facility. When asked what repairs were for the EZ lift utilized on 6/17/19, during Resident #231's transfer, the Administrator and DON were unable to provide an explanation. When asked why an Incident and Accident Report was not completed for the occurrence with Resident #231 on 6/15/19, the Administrator and DON did not provide an explanation. When queried if Resident #231's fracture was caused by the malfunctioning and broken EZ Stand lift, the Administrator stated, I see what you are talking about. DPS #2 Based on observation, interview and record review the facility failed to maintain a resident's personal in room microwave for one (R#76) of nine residents reviewed for accidents and hazards resulting in the potential for a fire hazard. Findings include: On 7/22/19 at 1:44 PM, resident #76 was interviewed regarding the care received at the facility. A small refrigerator and a microwave was observed at the bed side. R#76 was asked if the microwave was a facility issued appliance or brought in by family and stated, Mine. R#76 was then asked if the room mate was able to use it and shrugged. R#76 allowed an inspection for the microwave the interior was clean but had clearly been used. The outside of the microwave did not have an indication of inspection by the facility. Record review of Electronic Health Record (EHR) revealed that R#76 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Date Set assessment dated [DATE] revealed R#76 had a Brief Interview for Mental Status (BIMS) score of 14 indicating an intact cognition and required minimum of supervision to limited assistance for Activities of Daily Living (ADLs) including eating. Review of R#76's record revealed no documentation of the microwave brought in by family and a resident's belonging inventory. There were no progress notes of the maintenance department's inspection of the microwave for electrical safety and there were no progress notes indicating a nursing assessment or care plans for safe use of the microwave. There were no documents of a safety assessment, physician's orders [REDACTED].#76 was assessed to use the microwave safely. A review of R#76's current care plans included interventions for Self Care Deficit related to decreased functional dependence, and a care plan for Non-compliance (inability to comply with instructions). Both of these care plans were in the active category. On 7/24/19 10:22 AM, Nurse D asked the source of R#76's microwave and stated, The family brought it in when (R#76) was admitted . It's been there for a long time. Nurse D was asked if R#76 was assessed for safe use of the microwave and stated, I don't know that (R#76) uses it. Nurse D was asked if R#76's room mate could use the microwave safely and stated, (R#76's room mate) couldn't open it. On 7/24/19 at 10:301 AM, Certified Nurses Aide (CNA) was asked if R#76 was ever observed using the microwave and stated, Yeah. On 7/24/19 at 10:36 AM, the Director of the Maintenance Department was asked about the facility's policy for the use of microwaves by residents in their rooms and stated, We have to check the microwave first. I've only had one request to bring a microwave in and we said no. The trouble is that families bring them in on weekends and we don't know about it. On 7/24/19 at 11:03 AM, the Director of Nursing (DON) was asked about the facility's policy on residents having microwaves in their rooms and stated, I didn't know about the microwave. I don't know that she uses it. The DON was asked for the facility's policy and procedure on the use of microwaves by residents in their rooms. On 7/24/19 at 11:48 AM, the Assistant Administrator stated We don't have a policy on kitchen appliance use by residents.

This citation pertains to intake MI 411. Based on observation, interview, and record review, the facility failed to prevent (R#903 - male) from touching the breast and upper thigh of (R#904 - female) for 1 of 7 sampled residents, resulting in unwanted and nonconsensual touching and sexual abuse. Findings include: A review of R#904's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was most recently admitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4/15, indicating the resident was severely cognitively impaired. A review of R#903's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted into the facility on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident had a BIMS score of 13/15, indicating the resident was cognitively intact. On 4/11/19 at 10:00 AM, R#904 was observed in the hallway at the 200 unit nurses' station. R#904 was observed to slowly move themselves forward in their wheelchair and was observed saying a female name multiple times. On 4/11/19 at 10:14 AM, R#903 was observed sitting alone in the hallway in his wheelchair. R#903 was interviewed and asked if they recalled an incident that happened with another resident on 3/26/19. R#903 indicated that they remembered and stated, You're about the 10th or 11th person to talk to me about it. R#903 was then asked to explain what happened. R#903 put their head down and responded, I touched a female on the breast. When asked why they touched the other resident, R#903 stated, I thought she was coming onto me a little bit. R#903 was then queried if they asked the other resident if they could touch them, and stated, No, I didn't ask if I could. When asked if R#903 thought touching the other resident was an appropriate response the resident stated, No, not appropriate. R#903 was then asked if it was their intention to touch the other resident and stated, I guess so. They've told me that was wrong and I can't do things like that. On 4/11/19 at 10:17 AM, an interview was attempted with R#904. R#904 was unable to propel themselves from the nurses' station to their room when asked. R#904 was assisted to their room via wheelchair by Nurse E. Upon questioning, the resident was unable to recall any events that happened on or around 3/26/19. On 4/11/19 at 11:08 AM, Unit Manager and Nurse (UM) C was queried regarding the incident between R#903 and R#904 on 3/26/19. UM C stated, It was brought to my attention that it happened. One of my staff told me (R#903) had possibly been touching (R#904) inappropriately, and it was reported to me that (R#904) had said, 'He touched my (expletive) (vagina).' It was observed by a Certified Nursing Assistant (CNA), and she (CNA A) was the one that separated the residents. She saw something going on that didn't look appropriate. (R#903) does propel themselves and go around. We put him on 15-minute checks after reporting it. We spoke to (R#903) and he did say that he did it, but couldn't explain why. Families were contacted. Video surveillance did show that there was some inappropriate touching. On 4/11/19 at 11:21 AM, an attempt to contact CNA A was made, and a voicemail was left for call back. On 4/11/19 at 12:25 PM, Family Member AA for R#904 was contacted and queried regarding the incident between R#903 and R#904. Family Member AA stated, All I can tell you is the nursing home called me and told me there was (a resident) that put their hands on (my family member's) thigh. I asked if she was okay. They told me (R#904) was okay and they had to notify me that it happened. Then they told me they asked her (R#904) again later on about it but that she didn't remember. And I said to them, 'Well yeah, she does have Dementia .' Family Member AA was then asked if they had seen any video surveillance of the incident but denied that they had. On 4/11/19 at 1:11 PM, The Director of Nursing (DON) was interviewed regarding the incident between R#903 and R#904. The DON stated, I was coming around to the unit and I was informed that it happened. I know that they separated them. I did not see surveillance footage. I do believe there was some. The DON was then asked if she spoke to the residents after the incident and stated, I did not interview them after it happened. On 4/11/19 at 1:36 PM, R#903 was interviewed and asked to provide further details about the incident on 3/26/19. The resident stated, The girl, I touched her breast. I grabbed at her blouse. I knew it was wrong. R#903 was then asked where they were located in the building and responded, We were in the hallway. She came up to me to begin with. I touched her leg, right about here. R#903 touched the top of their own left thigh. R#903 was then asked how they and the other resident were sitting. R#903 stated, She was facing me. They called the police. The police came out and asked me what happened and I told them I touched her breast. R#903 again indicated they do not know why they touched R#904 and stated, I wish it never would've happened. On 4/11/19 at 1:54 PM, The Administrative Assistant was asked about surveillance video showing the incident between R#903 and R#904. The Administrative Assistant stated, I don't believe anything was transcribed. We just reviewed it to verify that it correlated with (CNA A)'s witness statement. On 4/11/19 at 2:10 PM, CNA A was interviewed and asked what occurred between R#903 and R#904 on 3/26/19. CNA A stated the following: I just happened to come out of the dining room. As I was coming out I was coming toward (R#903 and R#904). She was facing me, and his back was toward me. I saw he had her chair blocked in. As I was coming, I could see (R#904) pushing (R#903)'s hand away. He was tugging at her midriff and tugging at her clothes. So, I'm saying as I'm coming towards them, 'Hey! What are you doing?' I saw he had his forearm in her chair and I could see him moving his hand. When I went to separate them, I told (R#903) to let her (R#904) go. I went to take her with me and she whispered to me, 'He just tried to touch my (expletive) (vagina).' And I said, 'What?!' Now it's kind of weird because this is a resident (R#904) who says a lot of things, but I think for her to whisper that to me immediately, that was different. It was different from how she normally says things. I've taken care of her for a really long time, and that concerned me. I saw her pushing his arm away so that concerned me. I took (R#904) up to the desk so the other aide could watch her, and I explained what happened. That CNA went to let their nurse know what happened, and then I went to tell my nurse (Nurse B) what happened. (R#903) was mine that day. (R#903 and R#904) were in the 200-hall right up under the camera. The footage was looked at and apparently they (facility) did see on the tape that he had done it. (R#903) never answered me, he just looked at me when I asked him what he was doing and why he was doing it. (R#903) turned around and I saw him wheeling quickly through the dining room away from the situation. On 4/11/19 at 2:46 PM, Nurse B was interviewed and asked what occurred between R#903 and R#904 on 3/26/19. Nurse B stated, The nursing assistant (CNA A) assigned to (R#903) came up to me and said that she observed on the other unit that he parked his wheelchair in front of (R#904) so she was blocked in, and he was grabbing at (R#904)'s shirt and crotch area and that she saw (R#903) abruptly leave after. Nurse B stated they notified their supervisor of the situation but did not interview either resident after the reported incident. A review of R#903's care plan revealed the following: Focus: Socially Inappropriate Behavior, I touched another female resident inappropriately (on the pubic area over clothes), Active, Effective: 3/28/2019. A review of R#903's progress notes revealed the following: Entered By: (UM C) on 3/26/2019 11:25 AM, (UM C and Nursing Home Administrator (NHA)) had a meeting with the above resident in regards to reports of inappropriate touching .resident on another unit. The above resident admitted to inappropriately touching the .resident and states that (they) will not inappropriately touch .residents again and .understands the consequences that could occur with this type of behavior . 