Every finding on record at Regency at Lansing West

This citation pertains to Intake 2740541.Based on interview and record review, the facility failed to prevent a fall for 1 (R1) of three reviewed.Findings include:Review of the complaint received by the State Agency revealed [R1] had a fall on 12/26/25. [R1] was in her bedroom, and the tech [Certified Nursing Assistant (CNA)] got her up from her bed and left her standing on her own and went around to the bathroom and [R1] fell on her arm and leg.Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included history of falling, fracture of humerus, and joint replacement surgery. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/25 revealed R1 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The Discharge MDS with an ARD of 1/30/26 revealed R1 had one fall without injury since admission/prior assessment. Review of the Functional Ability Deficit care plan initiated 12/13/25 revealed an intervention dated 12/15/25 that revealed R1 requires touching assistance with one helper and 2ww [2-wheel walker] for ambulation/walking. Review of the Nurses Note dated 12/26/25 and authored by Licensed Practical Nurse (LPN) D revealed guest attempted to transfer from bed to walker. Guest observed on the floor at the foot of the bed .complained of mild [pain] near incision site on shoulder. Guest encouraged to use call light for assistance with ambulation. Review of a second Nurses Note dated 12/26/25 revealed Guest observed on the floor by nursing staff. Guest stated I was trying to get to my walker .Guest educated on safety measures and to request assistance with ambulation. Review of the fall Incident Report dated 12/26/25 revealed R1 had an unwitnessed fall and was observed on the floor at the foot of the bed. The resident description of the event revealed Resident stated that she was ambulating to the bathroom, using her walker with CNA present and she lost her balance. In a telephone interview on 3/5/26 at 3:13 PM, LPN D reported on 12/26/25 a code purple was called to R1's room and by the time she arrived at the room, R1 was on the floor at the foot of her bed. In an interview on 3/5/26 at approximately 3:45 PM, RN F reported R1 was a touch assist with ambulation which meant a gait belt should be used and touching/guiding assistance was needed. RN F reported she did not witness R1's fall. In a telephone interview on 3/5/26 at 4:10 PM, CNA E reported they came in at the tail end of R1's fall and saw the other aide lowering her [R1] to the floor. CNA E reported there was a walker, but they had it to the side of them with a hand on the walker, but not really using it. CNA E reported a gait belt was not being used. Attempts were made to contact CNA C via telephone on 3/5/26 at 2:46 PM and 4:25 PM without success. On 3/5/26 at 4:28 PM, Director of Nursing (DON) B reported CNA C was on leave. In an interview on 3/5/26 at 4:45 PM, DON B reporting touching assistance required staff to touch, guide, and maneuver the resident while using a gait belt. DON B reported CNA C assisted R1 to a standing position and then left R1 standing while CNA C went into the bathroom to get things ready. R1 then fell. DON B reported according to R1's care plan, staff should not have left R1 standing alone and that R1 required touching assistance with one helper and a 2-wheeled walker.

This citation pertains to Intake 2740541.Based on interview and record review, the facility failed to maintain accurate medical records for 1 (R1) of three reviewed.Findings include:Review of the complaint received by the State Agency revealed [R1] had a fall on 12/26/25. [R1] was in her bedroom, and the tech [Certified Nursing Assistant (CNA)] got her up from her bed and left her standing on her own and went around to the bathroom and [R1] fell on her arm and leg .[Name of Registered Nurse (RN) F] wrote in the medical report that [R1] got up on her own out of bed and fell on her own. The report was falsified and [R1] fell due to the tech not providing [R1] with support. Review of the medical record revealed R1 was admitted to the facility on [DATE] with diagnoses that included history of falling, fracture of humerus, and joint replacement surgery. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/20/25 revealed R1 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The Discharge MDS with an ARD of 1/30/26 revealed R1 had one fall without injury since admission/prior assessment. Review of the Nurses Note dated 12/26/25 and authored by Licensed Practical Nurse (LPN) D revealed guest attempted to transfer from bed to walker. Guest observed on the floor at the foot of the bed .complained of mild [pain] near incision site on shoulder. Guest encouraged to use call light for assistance with ambulation. Review of a second Nurses Note dated 12/26/25 revealed Guest observed on the floor by nursing staff. Guest stated I was trying to get to my walker .Guest educated on safety measures and to request assistance with ambulation. Review of the fall Incident Report dated 12/26/25 and completed by LPN D revealed the report was Privileged and Confidential-Not part of the Medical Record. The incident report revealed R1 had an unwitnessed fall and was observed on the floor at the foot of the bed. The resident description of the event revealed Resident stated that she was ambulating to the bathroom, using her walker with CNA present and she lost her balance. In a telephone interview on 3/5/26 at 3:13 PM, LPN D reported on 12/26/25 a code purple was called to R1's room and by the time she arrived at the room, R1 was on the floor at the foot of her bed. When asked about the discrepancies in the incident report and medical record and whether staff was with R1, LPN D reported there were mixed stories as to how R1 fell. In an interview on 3/5/26 at approximately 3:45 PM, RN F reported she did not witness R1's fall. When asked about the discrepancies in the documentation, RN F reported there was a lot of confusion as to what happened. In a telephone interview on 3/5/26 at 4:10 PM, CNA E reported they came in at the tail end of R1's fall and saw the other aide lowering her to the floor. CNA E reported there was a walker, but they had it to the side of them with a hand on the walker, but not really using it. CNA E reported a gait belt was not being used. Attempts were made to contact CNA C via telephone on 3/5/26 at 2:46 PM and 4:25 PM without success. On 3/5/26 at 4:28 PM, Director of Nursing (DON) B reported CNA C was on leave. In an interview on 3/5/26 at 4:45 PM, when asked about the documentation discrepancies surrounding R1's fall, DON B reported there was some confusion with what occurred. DON B reported she interviewed CNA C and CNA C reported she assisted R1 to a standing position, left R1 standing while CNA C went into the bathroom to get things ready, and then R1 fell. R1's medical record did not accurately reflect the incident as it occurred.