3/26/2019 3:56 PM .SW (Social Worker) met with resident to discuss incident that occurred with another .resident. When SW brought up the incident (the resident) put his head down and said 'I don't want to talk about it'. SW informed him that his actions are taken very seriously at this facility. Informed him that the staff is obligated to ensure the safety of all residents, whether they are competent or not .SW asked if he would like to say anything in relation to this matter and he expressed that he understood that this incident is serious and assured the SW that such incidents would not happen again. A review of the facility's investigation for the incident involving R#903 and R#904 revealed the following: Conclusion: The facility can substantiate the inappropriate touching between (R#903) and (R#904) did take place . A review of the facility's policy titled, Abuse and Neglect Policy, revised (MONTH) (YEAR), revealed, Each resident has the right to be free from abuse, mistreatment, neglect, exploitation, involuntary seclusion, misappropriation of property and mental abuse facilitated or enabled by the use of technology .sexual abuse includes, but is not limited to sexual harassment, sexual coercion, or sexual assault . The policy did not address resident-to-resident abuse.

This citation pertains to intake #MI 06. Based on observation, interview, and record review the facility failed to follow the plan of care for transfers, by using a mechanical lift that was not appropriate or assessed for use, for one (#801) of three sampled residents, resulting in a left arm elbow fracture. Findings include: On 3/19/19 at 10:14 AM, Resident #801 was observed sitting in the dining area watching a movie. Resident #801's left arm was observed to be wrapped in an ace bandage and inside a black sling. A interview was attempted with Resident #801, but was unable to be interviewed due to cognitive deficit. On 3/19/19 at 12:48 PM, Resident #801 was observed sitting in the lobby with their daughter watching television. Resident #801's daughter was asked about their injury. Resident #801's daughter stated, (R801's) left arm already has hardware in it, that arm is not able to stretch all the way out. Resident #801's daughter was asked if the facility explained what happened. Resident #801's daughter stated, I was told it was unknown and that (R801) came out of the shower room like that. When I came in (R801) was crying and (their) arm was on top of a pillow. Resident #801's daughter was asked how has Resident #801 been since the injury. Resident #801's daughter stated, (R801) is no longer able to feed (themselves). Resident #801 medical record was reviewed and revealed that the resident was admitted into the facility on [DATE] and with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set ((MDS) dated [DATE] noted, Resident #801 with a severely impaired cognition and the need for assistance of one person with bed mobility, transfers, toileting, dressing, and hygiene. Care plan prior to fracture noted Resident #801 as a non mechanical lift, one person assist with transfers. Physician order [REDACTED]. Continued review of Resident #801's medical record revealed, that Resident #801 had some right side weakness. Visit Date: 01/09/2019 . CHRONIC CARE MANAGEMENT PROGRESS NOTE . EXTREMITIES: Right sided weakness, right hand contractor, Keeps in (their) lap, can move right leg on command . X-Ray Results: Pt (Patient) report Date Service: 02/26/2019. Procedure Left Elbow, Complete, 3+ views. Findings: Indication: Pain. Findings: There is an acute [MEDICAL CONDITION] humeral shaft, with posterior displacement of the distal fx (fracture) fragment . Impression: Acute [MEDICAL CONDITION] humeral shaft. On 3/19/19 at 1:24 PM, Certified Nurse Assistant (CNA) A was identified as the last person to have contact with Resident #801. It was reported that CNA A no longer worked at the facility. CNA A was contacted via phone for a interview, a voice mail was left. CNA A did not return the call by the end of this survey. On 3/19/19 at 1:28 PM, during an interview, CNA C was asked if they knew how Resident #801 fractured their elbow. CNA C stated, I was off for two days and it happened during that time. CNA C was asked if Resident #801 had in injuries prior to there days off. CNA C stated, Prior to that there was no problem the resident was able to do a lot with the left arm, but not able to use the right arm. (They) fed themselves with the left arm and was able to assist was some care. On 3/19/19 at 2:11 PM, during an interview, the Director of Nursing (DON) was asked how many people are to assist with a mechanical lift transfer. The DON stated, We like to have two for safety. The DON was asked if this could be reason for Resident #801's injury. The DON stated, Yes it could have. On 3/19/19 at 2:24 PM, during an interview, the Unit Manager Nurse B was asked when did she notice Resident #801's injury. Nurse B stated, I saw CNA A take the resident into the spa and I saw them come out. (R801) was placed at the nurses station, after about 30 seconds to a minute later after coming out I started to hear (R801) get anxious and agitated. On this day it was escalated more than normal (R801) was biting at (their) sleeve. I went to talk to (them) and tried to fix (their) sleeve and it seemed to not help, (they) were still fidgety. Later I saw (R801's) arm it looked deformed more than normal and (R801) kept saying 'He hit me.' There was no male aide, so I was trying to figure out what (they) were saying. That is when I called the Doctor and ordered the x-ray, because (R801) was so upset and pulling at (their) shirt. Nurse B was asked if they were aware how CNA A assisted Resident #801 in the spa. Nurse B stated, She used the Easy Stand (sit to stand) lift. That lift the resident has to be able to hold on to the lift, (R801's) right arm was affected by a [MEDICAL CONDITION] and CNA A should have not used the lift for (R801), because (they) are not able to hold on with both arms. CNA A also did not have another staff person and did not use her gait belt. Any type of transfer the gait belt has to be used. Nurse B was asked what was Resident #801's transfer status at that time. (R801) was a one person transfer and not a easy stand lift and it was was not appropriate for it. Nurse B was asked if CNA A explained the reason for the use of the easy stand lift and not getting assistance. Nurse B stated, No I don't recall why the CNA used the easy stand. Transfer status confirmed with Nurse B, A review of a Physician Note: HPI (history of the present): The patient is seen at nursing request to evaluate (their) left elbow. CENA (Certified Nursing Assistant) this morning noticed that (their) left elbow seemed to be deformed, told the nurse and therefore I am examining the patient. (R801) is a poor historian secondary to dementia. No history could be obtained from the patient. Co-morbid conditions include . The left elbow appears to be swollen possibly from a joint effusion . A review of the facility's investigation revealed, Employee Interview: (CNA A) Date: 2/28/19. Did you work on [DATE] and or 26th? 'Yes' . 7. Did you assist (R801) to the spa at or around 12pm on 26th. 'Yes. (they) was sitting in the hallway pointing at the door so I took (them) in there. I used the Easy Stand and put (them) on the toilet.' Did you use a gait belt while transferring? 'No. I had my belt on but didn't use it on (them).' Did you use any type of lift device? 'I used the belt on the device.' Did any other staff provide any assistance while you were assisting (R801) in the spa? 'No .' Continued review of the facility's investigation noted, (MONTH) 04, 2019 Re: Camera Review - (R801) . We reviewed the camera outside the (Unit) hallway on the date of 2/26/2019. At 12:02 p.m. CENA (A) is seen wheeling resident (R801) into the (Unit) spa room [ROOM NUMBER] . At 12:08 p.m., CENA (A) is seen wheeling resident (R801) out of the spa #2 . Immediately after exiting (Unit) spa room [ROOM NUMBER] (R801) does not appear to be in any distress and (their) left arm is at (their) side in the wheelchair. At 12:09 p.m., (R801) begins biting at (their) sleeve and dangles (their) left arm while in the (Unit) hallway . At 12:10 p.m., (R801) begins biting at (their) sleeve, raising and dangling (their) left arm. The Unit Manager (Nurse B) observes (R801) and comes over to (R801) and is seen talking to (them). Facility policy titled Lifting Policy - No tolerance safety dated, (MONTH) 2011, noted, Policy. It is the policy of this facility to reposition, transfer, and or lift residents safely and according to the resident care guide. The facility has a zero tolerance for employees that do not follow the resident's care guide. Employees who do not follow the resident's care guide related to repositioning, transfers and/or lifting will be terminated. Fundamental Information . 2. The type of equipment needed - GAIT BELTS ARE MANDATORY FOR ALL TRANSFERS AND ASSISTANCE WITH AMBULATION. Additional equipment needed for safe lifting or transferring will be identified on the care plan and must be used to assist the resident. ALL LIFTING DEVICES REQUIRE AT LEAST TWO PEOPLE TO ASSIST IN THE LIFTING .

This citation has two deficient practices. Deficient practice #1. Based on observation, interview, and record review the facility failed to provide adequate supervision and consistently implement appropriate safety devices and techniques for three (#'s 603, 605, and 609) of 18 sampled residents reviewed for accidents from a total sample of 25, resulting in falls, abrasions, lacerations, skin tears, a subdural hematoma (bleeding outside of the brain), intracranial hemorrhages (bleeding between the brain and brain tissue), fractures, and hospitalization s. Findings include: On 5/6/14 at 1:07 p.m., Resident #605 was observed eating lunch. The Resident was sitting in a wheelchair with anti-tippers to the back of the wheelchair and a safety alarm in place. When queried the Resident was able to answer yes and no questions but with confusion. On 5/7/14 at 10:50 a.m., Resident #605's medical record was reviewed and revealed an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident's Minimum Data Set Assessment (MDS), dated [DATE], revealed that the Resident's cognition was severely impaired and required extensive assistance with activities of daily living. The Resident's balance was not steady, only able to stabilize with human assistance moving from a seated to standing position. Review of Resident #605's Safety Assessment, dated 1/1/14, revealed a fall risk score of "21," a score of greater than or equal to 15 being high. Review of Resident #605's progress notes were reviewed and revealed the following: 1/1/14-"admitted from hospital...Resident had left hip surgery with 20 staples to incision. Resident alert to self only." 1/1/14-"Bed pad alarm in place for safety, wheelchair pad alarm in place." 1/4/14-"Resident was constantly needing to be readjusted in the wheelchair even though the Dycem non skid pad was applied three times. Resident was scooting herself down in wheelchair." 1/8/14-"Resident tried multiple times to get up. Her chair and bed pad alarm in place for safety." 1/10/14-"Resident tried multiple times to get up from her chair with confusion..." 1/11/14-"Resident alert and oriented times one with severe confusion. She tried multiple times to get up and stand from her chair." 1/12/14, 1/16/14, 1/17/14, 1/24/14-"She tried multiple times to get up and stand from her chair," "....resident standing up every few seconds," "....continuous attempts to stand occurs approximately every five minutes." 1/25/14-"Nurse heard alarm sounding in resident's room. Resident was standing...Resident was moved to wheelchair and put by nurse in hall. Resident continually tried to stand up." 1/27/14-"Resident constantly attempting to stand and ambulate from the wheelchair." 2/1/14-"Resident required 1:1 (one to one) supervision from staff. Resident continues to stand up out of wheelchair and ambulate with an unsteady gait." 2/3/14-"She was constantly up and down from her chair." 2/4/14-"Kept trying to stand up on her wheelchair." 2/5/14-"Resident was trying to get up by herself from the bed...She was trying to get up and down from her wheelchair." 2/7/14-"Resident after dinner just keep standing up on her wheelchair." 2/14/14-"Attempting to get out of wheelchair and ambulates every few seconds." 2/16/14-"Required one on one supervision...she would continuously attempt to stand out of wheelchair, very unsteady gait." 2/21/14-"At 3 p.m., was walking in her room as seen by CENA (Certified nursing assistant), put her on her wheelchair but she constantly getting up..." 2/22/14 at 12:36 p.m.-"Resident was at the end of 200 hall. Resident attempted to stand and fell forward head first, according to family member visiting (the visitor of another resident). Alarm sounding. Her face against the carpet. Noticed abrasion to right side of head, nose with small abrasion, right cheek with abrasion. Bright red blood from nose and mouth...send to hospital." 4:36 p.m.-"Late entry: Resident was constantly up and down from her wheelchair and was trying to stand up and walking with her unsteady gait from the morning after she got up. Nurses and CENA had to supervise her constantly." Per review of Resident #605's Physician order, dated 2/22/14: "Transfer to (name of hospital). Reason for transfer: Abrasion to head, cheek, nose, bleeding from nose and mouth at time of fall." Review of a "Patient transfer form," dated 2/22/14: "Bleeding from nose and mouth. Abrasion: head/nose/right cheek. Fall forward head first." Review of a progress note, dated 2/22/14 at 11:46 p.m.: "Resident back from ... hospital 9 p.m." Review of Resident #605's "Emergency Center Report," dated 2/22/14, revealed "Medical Problem List: Fall, nasal bone fractures, facial abrasion, head injury." Review of Resident #605's "Resident Accident/Incident Report," dated 2/22/14, revealed "Family member visiting other resident. She was trying to stand up and fell . The writer approached and observed she was laying on her right side with legs laying across foot rest and fell on head (front forehead right side) was bleeding through the nose and noticed bright red from mouth..." Review of the following care plans for Resident #605 revealed: "Fall risk," dated 1/1/14- "Potential for injury related to: unsteady gait, cognitive deficits, impaired safety awareness, weakness, dizziness, use of psychotropic medications, impaired mobility, balance problems, postural hypotension, risky behaviors. Goals: Resident will remain free from injuries." "Psychotropic-Potential for side effects, "dated 1/1/14-"Interventions: Monitor for gait disturbances. Assist resident with bed mobility, transfers and ambulation." On 5/9/14 at 9:35 a.m., Resident #605's medical record and fall was reviewed with the Director of Nursing (DON), Occupational Therapist (OT) "G" and Unit Manager (UM) "D." The DON, OT "G" and UM "D" were queried regarding Resident #605's supervision, continual attempts to get up out of her wheelchair and interventions put into place after 1/1/14 (alarms). OT "G" stated, "We responded to her alarm each time it was alarming." The DON stated, "We did at some point have her (Resident #605) on a 1:1 (supervision). Her dementia process was against her. I don't think restraining her was a good option at that time." The DON was unable to provide any documentation of further interventions put into place after the alarms being placed on 1/1/14 despite Resident #605's continuous attempts to get up out of the wheelchair. On 5/6/14 at 9:30 