This citation pertains to intake MI00150279. Based on interview and record review, the facility failed to prevent a fall for one (Resident #150) of three reviewed for accidents, resulting in a fall with bilateral femur fractures when Resident #150 fell from her bed. Findings include: Resident #150 (R150) Review of the medical record reflected R150 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included dementia, senile degeneration of brain, right femur pathological fracture, and left femur pathological fracture. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/20/24, reflected R150 scored 7 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R150 no longer resided in the facility. Review of R150's Care Plan revealed R150 was a two person assist with the use of a Hoyer for transfers and ambulated via wheelchair with staff assist. Review of a Nurses Note dated 7/22/2024 at 7:28 PM revealed Guest (R150) was observed on floor next to bed .with head towards foot of bed. Bed was noted to be in elevated position. Guest not able to state how incident occurred r/t (related to) cognitive impairment. Guest c/o (complained of) pain to LUE (left upper extremity), and left knee. Guest not able to provide pain details r/t (related to) cognitive impairment. Rounding provider at facility in to evaluate guest at time of incident, and unable to assess guest for injury r/t positioning and c/o pain .and potential injury r/t height of bed at time of fall. Review of an Incident Report dated 7/22/24 confirmed that R150's bed was in an elevated height position at the time of her fall out of bed. Review of R150's Fall Care Plan revealed an intervention added on 7/23/24 which stated Bed to be in lowest position at all times unless performing cares. Bed remote to be out of patient reach due to cognitive inability to safely position bed. Review of a Nurses Note dated 2/1/25 at 6:56 AM revealed Guest (R150) had had an unwitnessed fall upon shift change. She was found in the opposite side of her bed hollowed [sic] for help . Called 911 to send guest out due to fall generalized pain. Resident states that she has intense pain on Left knee and lower limb and back .transferred to [NAME] Hospital at 7 AM . Review of an Incident Report dated 2/1/25 stated guest (R150) observed on the floor with her head at the foot of her bed with head slightly under and her hands holding the side of the bed. The incident happened upon shift change. Both caregivers who happened to be close to the guest's room upon overhearing guest called for help. The fall was unwitnessed .guest voiced to be in severe pain .guest stated that she was trying to go to the bathroom . The immediate action taken section of the Incident report stated, resident transferred to hospital .Ct scan and x-rays of bilateral lower extremities showed pathological fractures to bilateral femurs .resident underwent surgical repair .discipline provided to CENA (certified nursing assistant) as bed was waist level after cares provided .physician documentation and orthopedic review indicated pathological fractures that likely [were] caused [by] the fall when resident attempted to stand out of bed. The same incident report revealed an investigation for the fall that occurred on 2/1/25. The investigation revealed R150 was interviewed prior to being transferred out to the hospital and R150 stated that she was attempting to stand up and walk to the bathroom. She reported that she stood up, immediately went down, and was in pain. R150's room was evaluated post fall, and her bed was noted at a waist level height and the bed controller was attached to the headboard. Director of Nursing (DON) B interviewed LPN E and CNA F on 2/3/25 who stated that they observed R150 on the floor calling for help. They reported that the call light was on the floor at the head of the bed and that R150's bed was waist high. The investigation report indicated that CNA H was interviewed and stated that she performed care on R150 at approximately 5:15 AM. CNA H reported that she left the bed at waist level position upon completion of care. CNA H was educated that the bed was to be in the lowest position possible, and at the time of the fall the bed was noted to be at waist level. Review of the After Visit Summary from R150's hospitalization revealed the following (R150) female was admitted to the trauma service following a fall that resulted in bilateral (left and right) femur fractures. Upon evaluation, it was determined that she required surgical intervention. Orthopedic surgery was consulted, and the patient underwent an open reduction internal fixation (ORIF) procedure using a . rod for stabilization of the fractures .Although the decision was made to proceed with surgery initially, post-operative discussions led to the conclusion that the focus should shift to comfort measures only, in alignment with the family's wishes. Throughout her hospital stay, [R150'S] pain was well-managed, and efforts were made to ensure her comfort during recovery .Despite her surgical intervention, the overarching goal was to honor her and her family's preferences regarding end-of-life care. The medical team provided education and support for transitioning to hospice care, emphasizing the importance of quality of life during this time . Further review of the After Visit Notes from the hospital revealed R150 sustained bilateral supracondylar fractures of the femur. According to the National Library of Medicine, this classification of fracture is most commonly causes by a high impact trauma to the bone. In an interview on 2/20/25 at 10:38 AM, Certified Nursing Assistant (CNA) D reported having familiarity with R150 and the fall that occurred on 2/1/25. CNA D stated that she was walking down the hallway when she overheard R150 calling out for a doctor. When CNA D entered the room, she observed R150 on the floor of her room next to her bed. R150 had obvious deformity of both legs. CNA D stated that the height of the bed was waist level, confirming that the bed was not in the lowest position per the plan of care. In an interview on 2/20/25 at 11:30 AM, Licensed Practical Nurse (LPN) E stated that she was working the day of R150's fall on 2/1/25. LPN E indicated that she observed R150 on the floor next to her bed with obvious deformity to both legs. LPN E stated that R150's bed was up pretty high confirming that the height of the bed was not low, per the care plan. In an interview on 2/20/25 at12:47 PM, CNA H reported that she was working the night shift when R150 sustained the fall on 2/1/25. CNA H stated that she had completed care on R150 at 5:15 AM, and before exiting the room, did not ensure that R150's bed was in the low position like it should have been. CNA H confirmed that she had received education regarding the bed height after R150's fall. In an interview on 2/20/25 at 1:27 PM Registered Nurse (RN) C stated that she was working the morning that R150 sustained the fall out of bed. RN C stated that she had entered the room of R150 and observed her on the floor next to her bed. RN C reported that the height of the bed was high and not in the low position per the care plan. Review of a Social Services reevaluation dated 2/7/25 reflected R150 had experienced trauma from a nursing care setting and stated, resident fell out of bed, [family member] stated that this was traumatic for the resident. Review of the Physician orders for R150 reviewed a new order dated 2/6/25, after readmission, for oral solution Morphine 0.25 milliliters every four hours for pain. In an interview on 2/20/25 at 1:21 PM, RN G stated that R150 had increased pain after the readmission to the facility, especially with activities of daily living and with repositioning. In an interview on 2/20/25 at 2:16 PM, DON B stated she was contacted the morning of R150's fall. Staff reported R150 was found on the floor after calling out for help and presented with pain and obvious deformity on bilateral lower extremities. DON B interviewed staff and concluded that the plan of care was not followed when the CNA did not ensure that R150's bed was low before exiting the room. DON B confirmed that the CNA received a disciplinary action and education.

This citation pertains to Intake MI00149066. Based on observation, interview, and record review, the facility failed to immediately report an allegation of abuse to the State Agency for one (Resident 200) of three reviewed, resulting in a sexual abuse allegation to go unreported to the State Agency. Findings include: Review of the medical record revealed Resident 200 (R200) was admitted to the facility on [DATE] with diagnoses that included: generalized anxiety disorder, major depressive disorder (recurrent, moderate), and dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/1/24 revealed R200 scored 8 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the complaint filed with the State Agency revealed Complainant states that on 12/18/24, she was informed by R200 that a CNA (certified nursing assistant) named (CNA A) sexually assaulted R200. Complainant states that CNA A gave R200 a bed bath on 11/28/24. Complainant states that CNA A took a washcloth, and she was moving it around on R200's genitals, and then R200 had an orgasm .Complainant states that staff in the facility said that they did not believe that this incident was reported to the state .Complainant states that the director of nursing said that the sexual assault did not occur, so there was no need to do an incident report. On 1/2/25 at 9:22 AM, R200 was observed sitting up in bed. When asked about an incident involving a CNA in the facility, R200 stated they believed the incident had occurred a couple months ago and the details are coming out in pieces. R200 stated CNA A had sexually molested her and she was too afraid to tell anyone initially. R200 stated that she had discussed the incident with the director of nursing (DON), LPN B. director of social work C and Unit Manager E. In a telephone interview on 1/2/25 at 4:48 PM, CNA A stated that the incident alleged by R200 never occurred. CNA A stated that on 11/28/24 when R200 alleged the abuse, R200 had asked her to clear off her power wheelchair. CNA A explained to R200 that they had not used their power wheelchair in a while and CNA A was not comfortable clearing it off for her to use until it had been determined she was safe to use it. R200 became upset, CNA A reported this interaction to LPN B, and a few minutes later R200 came out to the nurses station using her power wheelchair and alleged CNA A had been inappropriate while providing care. CNA A further stated that R200 had been making allegations against other staff over the past two to three months and that she had not provided R200 any peri-care that shift. In a telephone interview on 1/3/25 at 9:57 AM, LPN B reported that on the night of the allegation CNA A had reported to her that R200 was upset with her because she wouldn't remove her personal belongings from her power wheelchair which made R200 upset. LPN B further reported that approximately fifteen minutes later R200 came out of her room using her power wheelchair and approximately ten minutes after that R200 reported that she was having issues with CNA A. R200 reported to her that she didn't want to tell her why she was upset with CNA A because she believed CNA A and LPN B were in a relationship together. LPN B informed R200 that CNA A was married. R200 argued about whether CNA A was married or divorced, then reported that CNA A had sexually touched her. LPN B asked R200 what she meant and she kept repeating when you climax, you know when you climax. LPN B said that she reported this information to the DON, including that R200 said she was being sexually touched by CNA A when she was giving her care and that she climaxed. DON instructed her to remove CNA A from being the assigned CNA for R200. In an interview on 1/3/25 at 1:25 PM, DON stated that LPN B reported to her that R200 stated she had an orgasm while CNA A was providing care, CNA A had not been providing care when R200 made the allegation but she had been asked by R200 if she would clear off her power chair. DON reported that LPN B had told her that R200 did not want CNA A to care for her so CNA A was removed from that hall. DON stated that an orgasm is a normal bodily function, and when she interviewed her R200 was not tearful or in anguish and all residents interviewed reported no concerns with abuse or any observations of abuse. Additionally, DON asked like residents if they felt safe in the building and specifically if they had any concerns with care provided by CNA A. DON reported that she investigated the concern to protect the resident and staff. When asked why the allegation was not reported to the State Agency, DON reported that they didn't see it as a sexual assault allegation or an allegation of abuse and it was handled as a concern/grievance. DON reported she would have reported it if the resident had said anything more specific like staff had inserted fingers into her vagina during patient care and the way it was presented to her it was not an allegation of abuse and the resident denied allegations. The facility administrator, NHA (Nursing Home Administrator) was not available during the time of the survey and is the designated abuse coordinator. DON reported that the incident was discussed with the NHA/abuse coordinator and he was in agreement that it did not need to be reported to the State. Review of the facilities policy titled Abuse Prohibition Policy updated 9/9/22, documented in part Allegations of guest/resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representative .Allegations by anyone who becomes aware of verbal, physical, mental, sexual or emotional abuse and mistreatment, neglect, exploitation, involuntary seclusion or misappropriation of property must be immediately report it to his/her Administrator .

Based on interview and record review the facility failed to ensure laboratory blood tests were provided and completed timely and as ordered for one out of one residents (Resident #11). Findings Included: Per the facility face sheet R11 had an initial admitted [DATE], and a readmitted [DATE]. Record review of R11's Physician's orders dated 1/6/2024, revealed R11 was to have a CBC (complete blood count) CMP (comprehensive metabolic profile), and Liver tests done annually. A BMP basic metabolic panel), lipids, TSH (thyroid stimulating hormone) test perform every six months, and an HgbA1c (measures average blood sugar levels over the past three months) performed every three months. Review of R11's pharmacy medication review recommendations (MRR) dated 1/9/2024, and signed by Director of Nursing (DON) B on 1/11/2024, revealed R11 was ordered to have the CBC, CMP, Lipid, Liver, BMP, and HgbA1c performed, but the Pharmacist noted, at the time of the MRR, the labs were not available. Review of an MRR dated 7/3/2024, and signed by DON B on 7/3/2024, revealed the Pharmacist documented that at the time of the MRR the results of R11's HGBA1C was not available. Review of the same MRR dated 7/3/2024, and again signed by the DON on 7/5/2024, revealed the Pharmacist documented that at the time of the MRR the results of R11's HGBA1C was not available. Review of a laboratory report revealed R11's CBC, CMP, Lipid, Liver, BMP labs were not performed until 1/12/2024. Review of a laboratory report revealed R11's HGBA1C lab blood test was not performed until 7/5/2024. In an interview on 7/25/2024 at 9:16 AM, DON B stated that the facility had changed to a new laboratory on 12/21/2023 and had put all lab orders into the new lab system. DON B R11's lab orders were put into the system incorrectly and no one noticed. DON B said all of R11's labs were not ordered at the time the Physician ordered them 1/6/2024, but were instead ordered a year, six months, and three months out so R11's labs were never done.

Based on observation, interview, and record review the facility failed to ensure one out of five residents (Resident #9) had water available at the bedside, resulting in the potential for dehydration. Resident #9 (R9) Review of the medical record revealed R9 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction (one sided weakness caused by a stroke), glaucoma (condition that causes damage to the optic nerve, and dry eye syndrome of bilateral lacrimal glands (gland that produces tears). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/11/24 revealed R9 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental status. Review of R9's Care Plan reflected R9 required the assistance of one staff member for personal hygiene and was dependent for toileting with the use of a bed pan and briefs. On 7/23/24 at 3:02 PM, R9 was observed in her bed wearing a hospital gown. R9's call light was out of reach and R9 did not have any water available for her. R9 asked for assistance with obtaining her call light stating that she wanted some water because she felt so dry, having water is important to me. R9 stated that she felt she did not receive enough water throughout the day and often times, she would use her call light to ask for staff for fresh water and staff would acknowledge the request but forget to bring a water. On 7/24/24 on 3:43 PM, R9 was observed in bed, resting. R9 did not speak when greeted. R9 had an intravenous catheter in her right hand and intravenous fluids running. Review of a Physician Order dated 7/24/24 revealed sodium chloride solution (normal saline) 0.9% (percent) use 100 ml/hr (milliliters an hour) intravenously x 10 hours (for ten hours) for fluid support for one day. Review of a Progress Note dated 7/25/2024 revealed Patient was noted with drier mucus membranes yesterday and she did agree to labs, IV fluids and urine sample. Patient did get one liter of NS (normal saline) with improvement noted with vitals and alertness. Patient is drinking oral fluids and labs show continued need for hydration and will continue with one additional liter of NS. On 07/25/24 at 3:50 PM, R9 was observed in bed. R9 smiled and greeted when addressed. R9 stated that she was feeling a little better after receiving fluids. During the week of the survey, a confidential staff member stated that she was familiar with R9. The confidential staff member reported that it was a standard of care to bring a fresh water to all the residents at the start of every shift, however there are times when there is no time to pass waters. The confidential staff member stated that R9 will refuse things like to get out of bed and refuse showers, however, does not refuse water.