a.m., during the initial tour of the facility with the In-service Director, Nurse "V", Resident #603 was observed sitting in the Houghton Unit day room watching the television. The Resident was in a high back geri chair, had a slider cushion belt (restraint that goes between the legs and around the resident and ties behind the geri chair) in place. Resident #603 was noted to have involuntary movements of the arms and legs. Nurse "V" stated, "She has a history of a mandibular (jaw) fracture." On 5/7/14 at 12:33 p.m. Resident #603's medical record was reviewed and revealed an admission into the facility on [DATE] and a re-admission on 3/28/14 with [DIAGNOSES REDACTED]. Resident #603's MDS, dated [DATE], revealed that the Resident's cognition was moderately impaired, and required extensive assistance for activities of daily living. On 5/9/14 at 10:00 a.m., Resident #603's medical record and Accident/Incident (A/I) Reports were reviewed with the Director of Nursing (DON), Occupational Therapist (OT "G") and Unit Manager, UM "D" and revealed the following: Review of Resident #603's "Resident Safety Assessment," dated 5/3/13, revealed that Resident #603's "Fall Risk score was a 21, high risk. "Comments: High back wheelchair with cushion and non skid pad-foot board to wheelchair for stability of lower extremities." A/I reports for resident #603 noted the following: 1. 10/24/13-"In Houghton Day Room. 'I fell forward.' Staff observed on floor lying on her right side. Did resident have alarm on? Yes. Was it attached: No. Was it sounding? No. Initial corrective action: pad alarm to wheelchair applied." When queried as to why Resident #603's alarm was not in place and functioning, the DON provided no comment. When queried as to the purpose of Resident #603's pad alarm, OT "G" stated, "It is to alert us to positional changes." 2. 10/26/13-"Resident room. Skin tear to left forearm 4 cm (centimeter) by 2 cm." Review of Resident #603's progress note, dated 10/26/13 at 5:35 p.m., revealed "At 7:25 a.m., heard alarm sounding. Resident was observed lying down on the floor with her face down next to her wheelchair and bed." 3. 11/1/13-"Resident was inclined (reclined) on geri chair, we are trying to put her in upright position so we can get her weight then she suddenly place her right arm in between chair. Resident had a skin tear 2 cm by 0.7 cm right upper arm. Initial corrective action: CENA (certified nursing assistant) instructed to watch over residents arm when moving/transferring. Therapy to evaluate." OT "G" provided documentation of a therapy in-service to staff, dated 11/8/13, caring for Resident #603 which educated on Resident #603's "Involuntary movements, risk for fall-injury. Unable to maintain safe position when upright (in geri chair). Educate on risk for fall and injury related to fall in upright position (except for meals). Educate resident has non skid pad and pressure relief cushion. Educate on proper position of geri-chair." 4. 11/7/13-"Houghton Day Room. Resident observed on floor on her right side. Resident slid off her chair at the day room. Non skid pad on the floor. Initial corrective action: PT (physical therapy) to review geri chair. Add non skid pad to back of geri chair." 5. 12/21/13-"Great Lakes dining room. Resident restless, pushed her table away from her and her geri chair move backwards. She slow slid to floor. Did resident have an alarm on? Yes. Was it attached? No. Was it sounding? No. Initial corrective action: apply Dycem/non skid pad to geri chair, apply chair alarm. Therapy to assess safety device." Resident #603's progress notes, dated 12/21/13 at 11:45 a.m., revealed "Staff reported that resident became restless and pushed her table away from her and geri chair which is unlocked at that time moved backwards then resident slowly slid out to floor. Noted geri chair with cushion in place but no nonskid pad or Dycem. Resident motion monitor did not work, was unhooked at the time of fall." When queried why the non skid pad was not in place, why the geri chair was not locked and why the motion monitor had not worked. The DON stated, "The geri chair should have been locked." Review of Resident #603's "Resident Falls Assessment Tool," dated 12/21/13, revealed "Physical status: sitting balance unstable. Poor safety awareness. Transfer difficulty. History of dementia." The DON and OT "G" were queried regarding the therapy safety device assessment. OT "G" stated, "We did not do another safety assessment." When queried regarding an order for [REDACTED]. When queried as to what the safety assessment would provide, OT "G" stated, "We would evaluate the appropriateness of the current safety interventions and recommend new interventions if needed. We seen her later in January for positioning in the geri chair but we didn't receive an order for [REDACTED]. Review of Resident #603's progress notes, dated 1/9/14 at 2:44 p.m., revealed "On 1/7/14 meeting held alarms...usage discussed. It was decided to keep Tab (motion) monitor on resident to alert staff to resident's involuntary movements while up in chair. Resident with noted 'spasmodic' type movements in all extremities. These movements cause resident to shift her body while up in chair creating a potential for falls." 6. 1/23/14-"Resident put right arm inside a gap of chair and caught her arm between her body and right side of geri chair. Skin tear right upper arm 2.5 by 1.5 cm. Staff interview: I positioned her geri chair from laying down to upright sitting postilion she put her arm inside of the chair and got caught between her right side of body and arm of chair." The staff member did attend the prior in-service provided by therapy on 11/8/13 that discussed Resident #603's involuntary movements and risk for injury. 7. 2/6/14-"Resident slid out of geri chair with the whole bottom cushion of chair. Resident observed sitting up with cushion on floor. Initial corrective action: straps to the cushion reattached to the back of geri chair." Review of progress notes, dated 2/6/14 at 12:43 p.m., revealed "after breakfast at (9:40 AM) resident was sitting at the table in the Great Lakes dining room when all of a sudden she slid out of geri chair. On evaluation the whole geri chair cushion slid out of the geri chair along with the Dycem non skid pad." When queried, the DON stated, "Her (pressure relief cushion) safety latch was not attached to the back of the geri chair. She slid right out of the chair." 8. 