Based on interview and record review the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) were provided and completed for three Resident Residents (#43, #53, and #91) out of three reviewed for Beneficiary Notification. Findings Included: Resident #43 (R43) Review of the medical record revealed R43 was admitted to the facility 12/01/2022 with diagnoses that included cerebral atherosclerosis (arteries in brain become hard, thick, and narrow due to build up of plaque), pain in left wrist, anxiety, dementia, delusional disorders, emphysema, polyneuropathy, atrial fibrillation, communication deficits, chronic obstructive pulmonary disease (COPD), depression, stroke, and hypertension. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/15/2024, revealed R43 had a Brief Interview of Mental Status (BIMS) of 8 (moderately impaired cognition) out of 15. Review of R43's medical record revealed she had been discharged from the facility on 05/19/2024, related to recent hospitalization , and had returned to the facility 05/23/2024 with Medicare A Services. Review of R43's medical record demonstrated Medicare A Services were ended on 06/20/2024 and that Medicaid Services were started on 06/21/2024. Review of R43's Notice of Medicare Non-Coverage (NOMNC) revealed that her services would end 06/20/2024. The NOMNC did not demonstrate a signature and date which would verify receipt of the NOMNC. Review of 43's Skilled Nursing Facility Advance Beneficiary notice of Non-Coverage (SNFABN) did not have a signature and date which would verify receipt of the SNFABN. Resident #53 (R53) Review of the medical record revealed R53 was admitted to the facility 06/09/2024 with diagnoses that included pneumonia, muscle weakness, chronic kidney disease, insomnia, obstructive sleep apnea, hyperthyroidism (high thyroid hormone), atrial fibrillation, type 2 diabetes, end stage renal disease, dependence of renal dialysis, osteoarthritis (flexible tissue at the end of bones wears down), hyperlipidemia (high fat content in blood), and restless leg syndrome. R53's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/15/2024, revealed a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. R53's medical record revealed he was discharged from the facility 07/16/2024. Review of R53's medical record did not demonstrate that he had been provided a Skilled Nursing Facility Advance Beneficiary notice of Non-Coverage (SNFABN) prior to the completion of his Medicare A Services. Resident #91 (R91) Review of the medical record revealed R91 was admitted to the facility 01/11/2024 with diagnoses that included dementia, type 2 diabetes, hypertension, hyperlipidemia (high fat content in blood), and Transient Cerebral Ischemic Attack (a brief stroke like attack). Review of R91's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/18/2024, revealed a Brief Interview of Mental Status (BIMS) of 6 (severe cognitive impairment) out of 15. Review of R91's medical record demonstrated that Medicare A Services were discontinued on 03/01/2024 and Medicaid Services were started on 03/02/2024. Review of R91's Skilled Nursing Facility Advance Beneficiary notice of Non-Coverage (SNFABN) demonstrated a signature date of 02/28/2024. R91's SNFABN did not demonstrate any option that had been selected to appeal the discission or desire to receive the same level of care and be responsible for payment or if she did not want the same level of care to be provided. In an interview on 07/25/2024 at 12:57 p.m. Nursing Home Administrator (NHA) A explained that a Skilled Nursing Facility Advance Beneficiary notice of Non-Coverage (SNFABN) had not been completed for R53. NHA A reviewed 43's Skilled Nursing Facility Advance Beneficiary notice of Non-Coverage (SNFABN) but could not explain why a signature was not present. NHA A also reviewed R43's Notice of Medicare Non-Coverage (NOMNC) but could not explain why a signature was not present. NHA A reviewed R91's Skilled Nursing Facility Advance Beneficiary notice of Non-Coverage (SNFABN) but could not explain why R91's SNFABN did not demonstrate any option that had been selected to appeal the discussion or desire to receive the same level of care and be responsible for payment or if she did not want the same level of care to be provided.

Based on observation, interview, and record review, the facility failed to ensure the necessary services were provided for Activities of Daily Living (ADL) for three out of four residents (Resident #9, 71, and 83) resulting in the potential for care needs not being met. Findings include: Resident #9 (R9) Review of the medical record revealed R9 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), hemiplegia and hemiparesis following cerebral infarction (one sided weakness caused by a stroke), glaucoma (condition that causes damage to the optic nerve, and dry eye syndrome of bilateral lacrimal glands (gland that produces tears). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/11/24 revealed R9 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental status. Review of R9's Care Plan reflected R9 required the assistance of one staff member for personal hygiene and was dependent for toileting with the use of a bed pan and briefs. On 7/23/24 at 3:02 PM, R9 was observed in her bed wearing a hospital gown. R9's hospital gown had food debris on it. R9's left eye was crusted shut. R9 had long, uneven fingernails and caked in dark debris was observed under her thumbnails. R9's call light was out of reach and R9 did not have any water available for her. R9 stated that her eye had been crusted shut for over a day and that she had been wearing the same hospital gown for days. R9 reported that she was currently sitting in a wet brief and would like to be changed. R9 stated that her water pill (diuretic) made her urinate often and felt that she often had to wait too long to be changed into a clean, dry brief, especially after lunch. R9 asked for assistance with obtaining her call light stating that she wanted some water because she felt so dry, having water is important to me. When asked about her bathing and assistance needs for her hygiene, R9 asked this surveyor if I could assist her with obtaining her tweezers to help pluck out her chin hairs. R9 had several longer chin hairs which she stated have been bothering her for quite some time. On 7/24/24 on 3:43 PM, R9 was observed in bed, resting. R9 did not speak when greeted. R9 had an intravenous catheter in her right hand and intravenous fluids running. R9's wore a clean gown but the rest of R9's appearance appeared the same. In an interview on 07/26/24 at 9:39 AM, Director of Nursing (DON) B stated that R9 will often refuse showers, however, the expectation would be to ensure that despite R9 not receiving a shower, staff should still be completing grooming and hygiene for R9. 45038 Resident #83 (R83) Review of the medical record revealed R83 was admitted to the facility 01/17/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD), depression, insomnia, anorexia, dementia, pulmonary fibrosis (lungs become scarred over time), chronic kidney disease, gastro-esophageal reflux, dysphagia (difficulty swallowing), type 2 diabetes, tachycardia (fast heart rate), peripheral vascular disease (PVD), stroke, hypertension, hyperlipidemia (high fat content in blood), and anemia (low red blood cells). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/25/2024, revealed R83 had a Brief Interview of Mental Status (BIMS) of 15 (cognition is intact) out of 15. During observation on 07/23/2024 12:20 p.m. R 83 was observed lying down in bed. R83 was observed to be in a hospital gown and hair appeared to be unkept and a strong foul odor was smelled. R83 was observed to be sleeping. During observation and interview on 07/24/2024 at 07:47 a.m. R83 was observed lying down in bed. He was observed to have the same style of hospital gown on, and hair appeared to be unkept and a strong foul odor was smelled. R83 explained that he was supposed to have a shower twice per week and explained that he did not get them also twice per week. R83 also could not explain the last day of his shower. During observation and interview on 07/25/2024 at 08:44 a.m. R83 was observed lying down in bed. He was observed to have the same style of hospital gown on, and hair appeared to be unkept and a strong foul odor was smelled. A wash basin, in a tied clear bag, was observed to be on R83's over bed table. R83 explained that the staff does not always provide him with assistance of cleaning up daily. R83 explained that he was supposed to have a shower today and he wanted a shower. R83 explained that he did not want a bed bath but wanted to have a shower today. Review of R83's medical record demonstrated that R83 was care planned to receive a shower/bath/bed bath twice per week. R83's Point of Care (POC) documentation, which is used by direct care staff to determine a resident's plan of care, demonstrated that R83 was scheduled to receive a shower/bath/bed bath on Sunday day shift and Thursday day shift. Review of the past thirty-day POC documentation revealed that R83 did not have a shower/bath/bed bath completed 07/04/2024 and 07/14/2024. Review of R83's plan of care revealed R83 required assistance of staff with selfcare and that he was dependent for bath/shower. R83's plan of care revealed that R83 required partial to moderate assistance of one person for personal hygiene. Review of R83's Point of Care Documentation of ADL Documentation (activities of daily living- including hygiene), for the last 30 days, revealed no documentation for the day shifts of 07/05/2024, 07/09/2024, 07/24/2024/ and 07/19/2024. In an interview on 07/25/2024 at 09:03 a.m. Director of Nursing (DON) B explained that it is the expectation that care givers provide ADL Care (activities of daily living) each shift for all residents. DON B explained that ADL Care included personal hygiene. DON B explained that residents are given bath/shower/bed bath as listed by their plan of care. DON B explained that frequency of the bath/shower/bed bath was determined at the request of the resident. DON B reviewed R83's Point of Care (POC) documentation for shower/bath/bed bath and confirmed documentation was not present for the dates and times as listed above. DON B reviewed R83's POC documentation for ADL care and confirmed that documentation was not present for the dates and times as listed above. DON B could not explain why R83 had not received ADL care as required and why shower/bath/bed bath was not completed as required in R83's plan of care. 45135 Resident #71 (R71) Review of the medical record reflected R71 was an initial admission to the facility on [DATE] with a readmission on 06/25/24. Diagnoses of after care of joint replacement, need for assistance with personal care, displaced fracture of base of the neck of left femur, muscle weakness, dysphagia, cognitive communication deficit, aphasia following stroke, weight loss, and difficulty with walking. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/01/2024, revealed R71 had a Brief Interview of Mental Status (BIMS) of 00 (severely impaired) out of 15. Under section G0100, Activities of Daily Living (ADL) assessment revealed R71 requires substantial/maximal assistance with eating, oral hygiene. R71 is dependent on toileting, shower/bathing, getting dressed, repositioning in bed, and sit to stand. During an interview and observation on 07/23/24 at 01:34 PM, R71's husband stated she needed her nails cleaned and trimmed. R71's toenails were uneven and unkept. Fingernails are long, half painted, uneven and unkept. R71's husband stated he had tried getting her nails addressed and got nowhere. Record review revealed nail care was on R71's care plan. o Keep fingernails trimmed and clean. Date Initiated: 06/26/2024. Record review revealed on 7/19/2024 at 10:21. Social Services Note Late Entry: Note Text: Resident scheduled to be seen by podiatry services 7/19/2024. Resident refused. During an interview and observation on 07/25/24 at 08:27 AM, R71 was attempting to eat breakfast independently with her fingers. Sign above her bed stated she is a 1:1 to be assisted/supervise during meals. R71 had approximately 75% of her breakfast still on the tray. During an interview and observation on 07/25/24 at 08:38 AM, R71 was attempting to eat breakfast independently. R71 was eating some scrambled eggs with her fingers. During an interview and observation on 07/25/24 at 08:48 AM, R71 was attempting to eat breakfast independently. R71 was eating some mandarin oranges one piece at a time. R71 had approximately 50%-60%% of her breakfast still on the tray. During an interview and observation on 07/25/24 at 09:06 AM, R71's breakfast tray was no longer in her room on the over the bed table. R71's fingernails and toenails had not been filed, cleaned, or trimmed. During an interview on 07/25/24 at 09:56 AM, Social Worker (SW) X stated on the resident refusal note, the podiatrist documented that the resident refused without asking a staff member to make the rounds with him, or knowing he was in the building. SW X also stated noted this problem and have addressed this issue with him and working on a resolution. During an interview on 07/25/24 at 10:34 AM, Director of Nursing (DON) B stated R71 was care planned for nail care. Writer asked DON B if she was aware of the problem with podiatry not seeing this resident. DON B stated no, but she would address it after this interview. Writer also asked DON B about staff not completing nail care or showers marked as refused. DON B stated R71 is not as cooperative when her husband is not here. DON B stated that R71 can be a totally different person when he is here with her. DON B added that R71's husband comes in every afternoon from 1:00pm to 3:30 pm. During this same interview, DON B stated the sign above R71's bed met that Certified Nursing Assistances (CNA's) were to sit with her while she is eating and to supervise R71's food intake as she is marked for weight loss. Writer shared during three observations during breakfast, that nobody was in the room with R71 while she was attempting to feed herself with her fingers. During an interview and observation on 07/26/24 at 08:55 AM, R71 was sitting up in her bed playing with a fidget blanket. Noted her fingernails are trimmed and neatly painted. Also noted that her toenails appeared to have been cleaned, trimmed, not painted. Record review of policy titled Routine Resident Care last updated on 03/07/2023 stated Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Steps are taken to ensure that a residents capacity for self-performance of these activities does not diminish .

Based on observation, interview and record review the facility failed to ensure care plan interventions were maintained for one resident (#4) of 3 residents reviewed for falls, resulting in resident 4 sustaining a fall with a left elbow abrasion. Findings Include: According to the clinical record including the Minimum Data Set (MDS) dated [DATE] and 09/08/23 Resident #4 (R4), was admitted to the facility with diagnoses that included cerebral infarction with left sided hemiplegia and hemiparesis. R4 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) on the 06/08 and the 09/08/23 MDS, both MDS assessments also reflected R4 was coded to require extensive assist with two persons for transfers. Review of the incident report dated 07/10/23 reflected R4 slid out of the sling from the sit to stand lift during a transfer performed by one staff member from bed to the bathroom and landed on his left side sustaining a left elbow abrasion. Further review of the incident and accident report reflected the Certified Nursing Assistant (CNA) was using the sit to stand lift without another staff person present and the sling was not properly set up correctly. Review of R4's care plan that was in place in July 2023 reflected R4 required 2 staff persons for transfers and no type of mechanical lift. On 10/31/23 at 9:10am, R4 was observed resting in bed and described the 7/10/23 incident occurred using a lift and one CNA present, as described in the incident report. On 10/31/23 at 10:45 am during an interview with Director of Nursing (DON) B it was reported a reenactment was done with former employee CNA J who performed the transfer. DON B reported she observed the reenactment and former employee CNA J hooked the sling backwards to the lift and failed to obtain a second staff person for assistance with the transfer per care plan. When queried abut the use of a lift DON B acknowledge that R4 was not care planned to have used a lift of any kind and DON B could not account for why former CNA J used a mechanical lift and choose not to obtain assistance per the directive on R4's care plan.

This citation pertains to MI00139852 Based on interview and record review the facility failed to honor one resident's (#7) Advance Directives (a written statement of a resident's wishes regrading medical treatment) for DNR (Do not Resuscitate) of three residents reviewed resulting in the resident's medical preferences not to be followed at the end of life and the potential of other residents not to have their medical preferences followed at the end of life. Findings Included: Resident #7 Review of the medical record revealed R7 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, dysphagia (swallowing difficulties), neuromuscular dysfunction of the bladder, REM (rapid eye movement) sleep behavior disorder, dementia, hypertension, anxiety, type 2 diabetes, chronic kidney disease, constipation, urinary retention, benign prostatic hyperplasia (enlarged prostate) gastro-esophageal reflux, restless leg syndrome, hyperlipidemia (high fat content in blood), and diabetic neuropathy (weakness, numbness, pain form nerve damage). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R7 had a Brief Interview for Mental Status (BIMS) of 9 (moderately impaired cognition) out of 15. R7 was discharged from the facility [DATE]. In a telephone interview on [DATE] at 09:37 a.m. family member C explained that R7 had desired not to have cardiopulmonary resuscitation (CPR) completed if he did not have a pulse or respirations. Family member C explained that DNR (Do Not Resuscitate) documents had been completed. She explained that R7 had an event on [DATE], at which time he did not have a pulse or respiration, and the facility staff performed CPR. She explained that the facility did not honor his wishes of the DNR status and was in a vegetative state until he died at the facility on [DATE]. During record review it was revealed that R7 had a Do not Resuscitate order that was active as of [DATE]. The medical record also demonstrated that family member C was R7's Durable Power of Attorney and had been activated [DATE] by one physician and one psychologist. Further review of the medical record revealed a document entitled resident code status'' which had been signed by family member C - the Durable Power of Attorney. Review of R7 clinical progress notes revealed an entry on [DATE] at 05:01 p.m. by Licensed Practical Nurse (LPN) L which stated, Resident noted to be unresponsive slumped over in chair. Floor nurse assessed and resident with no pulse, one round of CPR completed, and resident vitals returned with pulse between ,d+[DATE]. Resident assessed and not with no carotid pulse, 2 rounds of CPR completed and resident with vitals return pulse ranging form ,d+[DATE], BP ,d+[DATE], O2 90% RA (room air). Resident assisted to recliner chair, noted to be unresponsive to verbal stimuli but responsive to painful stimuli. In an interview on [DATE] at 09:42 a.m. Licensed Practical Nurse (LPN) J explained that if a resident became unresponsive and was absent a pulse or respirations that it would first be necessary to see what the Code Status would be on the resident. She explained that Full Code meant the resident wanted Cardiopulmonary Resuscitation (CPR) and if the resident did not want CPR than the resident would be determined to be a No Code. LPN J explained that it was on the very top of a resident's profile in Point Click Care (computerized resident chart). In an interview on [DATE] at 10:05 a.m. Licensed Practical Nurse (LPN) L explained that she had been providing care to R7 on [DATE]. She explained that R7 had issues with constipation and that she had given him a suppository, around 04:45 pm., to relief the constipation and assisted him to his reclining chair at that time. LPN L explain that at approximately 05:00 p.m. she was notified by a Certified Nursing Assistant that R7 was slumped over'' in his reclining chair and not responsive. She explained that went into R7's room and found him with no pulse and directed the initiation of Cardiopulmonary Resuscitation (CPR). She explained that she did not determine R7's code status prior to initiating CPR. She explained that she had reacted in a natural human response. When asked to clarify what natural human response was, she explained that nurses are trained to same lives and that is what she attempted to do. LPN L explained that it was the facility practice to verify a resident's desire for CPR, but she had not in this care. She admitted that she did not honor R7's wishes for not having CPR performed. In an interview on [DATE] at 10:10 a.m. Director of Nursing explained that it was her expectation that the nursing staff follow professional guidelines and determine a resident CPR status before initiating CPR. She acknowledges that the facility did not honor the R7's 'Advance Directives for not having CPR performed. The DON provided a past noncompliance (PNC) for this event. During onsite survey, past noncompliance (PNC) was cited after the facility implement actions to correct the noncompliance which include: 1). A root cause analysis of the deficient practice, a complete audit of all residents to determine Advance Directives. 2). The Advance Directive Policy was reviewed. 3) All nurses were re-educated on Advance Directives, Code Blues, Code Status, and Death of a resident. 4). The interdisciplinary team (IDT) will interview staff on advance directives policy, an Code blues, to validate they know when to initiate CPR, an dhow to handle the death of a resident weekly for 4 weeks then monthly for 2 months, any concerns will be addressed at that time. 5. Finding with be report to the Quality Assurance and Performance Improvement committee monthly for 3 months. The facility was able to demonstrate the corrective action and maintained compliance as of [DATE]

Based on observation, interview and record review facility failed to: 1) accurately assess, monitor and prevent the development and worsening of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for two Residents (R29 and R94) of four reviewed for pressure ulcers, resulting in worsening of pressure wounds requiring re-hospitalization related to wound infection that required use of intravenous antibiotic treatment and multiple debridement's for R94 and development of two facility acquired unstageable deep tissue pressure ulcers, and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status. Findings include: Resident #29(R29) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R29 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included alzheimers disease, diabetes, chronic kidney failure, and anxiety. The MDS reflected R29 had a BIM (assessment tool) score of 10 which indicated her ability to make daily decisions was moderately impaired, and he required one person physical assist with locomotion on unit, dressing and toileting. During an observation and interview on 5/08/23 09:37 AM R29 was sitting on side of bed, appeared well groomed an able to answer questions without difficulty. Review of EMR, dated 9/22/22 to current 5/15/23, reflected R29 had a stage 3 coccyx pressure ulcer present on admission. Review of the Skin and Wound Evaluation, dated 5/11/23 reflected area with base of wound observed with no slough noted over base and no evidence of depth measurements. Resident #94(R94) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R94 was a [AGE] year-old male admitted on [DATE] with hospital re-admission related to wound infection 2/2/23 to 2/13/23, hospital re-admission 3/21/23 with diagnosis that included wound infection and re-admission 4/18/23, with diagnoses that included hypertension (high blood pressure), diabetic (high blood sugar), anemia, malnutrition, obstructive uropathy, stage 4 pressure ulcers, and anxiety. The MDS reflected R94 had a BIM (assessment tool) score of 11 that indicated his ability to make daily decisions was minimally impaired, and he required two-person physical assist with bed mobility, transfers, toileting, dressing, hygiene and bathing and one-person physical assist with locomotion on unit. During an observation on 5/08/23 at 10:45 AM, R94 was laying on back in air mattress with eyes closed. R94 appears very thin and pale. Review of the discharge MDS, dated [DATE], reflected R94 had two stage 2 pressure ulcers(partial thickness loss of dermis) on admission 12/22/23. Review of the Admission MDS, dated [DATE], reflected R94 had two unstageable pressure ulcers, slough and or eschar(non-viable tissue), and two suspected deep tissue injuries on re-admission 1/2/23. Review of the 5-day Re-admission MDS from acute care setting, dated 2/19/23, reflected R94 had two stage 4 pressure ulcers(full thickness tissue loss with exposed bone, tendon or muscle) present on admission 2/13/23. Continued review of MDS reflected R94 two suspected deep tissue injuries not present on admission 2/13/23. Review of the Nurse Practitioner Progress Note, dated 1/18/23, reflected R 94 had 0/10 pain scale. Review of the Nursing Progress Note, dated 1/19/23 at 12:06 p.m., reflected, Wound rounds completed with [named facility wound physician]. Left thigh sharps debrided. Treatment order updated with changes as recommended. Plan to reassess next week.