3/24/14-"Multiple staff present in Great Lakes Dining Room heard resident calling out 'help me' observed laying on her left side, geri chair facing to the right in locked position, and dining table appeared pushed to the right side. Resident lying on floor on left side. Approximately three minutes unconscious. Swelling left parietal head. Bleeding left parietal head. Laceration, bruise and hematoma to left parietal head. Called 911." Recap of incident by the DON revealed "An incident occurred on 3/24/14 approximately 9:20 am in Great Lakes dining area, while breakfast meal served. It was observed her dining table pushed to the right side, noted also that her locked cardiac chair/geri chair was facing to the right side, noted she was laying to her left side on floor. No staff had witnessed how she ended/landed on the floor except that staff heard resident calling out for 'help' when staff direct their attention to the calling out-observed resident on floor. Resident is known for spontaneous unpredictable physical movement such as lifting legs to different directions, both hands flapping/flipping to different directions... It is concluded with this investigation that resident physical spontaneous activities may have over 'executed' her physical movement thus caused her to potentially push the dining table and eventually lead her to fall from cardiac/geri chair." When queried as to if Resident #603 was still in the same geri chair, OT "G" and the DON stated, "No, after she was evaluated for a different safety device." OT "G" stated, "She now has a different geri chair, a high back chair/geri chair with a cushion slider belt (restraint)." Review of Resident #603's physician orders [REDACTED]. Reason for transfer: Laceration to left temporal lobe." A hospital Discharge Summary," printed 3/27/14, revealed: "....Diagnosis-Intracranial bleed. Fracture of condylar process of mandible (left), Fall, Laceration of the head, Head contusion. History of present illness: Head CT shows small intracranial hemorrhages in the temporal regions without mass effect." Review of Resident #603's "Fall risk" care plan dated 12/14/13 revealed: "Potential for injury related to: unsteady gait, cognitive deficits, impaired safety awareness, weakness, use of psychotropic medications, impaired mobility, balance problem, risky behavior. Goals: Resident will remain free from injuries. Interventions: Assess resident's balance, endurance gait, stability and ability to perform activities of daily living safely. Monitor resident when call light not available (e.g. dining room, activities). Resident should be on the Falling Star Program." On 5/7/14 at 9:45 AM, resident #609 was observed lying in bed. The resident was alert, non-verbal, and immobile. Both legs were severely contracted with the knees flexed and unable to extend, causing the calves to be in a fixed position going back underneath the thighs. Nurse Aides 'S' and 'T' transferred the resident via mechanical lift to a reclining geri-chair. Aide 'S' said, "We have to move her (resident) up." Aide 'T' said, "We can't move her up too much because you know this chair will flip backwards." On 5/8/14 at 10 AM, resident #609's clinical record and an accident/incident (A/I) report were reviewed. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted that the resident had severe cognition impairment, was non-ambulatory, and required total assistance for transfers. A "Resident Safety Assessment" dated 6/25/13 noted that the resident was at high risk for falls. A hospital record was contained in the clinical record for resident #609 and was reviewed that revealed the following: The resident was hospitalized from [DATE] thru 1/27/14 and transferred back to the facility following a laceration to the back of the head, requiring three staples, and a subdural hematoma shown on a CAT scan of the head. Per review of an A/I report dated 1/23/14, a Nurse Aide (no longer a facility employee and unavailable for comment) "....was pushing (resident #609) down the hall slowly....into the day room and the (geri) chair flipped over backwards." A summary of the incident written by the Director of Nursing (DON) dated 1/23/14, noted: "....both lower extremities severely contracted, flexed towards the back area causing....resident not to (be) able (to) completely (sit) in a sitting position as designed to sit in (the geri-chair) and because of poor execution due to contractures-this appeared to sit resident in the back of (the) geri-chair support frame area-leading to cause off balance...." A referral was made to the therapy department to evaluate the resident upon return from the hospital "....for positioning and proper chair to accommodate her physical contracture, sitting position." On 5/8/14 at 11:05 AM, Aided 'S' and 'T' were queried regarding the statement of concerns with the resident's chair during the mechanical lift transfer on 5/7/14. They stated that if the resident was pulled up too high in the chair, her weight would tip the chair backwards. At 10:10 AM and 12:15 PM, the DON and Unit Nurse Manager 'D', who witnessed the incident, were interviewed. Nurse 'D' stated that when the chair flipped backwards, the backrest portion of the chair ended up hitting the floor with the resident in the chair. The DON demonstrated that resident #609's leg contractures prevented her bottom from resting onto the seat of the geri-chair and that her legs caused her body to shift upwards onto the backrest portion of the chair. The DON stated that the Nurse Aide transferred the resident into the geri-chair and was pushing the resident with the geri-chair in a reclined position when the incident occurred. The DON said, "The Aide was transporting the resident with the resident laying on the back (rest) of the chair. Her weight made it go backwards. It was an error. She should not have been lying on the backrest." There was no documentation in the A/I summary that the Nurse Aide received any corrective measures following the incident. The DON stated that therapy staff provided instructions to nursing staff to prevent reoccurrence. The date, the contents, and the names of staff that received training, were requested, but not provided by the end of the survey. On 5/8/14 at 11:20 AM and 12:30 PM, Occupational Therapist (O.T.) 'U' and Physical Therapist (P.T.) 