(Facility wound Physician consult note scanned into EMR 3/7/23). Review of R94's Nurse Practitioner Progress Note, dated 1/25/23, reflected, CHIEF COMPLAINT pain management and blood glucose . HISTORY OF PRESENT ILLNESSES General: Patient is a [AGE] year-old Male with medical history of fall at home with rhabdomyolysis, right sided abdominal mass, HTN and DM. Patient readmitted after hospital stay for respiratory failure and aspiration pneumonia and fecal impaction. Patient is noted with increased pain with movement and was taking Norco in the past and requested to have medication restarted and scheduled twice a day . Noted with DTI to bilateral heels as well, no open areas but heels are boggy. Will start skin prep and off load heels . Pressure-induced deep tissue damage of unspecified heel: Noted on bilateral heels, skin prep and off load heels . Review of the Nursing Progress Notes, dated 1/30/23 at 1:31 p.m., reflected, wound dressing saturated, large amount of drainage, eschar tissue sloughing off, strong odor. No mention facility wound Physician notified of change in R94's wound. Review of the Nurse Practitioner Progress Note, dated 1/31/23, reflected, CHIEF COMPLAINT pain management . noted with continued pain with movement and dressing changes . Will add MS at low dose for dressing changes and extensive care, otherwise norco is reducing pain . Review of the Physician Progress Notes, dated 2/1/23, reflected R94's pain level was 5 out 10 on pain scale. Review of R94's Nurse Practitioner Progress Notes, dated 2/2/23, reflected CHIEF COMPLAINT: Change in wounds .Patient was noted with foul smelling wounds with increased purulent drainage and wound physician was in house and did debride thigh wound. Based on clinical presentation of wounds and collaboration with wound physician, decision was made to send patient to the hospital for evaluation and treatment of thigh and buttock wounds and need for extensive I&D .Pain Level: 6 .Pressure ulcer of sacral region, unspecified stage: Noted with increased purulent drainage from both sacral and thigh wounds, foul odor and deterioration, sent to ED for evaluation and debridement . Review of the EMR, dated 1/19/23 through 3/2/23, reflected no evidence R94's wounds were evaluated by facility wound physician during weekly rounds on 2/26/23 or wound physician was notified of worsening pressure wounds and development of two preventable facility acquired deep tissue injuries. The EMR reflected no visit notes for facility wound physician dated 2/26/23 by time of survey exit on 5/15/23. Review of R94's Nursing Progress Note, dated 2/13/23 at 11:11 p.m., reflected, Resident admitted from [named] hospital with a sacral and two L hip wounds. A&Ox3, Full code, takes meds whole, house diet, Foley in place(placed on 2/2/23), non-ambulatory,incontinent of bowel . c/o pain of both heels, L hip, and coccyx, PRN medication given, repositioned for some relief of coccyx pain . Review of R94's Nurse Practitioner Progress Notes, dated 2/14/23, reflected, CHIEF COMPLAINT: readmission from hospital . Patient readmitted after hospital stay for necrotizing fasciitis and abscess in left thigh and underwent multiple surgical debridements. Patient had coccyx wound debrideded as well and only has wound vac on thigh wound. Will continue with wound team to monitor and finished antibiotics with one dose after admission. Patient states that oxycodone is effective in treating his pain and will continue at this time .Pain Level: 6 .NECROTIZING FASCIITIS: Continues on antibiotics for one day to complete course, will continue with wound team follow and pain medication . Review of R94's Skin/Wound Progress Note, dated 2/16/23 at 1:48 p.m., reflected, Wound rounds completed with [named facility wound physician] Left thigh wound with wound vac, sacrum is Dakin's packing with gentle foam dressing. Resident also has DTI to bilat heels. Heel boots in place. Plan to reassess next week. Review of the MDS Progress Note, dated 2/16/23 at 5:45 p.m., reflected R94 had reported 6 out of 10 pain over past five days. Review of the Nurse Practitioner Progress Note, dated 2/24/23, reflected, Encouraged to ask for pain medications and did not want to schedule any pain medications at this time. Has PRN roxanol if needed prior to treatments . Review of R94's Progress Note, dated 3/8/23 at 11:07 a.m., reflected, Reviewed Clinical Indicator: Resident receiving antifungal treatment r/t UTI with fungal infection, no adverse effects noted. Resident noted with pressure wound to left thigh with previous necrotizing fasciitis with wound vac in place, wound is improving. Resident with sacral stage4pressure ulcer with slough noted, current progress is stalled, is followed by wound physician, will review potential for woundvac following completion of Santyl treatment for slough. Resident receives multiple supplements to assist in wound management. Resident with right heel DTI,and left heel unstageable wounds. Treatments in place and continues to be followed by wound physician . Review of R94's Nursing Progress Note, dated 3/14/23 at 7:12 a.m., reflected, Guest sacral wound dressing was off patient when CNA change him. Needed to flush the wound with saline to remove fecal matter. Reapplied dressing and noted change of condition. Notified the physician to assess wound. Review of the Physician Progress Notes, dated 3/15/23, reflected R94 had 7 out of 10 pain. Review of R94's facility Wound Physician Consult Note, dated 3/16/23, reflected, A [AGE] year-old male seen and examined at [named] Skilled Nursing Facility with wound care team, wound care nurse, and nurse manager. 1. I was asked to evaluate a sacral area stage 4 pressure area ulceration at 8.9 x 9.4. Black eschar noted. Present on admission. No signs of infection. Periwound area is normal in color and temperature. Antibiotics were started on the patient via primary team undermining noted at 1 o' clock and 4 o' clock. Sloughy tissue noted. Black eschar tissue noted at the wound bed. 2. Left heel deep tissue injury at 3.7 x 3.9. [facility acquired] 3. Right heel deep tissue pressure injury at 3.8 x 4.0. 100% black eschar noted. [facility acquired] 4. Left thigh stage 4 pressure area ulceration at 9.1 x 5.6 with some granulation tissue noted at the wound bed. Treatment currently includes the application of negative pressure wound VAC system. Negative 125 mmHg, negative pressure. Change three times a week and as necessary . Review of R94's Nurse Practitioner Progress Note, dated 3/17/23, reflected, .patient was started on antibiotics for wound infection. Wound on coccyx with purulent drainage and change in odor . No mention facility wound physician was notified of worsening wound changes. Review of the Infection Progress Note, dated 3/17/23 at 2:34 p.m., reflected, Guest continues on Amoxicillin-Pot Clavulanate Tablet 875-125 MG 1tablet PO Q12 hours for Wound infection for 10 Days. Guest continues to have low BP and little output. Peripheral line placed in L hand and IV fluids started. Review of R94's Nurse Practitioner Progress Note, dated 3/21/23, reflected, CHIEF COMPLAINT Change in condition . Patient was noted to have increased fatigue and decreased appetite/fluid intake. Patient agreed to another bag of IV fluids and D5 ordered. Will obtain labs and continues on antibiotics for wound infection. Patient appears weaker and initially declined going to the hospital and declined to discuss code status with SW/nursing. Contacted by DON later in the day and decision was made to send to Ed for further evaluation and likely will need IV antibiotics . Review of R94's Progress Note, dated 4/18/23 at 4:33 p.m., reflected, Resident arrived from [named] Hospital on hospice, [named} hospice nurse in and assessed resident. Notified hospice nurse of red drainage noted in foley. Notified unit manager of dressings to BLE and wound nurse to assess tomorrow . Review of R94's Progress Note, dated 4/27/23 at 11:03 a.m., reflected, Resident readmitted from hospital on hospice services with multiple skin integrity concerns. Resident with bilateral heel unstageable pressure ulcers, coccyx is stage 4 with wound vac in place. Left thigh with stage 4 ulcer wound vac present on admission, vac discontinued during wound rounds on 04/20/23. Resident with venous ulcer to right calf with tx in place. Continue with wound physician evaluation for comfort and wound management . Review of R94's Skin/Wound Progress Note, 4/27/23 3:38 p.m., reflected, Wound rounds completed with Dr [named facility wound physician] Wound vac to sacrum dc'd. New orders in place. Plan to reassess next week. (Same day Progress Note reflected wound vac had been discontinued on 4/20/23.) Review