'W' were queried and their evaluations dated 1/29/14 following resident #609's incident, were reviewed. The P.T. stated that she was unaware how the incident occurred and stated that the geri-chair was appropriate for the resident's "comfort." The noted recommendations included transfers via mechanical lift, range of motion exercises, and application of leg braces, but no mention of safety related to the geri-chair. The O.T. stated that the incident occurred because a pressure relief cushion made the resident sit too high up in the chair and recommended removal of the cushion. There was no mention verbally or in the evaluation of the improper transfer causing the accident, but the O.T. noted that staff were instructed on safe transfers and seating techniques. The O.T. stated that the chair was safe to use, but when queried, was unable to respond how to prevent reoccurrence of the chair tipping backwards and stated that there were no anti-tipping devices available for geri-chairs. On 5/9/14 at 2:30 p.m., the following facility policies were reviewed: "Falls Management Program," dated 5/2010-"Purpose: To identify each resident at risk for falls and to adequately plan care and implement procedures to prevent falls. The Therapy Department shall receive orders to evaluate any resident reported to have a fall if determined appropriate... If therapy is ordered for the patient, therapy will complete the safety assessment... The Resident Safety Assessment will assess the following areas: Safety skills, history of falls, cognition, ability to follow one step commands, cognitive test sub-score, balance, predisposing diseases, medications. The safety interventions and recommendations, which result from the completion of the Resident Safety Assessment will be written as an order." "The Star Program," dated 08/2011-"A program to identify and alert all staff to the residents who are at high risk for falls and initiate individual intervention to potentially reduce the risk of injurious falls. Procedure: When the patient has been identified as a fall risk and qualifies for the Star Program, implement the following interventions: Those residents identified with safety interventions must not be left without those interventions in place." Per review of a "Safety Road Show" (safety interventions) in-service dated 12/26/13, there was no mention of safety techniques or precautions in the use of geri-chairs. ( / ) Deficient practice #2: Based on observation, interview and record review, the facility failed to secure one of one treatment carts on the Houghton Nursing Unit, resulting in the potential for accidental ingestion, abuse or diversion of medication. Findings include: On 5/8/14 at 9:15 a.m., during an observation of the facility's Houghton Unit the treatment cart was observed to be unlocked and unattended. the cart was located outside of resident rooms. Treatment Nurse "B" was observed to be walking out down the hallway of the nursing unit, when queried about leaving the treatment cart unlocked and unattended, Nurse "B" stated. "It should be kept locked." On 5/9/14 at 12.55 p.m., the Director of Nursing (DON) was queried regarding the facility's policy on locking of treatment carts and stated, "It should always be locked when not in the nurses sight. I just inserviced them on that and locking of the medication carts. The treatment carts follow the same policy as the medication carts." On 5/9/14 at 1:15 p.m., review of the facility's "Passing Medications" policy dated 8/03, documented; "Do not leave medication cart unattended at all times. Keep within your view. When leaving medication cart unattended be sure the cart is locked." ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 510 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IMPLEMENT EFFECTIVE INTERVENTIONS TO PREVENTS FALLS FOR ONE (#503) OF FOUR SAMPLED RESIDENTS REVIEWED FOR FALLS, FROM A TOTAL OF FOUR SAMPLED RESIDENTS, RESULTING IN A FALL WITH A FRACTURED RIGHT FEMUR WITH SUBSEQUENT hospitalization AND THE NEED FOR SURGICAL INTERVENTION. FINDINGS INCLUDE: ON 6/5/13, AT 10:50 A.M., #503, WHO WAS hospitalized DURING THE OBSERVATION, WAS OBSERVED IN BED AWAKE. UPON INTRODUCTION, #503 GRIMACED AND SAID, "...I'M IN PAIN..." WHEN ASKED OF THE LOCATION OF HER PAIN, #503 POINTED TO HER RIGHT LEG AND SAID, "...MY RIGHT LEG HURTS..." WHEN ASKED HOW SHE HURT HER RIGHT LET, #503 SAID, "...I fell OUT OF BED..." A "RESIDENT ACCIDENT/INCIDENT REPORT" DATED 5/24/13 REVEALED THAT ON 5/24/13 AT 3:30 A.M., #503 "...WAS SITTING ON THE GROUND NEXT TO THE BED..." STATEMENT BY RESIDENT "...I ROLLED OUT OF THE BED..." THE ACCIDENT/INCIDENT REPORT STATED THAT #503 HAD A MOTION MONITOR ALARM ATTACHED TO HER PERSON AND A PAD ALARM PLACED UNDERNEATH HER DURING THE TIME OF THE FALL. A "RADIOLOGY REPORT" DATED 5/24/13 REVEALED, "...THERE IS A FRACTURE INVOLVING DISTAL SHAFT OF FEMUR WITH MARKED LATERAL DISPLACEMENT. CONCLUSION: ACUTE DISTAL SHAFT FRACTURE..." A HOSPITAL "HISTORY AND PHYSICAL" DOCUMENT DATED 5/25/13 REVEALED, "...THIS IS AN [AGE] year OLD FEMALE WITH HISTORY OF ADVANCED DEMENTIA WITH PSYCHOSIS WHO PRESENTED TO THE ER (emergency room ) SECONDARY TO RIGHT FEMUR FRACTURE. SHE (#503) COMPLAINED OF PAIN. THEREFORE, AN X-RAY WAS OBTAINED WHICH SHOWED DISTAL FEMORAL FRACTURE. THE PATIENT WAS SENT TO THE HOSPITAL WHERE THE FRACTURE WAS CONFIRMED ON X-RAY. ASSESSMENT AND PLAN: RIGHT DISTAL FEMORAL FRACTURE SECONDARY TO FALL. SWELLING OF RIGHT LOWER EXTREMITY AND PROBABLY A HEMATOMA. ORTHOPEDICS HAVE BEEN CONSULTED. SHE (#503) IS MODERATE TO HIGH RISK FOR SURGERY BUT IT IS NOT PROHIBITED. I WILL ORDER AN EKG (ELECTROCARDIOGRAM) AND YOU MAY PROCEED TO THE OR (OPERATING ROOM)..." THE HOSPITAL RECORDS REVEALED THAT #503 HAD AN ORIF (OPEN REDUCTION INTERNAL FIXATION) ON 5/25/13. ACCORDING TO THE FACILITY'S "RESIDENT ADMISSION RECORD", #503 WAS AN [AGE] year OLD FEMALE WHO WAS INITIALLY admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ((MDS) dated [DATE] REVEALED THAT #503 HAD A BIMS (BRIEF INTERVIEW FOR MENTAL STATUS) SCORE OF "5" (0-7 = SEVERELY IMPAIRED COGNITION) AND REQUIRED 2 - PERSON PHYSICAL EXTENSIVE ASSISTANCE OF STAFF WITH ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY, TRANSFERS, DRESSING TOILETING, PERSONAL HYGIENE AND BATHING. THE MDS FURTHER REVEALED THAT #503 WAS NON-AMBULATORY AND WAS NOT STEADY, ONLY ABLE TO STABILIZE WITH STAFF ASSISTANCE IN AREAS OF MOVING FROM SEATED TO STANDING POSITION, MOVING ON AND OFF TOILET AND SURFACE TO SURFACE TRANSFERS. ACCORDING TO THE CLINICAL RECORD, #503 HAD BEEN IDENTIFIED AS A FALLS RISK ON ADMISSION AND ON 12/6/12 #503 HAD A FALL RISK SCORE OF 19/24 (HIGH RISK). FURTHER RECORD REVIEW REVEALED AN ACCIDENT/INCIDENT REPORT DATED 2/4/13 WHICH DOCUMENTED THAT #503 HAD A PREVIOUS FALL FROM HER BED ON 2/4/13 AT 2:15 P.M. THE REPORT REVEALED, "...RESIDENT'S (#503) HEAD/BACK WAS LYING AGAINST WARDROBE CLOSET. RESIDENT WAS LYING ON RIGHT SIDE UNABLE TO MOVE RLE (RIGHT LOWER EXTREMITY) BY ACTIVE OR PASSIVE ROM (RANGE OF MOTION). RIGHT HAND BLEEDING FROM SKIN TEAR. RESIDENT STATED I WAS TRYING TO GET OUT OF THIS BED. RESIDENT COMPLAINED OF PAIN IN RLE DURING ASSESSMENT OF ROM. RLE WITH MISALIGNMENT NOTED. RESIDENT SENT TO HOSPITAL 911..." ON 6/3/13 AT 10:45 A.M., DURING A TOUR OF THE FACILITY, LICENSED PRACTICAL NURSE (LPN) #1 REPORTED, "...(#503) WAS TRANSFERRED TO THE HOSPITAL. SHE HAD A FALL IN MAY..." WHEN ASKED IF #503'S hospitalization WAS A DIRECT RESULT OF THE ABOVE MENTIONED FALL IN MAY, LPN #1 SAID, "YES." ON 6/3/13 AT 4:15 P.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) WAS QUERIED ABOUT #503'S FALL WHICH RESULTED IN hospitalization AND REPORTED, "...(#503) ROLLED OUT OF BED. SHE HAD AN ALARM IN PLACE AT THE TIME. SHE HAD A LEFT FEMUR DISTAL FRACTURE. IT HAPPENED AT 3:00 A.M.. THE CNAS (CERTIFIED NURSING ASSISTANTS) NOTICED THAT HER BEDROOM DOOR WAS MOVING BACK AND FORTH SO THEY WENT IN. (#503'S) ALARM DID NOT SOUND. HER BED PAD ALARM WAS NOT PLACED ON THE BED PROPERLY..." THE DON FURTHER REPORTED, "...SHE (#503) WAS DOING SOME POSITIONING AROUND 2:00 A.M. WHICH COULD BE WHY THE BED PAD ALARM WASN'T UNDERNEATH HER AND DID NOT ALARM..." ON 6/4/13 AT 11:06 A.M., DURING AN INTERVIEW, LPN #1 (UNIT MANAGER) WAS QUERIED ABOUT #503'S FALL HISTORY AND REPORTED, "...SHE WAS IDENTIFIED AS A FALL RISK ON ADMISSION. SHE HAD A FALL ON 2/4/13 AT 2:15 P.M.. SHE SLID OUT OF BED AND HAD A LARGE SKIN TEAR ON HER HAND AND SHE COMPLAINED OF PAIN TO HER RIGHT LEG SO WE SENT HER TO THE HOSPITAL 911. SHE CAME BACK THE SAME DAY. THERE WAS NO FRACTURE. AFTER THAT FALL WE ADDED A BED PAD ALARM TO HER BED..." LPN #1 FURTHER REPORTED, "...#503 HAD ANOTHER FALL ON 5/24/13 AT ABOUT 3:30 A.M.. THE CNAS WHO WERE SITTING IN THE HALL SAID THEY SAW (#503'S) BEDROOM DOOR MOVING BACK AND FORTH SO THEY GOT UP TO INVESTIGATE AND SAW (#503) SITTING ON THE FLOOR WITH HER LEGS EXTENDED. (#503) DIDN'T APPEAR TO HAVE ANY INJURIES SO SHE WAS PUT BACK TO BED. LATER THAT DAY (#503) HAD A BRUISE TO HER RIGHT THIGH AND SHE COMPLAINED OF RIGHT KNEE PAIN. I (LPN #1) ORDERED A STAT (IMMEDIATE) X-RAYS OF HER RIGHT KNEE AND FEMUR AND IT WAS POSITIVE FOR FRACTURE. SHE HAD AN ACUTE DISTAL SHAFT FRACTURE OF THE RIGHT FEMUR. WE SENT HER TO THE HOSPITAL WHERE THE FRACTURE WAS CONFIRMED..." WHEN ASKED IF FLOOR MATS HAD BEEN PLACED ON THE FLOOR NEXT TO #503'S BED IN ORDER TO PROVIDE A CUSHION IN THE EVENT OF ANOTHER FALL AND IN LIGHT OF HER PREVIOUS FALL OUT OF BED ON 2/4/13, LPN #1 REPORTED, "...NONE THAT I SEE ORDERED..." WHEN ASKED IF #503 HAD A "LOW BED" IN LIGHT OF HER PREVIOUS FALL OUT OF BED, #LPN #1 REPORTED, "...NO. HER BED DIDN'T GO LOW. SHE HAD A CRANK BED. THE OLD KIND WHERE YOU HAD TO USE THE CRANK TO LET THE BED UP AND DOWN. BUT NO, SHE DIDN'T HAVE THE NEWER BEDS THAT GO ALL THE WAY TO THE FLOOR..." LPN #1 FURTHER REPORTED, "...(#503) HAD AN AIR MATTRESS AND THAT CAN CAUSE THE BED PAD ALARM TO SHIFT FROM UNDERNEATH THE PATIENT. (#503) HAD ALSO BEEN ILL ON 5/22/13 AND HAD INCREASED RESTLESSNESS AND WAS MORE LETHARGIC (DROWSY, SLUGGISH) AND HER CHEST X-RAY SHOWED THAT SHE HAD SOME ATELECTASIS IN HER LEFT LUNG. IT WAS THE RIGHT LUNG BEFORE..." WHEN ASKED IF STAFF CHECKED TO ENSURE THAT #503'S BED PAD ALARM WAS PROPERLY POSITIONED IN LIGHT OF HER INCREASED RESTLESSNESS AND REPOSITIONING IN BED, LPN #1 REPORTED, "...THE NURSES CHECK THE ALARMS ONCE A SHIFT..." WHEN ASKED IF STAFF INCREASED THEIR FREQUENCY OF ROUNDS IN ORDER TO ENSURE #503'S SAFETY IN LIGHT OF HER REPORTED INCREASED RESTLESSNESS AND LETHARGY, LPN #1 OFFERED NO RESPONSE. WHEN ASKED WHY ADDITIONAL INTERVENTIONS HAD NOT BEEN IMPLEMENTED IN LIGHT OF #503'S PREVIOUS FALL, INCREASED RESTLESSNESS AND CHANGE IN CONDITION, LPN #1 OFFERED NO RESPONSE AND THEN REPORTED, "...NOW THAT YOU SAY THAT, I CAN SEE THAT WE PROBABLY SHOULD HAVE DONE MORE..." A REVIEW OF #503'S "RISK FOR FALLS" CARE PLAN INITIATED 12/6/13 REVEALED THAT #503 WAS AT RISK FOR FALLS RELATED TO, "...HISTORY OF FALLS, DECREASED SAFETY AWARENESS, COGNITIVE IMPAIRMENT, DECREASED MUSCULAR STRENGTH, UNSTEADY GAIT AND, ATTEMPTS TO AMBULATE UNASSISTED..." A REVIEW OF THE FACILITY'S "THE STAR PROGRAM (FALLS MANAGEMENT)" PROGRAM DATED 8/2011 REVEALED: "...PURPOSE: IDENTIFY AND ALERT ALL STAFF OF THE RESIDENTS WHO ARE AT HIGH RISK FOR FALLS AND INITIATE INDIVIDUAL INTERVENTION TO POTENTIALLY REDUCE THE RISK OF INJURIOUS FALLS.

REFER TO INTAKE MI 468. BASED ON INTERVIEWS AND CLOSED RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT A FALL FOR 1 (#500) OF 4 RESIDENTS AT RISK FOR FALLS IN A TOTAL SAMPLE OF 6, RESULTING IN hospitalization FOR A HEMATOMA AND LACERATION OF THE HEAD. FINDINGS INCLUDE: RESIDENT #500, [AGE] years OLD, WAS admitted to the facility on [DATE], PER THE RESIDENT ADMISSION RECORD. THE RESIDENT WAS discharged TO THE hospital on [DATE], PER A NURSING PROGRESS NOTE. THE RESIDENT DID NOT RETURN TO THE FACILITY FOLLOWING THE hospitalization . A PHYSICAL MEDICINE & REHABILITATION HISTORY & PHYSICAL (H&P) REPORT, DATED 10/17/12, DOCUMENTED THAT RESIDENT #500 HAD BEEN hospitalized for [REDACTED]." IT WAS DETERMINED DURING hospitalization THAT THE RESIDENT HAD A LEFT FRONTAL AREA [DIAGNOSES REDACTED] (USUALLY BENIGN TUMOR INVOLVING THE PROTECTIVE MEMBRANES AROUND THE BRAIN AND SPINAL CORD). PER THE H&P, NO treatment of [REDACTED]. THE RESIDENT ALSO HAD COMPLAINTS OF CHRONIC BACK PAIN. THE RESIDENT HAD BEEN admitted TO THE FACILITY FOR REHABILITATION. A PHYSICIAN'S PROGRESS NOTE ON 11/2/12 DOCUMENTED THAT RESIDENT #500 WAS "GROSSLY COGNITIVELY IMPAIRED." SHE HAD "A SIGNIFICANT DEGREE OF AGITATION. SHE IS VERY AGITATED AT NIGHT CONSISTENT WITH HER COGNITIVE IMPAIRMENT." THE PROGRESS NOTE DOCUMENTED THAT THE RESIDENT WOULD REQUIRE A "SUPERVISED ENVIRONMENT AT DISCHARGE." A NURSING CARE PLAN, DATED 10/13/12, INDICATED THAT RESIDENT #500 WAS AT RISK FOR FALLS. THERE WAS AN INTERVENTION WHICH ADDRESSED SUPERVISION WHEN NOT IN BED, TO "MONITOR RESIDENT WHEN CALL LIGHT IS NOT AVAILABLE (E.G., DINING ROOM, ACTIVITIES)." ACCORDING TO A NURSING PROGRESS NOTE DATED 10/15/12 AT 6:30 A.M., RESIDENT #500 WAS FOUND ON THE FLOOR IN HER ROOM. SHE WAS SITTING ON HER BUTTOCKS. A CHAIR IN THE ROOM HAD BEEN KNOCKED OVER. THE RESIDENT WAS UNABLE TO EXPLAIN WHAT HAD HAPPENED. AN INCIDENT REPORT FOR RESIDENT #500, DATED 11/10/12, DOCUMENTED THAT RESIDENT #500 WAS FOUND IN THE SHOWER ROOM ON THE FLOOR CLOSE TO THE TOILET. THERE WAS A "GOLF SIZE LUMP TO BACK OF HEAD WITH LACERATION ABOUT 2 CM; BLEEDING." ACCORDING TO THE INCIDENT REPORT, THE RESIDENT WAS TRANSFERRED IMMEDIATELY TO THE HOSPITAL. LICENSED PRACTICAL NURSE (LPN) #4 WAS INTERVIEWED BY TELEPHONE ON 1/3/13 AT 9:30 A.M. LPN #4 STATED THAT SHE WORKED THE MIDNIGHT SHIFT ON 11/10/12, AND RESIDENT #500 WAS ONE OF THE RESIDENTS SHE PROVIDED CARED FOR ON THAT NIGHT. LPN #4 SAID SHE WAS ASSIGNED A GROUP OF RESIDENTS ALONG WITH THREE CERTIFIED NURSING ASSISTANTS (CNA), WHICH WAS THE USUAL STAFFING FOR THE SHIFT. RESIDENT #500, PER LPN. #4, WAS UP, OUT OF BED THAT NIGHT, WHICH WAS NORMAL BEHAVIOR FOR HER. THE NURSE SAID THE RESIDENT WAS PLACED IN THE DINING ROOM DURING THE NIGHT WHERE STAFF TRIED TO SIT WITH HER. BUT IT WAS A VERY BUSY NIGHT ON THE UNIT PER LPN #4, AND IF THE UNIT WAS BUSY, IT WAS NOT POSSIBLE TO MONITOR RESIDENT #500 ALL THE TIME. LPN #4 EXPLAINED THAT RESIDENT #500 REQUIRED FREQUENT CARE AND COULD BECOME "ANGRY." SHE CONTINUALLY ASKED TO GO TO BED OR TO BE TOILETED. USUALLY STAFF TOILETED HER EVERY 1 TO 2 HOURS, BUT ON 11/10/12, THE RESIDENT WAS ASKING TO BE TOILETED EVERY TEN TO FIFTEEN MINUTES. THE RESIDENT DID TRY TO STAND FROM HER WHEELCHAIR UNASSISTED. SHE COULD SELF-PROPEL HER WHEELCHAIR. LPN #4 SAID SHE HAD OBSERVED RESIDENT #500 WALKING IN THE PAST, BUT HER BALANCE WAS "WOBBLY," AND HER GAIT WAS UNSTEADY. LPN #4 SAID NO ONE HAD BEEN ASSIGNED TO SIT WITH RESIDENT #500, BUT SHE NEEDED SOMEONE TO DO THAT. LPN #4 SAID, "OBVIOUSLY THERE WAS NO ONE WITH HER PRIOR TO THE FALL OR SHE WOULD NOT HAVE BEEN ABLE TO PROPEL HERSELF INTO THE SHOWER ROOM WITHOUT SOMEONE NOTICING HER." CNA #5 WAS INTERVIEWED BY TELEPHONE ON 1/3/13 AT 3 P.M. CNA #5 SAID SHE WORKED THE MIDNIGHT SHIFT ON 11/10/12. SHE SAID SHE WAS NOT ASSIGNED TO RESIDENT #500, BUT SHE KNEW THE RESIDENT AND HELPED MONITOR HER WHEN SHE WAS OUT OF BED. CNA #5 SAID THAT RESIDENT #500 WAS THE ONLY RESIDENT UP OUT OF BED AND IN THE DAY ROOM THAT NIGHT. CNA #5 WENT ON TO SAY THAT RESIDENT #500 WOULD TRY TO STAND UNASSISTED. THE RESIDENT PROPELLED HERSELF OUT OF THE DINING ROOM A COUPLE TIMES, AND STAFF WOULD RETURN HER TO THE DINING ROOM. CNA #5 SAID, PRIOR TO THE RESIDENT'S FALL, SHE (CNA #5) AND CNA #7 HAD BEEN WITH THE RESIDENT IN THE DINING ROOM. CNA #5 SAID SHE LEFT THE DINING ROOM TO GO TO ANOTHER NURSING UNIT FOR A BLOOD PRESSURE MACHINE. CNA #7 REMAINED WITH RESIDENT #500 IN THE DINING ROOM. WHEN SHE RETURNED WITH THE BLOOD PRESSURE MACHINE, CNA #5 SAID SHE SAW RESIDENT #500 AND CNA #7 IN THE DINING ROOM. CNA #5 SAID SHE WENT DOWN THE HALL TO TAKE VITAL SIGNS. WHEN SHE FINISHED HER VITAL SIGNS, NO ONE WAS IN THE DINING ROOM. CNA #5 SAID SHE ASSUMED CNA #8, WHO WAS ASSIGNED TO CARE FOR RESIDENT #500, WAS WITH THE RESIDENT. CNA #5 SAID SHE SAT DOWN IN THE DINING ROOM, AND 5 OR 10 SECONDS LATER HEARD THE SHOWER ROOM CALL LIGHT SOUND. CNA #5 SAID SHE DID NOT KNOW WHO COULD BE IN THE SHOWER ROOM BECAUSE SHOWERS ARE NOT DONE ON THE MIDNIGHT SHIFT. CNA #5 SAID THAT SHE WENT TO THE HALLWAY LEADING TO THE SHOWER ROOMS. AN EMPTY WHEELCHAIR WAS SITTING JUST INSIDE THE MAIN SHOWER ROOM DOOR. A PUDDLE OF URINE WAS ON THE FLOOR IN FRONT OF THE WHEELCHAIR. CNA #5 SAID SHE WENT DOWN THE HALLWAY TO A SHOWER ROOM (APPROXIMATELY 5 FEET) AND OPENED THE DOWN TO THE SHOWER (WHICH ALSO CONTAINS A TOILET). THE RESIDENT WAS ON THE FLOOR IN FRONT OF THE TOILET. BLOOD WAS AROUND THE RESIDENT'S BODY, ACCORDING TO CNA #5. CNA #5 CALLED TO THE NURSE FOR ASSISTANCE. CNA #7 WAS INTERVIEWED BY TELEPHONE ON 1/3/13 AT 3:25 P.M. SHE SAID SHE WORKED THE MIDNIGHT SHIFT ON 11/10/12 AND HELPED MONITOR RESIDENT #500 WHEN SHE WAS OUT OF BED. SHE DESCRIBED THE RESIDENT AS "KIND OF ANXIOUS," "REALLY BUSY," AND "MORE CONFUSED THAN USUAL." CNA #7 SAID THAT SHE AND CNA #5 HAD BEEN WITH RESIDENT #500 IN THE DAY ROOM, BUT CNA #5 LEFT TO GET A BLOOD PRESSURE MACHINE. CNA #7 SAID SHE LEFT THE DINING ROOM TO ASSIST CNA #8 AND LPN #4 WITH ANOTHER RESIDENT. CNA #7 SAID SHE DID NOT KNOW WHEN RESIDENT #500 LEFT THE DINING ROOM. SEVERAL ATTEMPTS TO CONTACT CNA #8 WERE UNSUCCESSFUL. ACCORDING TO LPN #4, CNA #8 WAS ASSIGNED TO CARE FOR RESIDENT #500 DURING THE MIDNIGHT SHIFT ON 11/10/12. REGISTERED NURSE (RN) #6 WAS INTERVIEWED BY TELEPHONE ON 1/3/13 AT 3:15 P.M. ACCORDING TO RN #6, SHE WAS THE SUPERVISOR DURING THE MIDNIGHT SHIFT ON 11/10/12. RN #6 SAID SHE WAS ON AND OFF THE UNIT SEVERAL TIMES DURING THE SHIFT. SHE SAID SHE RETURNED TO THE UNIT AROUND 3 A.M., AND DID NOT SEE RESIDENT #500 IN THE DINING ROOM. SHORTLY AFTER RETURNING, SHE WAS ASKED TO ASSIST LPN #4 IN PROVIDING EMERGENCY CARE FOR RESIDENT #500 IN THE SHOWER ROOM. RN #6 SAID THE RESIDENT WAS ALERT AND TALKING, BUT CONFUSED. THE RESIDENT HAD A "BUMP" AND LACERATION AT THE BASE OF THE SKULL. SHE SAID SHE CLEANED RESIDENT #500'S HEAD TO ASSESS THE WOUND AND APPLIED ICE. EMERGENCY SERVICES ARRIVED AND THE RESIDENT WAS TRANSPORTED TO THE HOSPITAL FOR EVALUATION AND TREATMENT. HOSPITAL RECORDS FOR RESIDENT #500 WERE REVIEWED ON 1/4/13. THE TRAUMA CARE FLOWSHEET RECORDED THE RESIDENT'S ADMISSION ON 11/10/12 AT 3:50 A.M. AN EMERGENCY DEPARTMENT NURSE'S NOTE ON 11/10/12 AT 5:01 A.M. DESCRIBED "A GOLF BALL SIZE HEMATOMA TO (RESIDENT #500'S) POSTERIOR HEAD WRAPPED IN KERLIX WITH BRIGHT RED BLOOD DRAINAGE. . . PATIENT HAS PAIN TO LEFT HIP, A FIRM CONTUSION ON HER RIGHT BICEP (ARM MUSCLE) OUTER ASPECT." AN EMERGENCY DEPARTMENT PHYSICIAN'S H&P FOR RESIDENT #500 DOCUMENTED A "LACERATION AT THE RIGHT OCCIPITAL REGION (BACK PART OF THE HEAD)." A PHYSICIAN'S PROGRESS NOTE DATED 11/10/12 AT 6:47 A.M. DOCUMENTED THAT RESIDENT #500 HAD "A BRUISE OF THE RIGHT ARM" AND "LACERATION WHICH HAD A SMALL CONTUSION (BRUISE) AND SMALL PUNCTURE WOUND BUT NO EVIDENCE OF ANY LARGE LACERATION AMENABLE TO SUTURING. PATIENT IS admitted AND REMAINS HEMODYNAMICALLY STABLE." ACCORDING TO THE SAME NOTE, THE COMPUTERIZED AXIAL TOMOGRAPHY (CAT) SCAN OF RESIDENT #500'S NECK WAS NEGATIVE AND THE CAT SCAN OF HER HEAD WAS NEGATIVE. THE HEAD CAT DID SHOW THE FRONTAL [DIAGNOSES REDACTED], PREVIOUSLY diagnosed . ( )