of the Treatment Administration Record, dated 4/1/23 through 4/30/23, reflected R94's wound vac was discontinued 4/27/23. Review of R94's Skin/Wound Progress Note, dated 5/4/23 at 11:03 a.m., reflected, Late Entry:Note Text: Wound rounds completed with [named facility wound physician]. Left thigh and bilat heels are improving. Right trochanter deteriorating, sacrum stable .No change to treatment orders. Plan to reassess next week. On 12/26/2022, the resident weighed 156 lbs. On 04/30/2023, the resident weighed 138 pounds which is a -11.54 % Loss. Review of Hospice Start of Care Documentation, dated 4/18/23, reflected R94's weight was 135 pounds. Continued review of the documents reflected, .Reason for hospice referral/admission: Patient sent to emergency room with recurring infection leading to sepsis. Patient has multiple [NAME] [wounds] on bilateral lower extremities sacral region and his left hip. Increasing confusion and worsening vital signs. Patient has recurring aspiration leading to change in diet. Is bed bound continuous losing weight . During an interview on 5/10/23 at 8:22 AM, Licensed Practical Nurse (LPN) AA reported was R94 nurse, and reported wound rounds were on Thursdays and floor nurse completes daily dressings on other days. LPN AA reported R94 had orders for heels and hip treatments that day. During an observation on 5/10/23 at 9:40 AM, LPN AA and Assistant Director of Nursing/wound care nurse(WN) X entered R94 after gathering wound care supplies. WN X reported had been facility wound nurse for six months and worked at the facility for about 1 year. Observed bilateral heel dressings with black intact eschar, cleaned with normal saline and covered with iodine soaked gauze, covered with heel foam and secured with gauze wrap. LPN AA also changed dressing to Right trochanter that was dated 5/9/23 and cleaned with normal saline, applied medihoney and alginate and covered with foam border dressing. Reported plan to complete three other wounds the next day. During an interview on 5/10/23 at 10:00 AM, WN X reported R94's wound vac for sacral and left hip stage 4 pressure ulcers was no longer in place after most recent hospital stay. WN X reported bilateral heels and right trochanter were facility acquired pressure ulcers and reported R94 was admitted with sacral and left hip and right calf wounds. WN X reported R94 had fallen at home and laid in same position for long period of time. WN X reported after admission R94's left hip wound rapid declined and was admitted to the hospital and diagnosed with necrotizing fasciitis after 2/13/23 hospital admission. WN X reported wound measurements taken on every Thursday at wound rounds with use of camera that determines measurements. During an observation and interview on 5/11/23 at 10:22 AM, WN X and Unit Manager (UM) T entered R94s room after WN X gathered supplies reported today was wound rounds and facility wound physician M was no able to be present this week. R94 appeared alert and oriented and answer questions without issues and was positioned in bed on back on air mattress. Dressings were completed by WC X as follows: -right heel-dressing was removed that was dated 5/10/23, saline was used to loosen betadine soaked gauze, 100% black eschar observed, picture taken, applied betadine gauze, foam heel, secured with kerlex wrap. -right calf-old dressing removed, 100% eschar about nectarine size with loose slough edges, picture taken, cleaned with normal saline, applied xeroform, ABD and secured with gauze wrap. -left heel-old dressing removed dated 5/10/23, 100% eschar about nectarine size with loose slough edges, picture taken, betadine soaked gauze/foam/kling. -Observed undated dressing on posterior left calf that was not removed or spoke about. R94 rolled to right side with assist of WN X and UM T and WN X reported R94 had recent bowel movement and staff had reported had removed dressing because it was soiled. -sacral wound was observed opened, directly against soiled brief that was large(about softball size) dark pink tissue with about 10% slough between 9 o'clock and 12 o'clock with exposed bone. WN X reported R94 had another bowel movement and WN X change brief. WN X took a picture of the wound. (no manual measurements observed.) WN X applied silver alginate to R94s sacral wound with no cleaning of wound observed after direct contact with soiled brief with alginate placed about one inch over periwound between 12 o'clock and 6 o'clock and covered with border dressing. -left thigh dressing, dated 5/9/23 removed, 2 border dressings with xerofoam removed. (2 open areas), picture taken, normal saline single use sprayed on wound and dripped into brief, xerofoam, covered with border dressing. -right trochanter-dressing removed dated, dated 5/10/23, picture taken, Normal Saline single use(dripped down to observed open area on right buttock and clean brief, gloved finger applied medihoney to cut alginate placed on wound, and cover border dressing. -added dressing to left buttock, border dressing. R94 was rolled to his back, air mattress with rotation observed with no pillows noted in room for positioning except one with no pillowcase. WN X and UM T started pull up R94's covers and R94, stated, you're not done yet, (followed by long pause) with R94 turned and looked at offloading boots that WN X had placed in chair prior to dressing change), heels happed once, I'll be damned if it will happen again. WN X and UM T uncovered R94, applied boots to bilateral heels, covered, and R94 reported a little pain on backside. During an observation and interview on 5/11/23 at 11:36 am, WN X reported process for wound documentation that included after rounds sit and document same day off phone pictures and paper notes. WN X verified no written notes taken during R94 wound care. WN X reported usually only herself and facility wound physician for rounds unless CNA staff needed for positioning. WN X reported prints off wound notes and provides facility wound physician copy at the following week (Thursday) wound rounds. WN X reported the wound physician then dictates those prior week notes, sends out of the country for dictation and she can obtain notes between 2-3 weeks post actual wound care monitoring. WN X reported measure weekly with picture including height, width and depth. WN X reported depth was observed by eye because she was able to see changes and verified did not obtain manual depth of wounds including R94 sacral wound and reported could start to add to notes. WN X reported did not see that R94 had a dressing on the left posterior calf area and had no knowledge of open area to the left lower leg and WN X asked this surveyor if there was a dressing in place. WN X entered R94's again, observed undated border dressing on R94s posterior left calf. WN X removed border dressing with alginate over appear that appeared very dry but intact at that time. WN X reported unsure why treatment in place with no order and reported may have been in place for protection. Review of the weekly wound notes, dated 12/26/23 through current (5/11/23), reflected R94 had no evidence of depth measurements including wounds with without eschar or significant slough. Continued review of weekly wound round physician notes reflected the same for the visit notes prior to 3/16/23. Review of the EMR reflected no evidence of facility wound physician notes after 3/16/23. Review of R94's skin Care Plan, dated 1/11/23, reflected, [named R94] has actual skin impairment and is at risk for further impaired skin integrity/pressure injury: pressure injuries to - sacrum, left thigh, bilateral heels r/t Hx Necrotizing fasciitis to thigh ulcer, hx of debridement to sacral and thigh ulcers injuries .Goals .Will remain free from complications from pressure, dated 1/11/23 .Interventions . Assist with repositioning every 2 hours and prn Date Initiated: 01/11/2023 . Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician. Date Initiated: 12/22/2022 .Heelz up device to float heels while in bed and assist as needed Date Initiated: 01/11/2023 . Encourage to float heels while in bed and assist as needed, Date Initiated: 01/11/2023 Heel boots to float heels Date Initiated: 01/11/2023 Revision on: 04/27/2023(Heel boots to float heels verbiage added 4/27/23) During an interview on 5/11/23 at 1150 PM, Director of Nursing (DON) B reported would expect physician documentation to be in resident charts(EMR) within seven days. DON B reported would expect wounds to be measured weekly including length, width and depth measurements and reported depth must be taken manually because the camera does not obtain depth. DON B reported nursing staff are not expected to eye ball wound depth. DON B reported not aware physician was provided copy of nurse wound notes seven days after actual observation to dictate then sent out and reported was aware of long delay but not aware physician going by nurse notes. DON B reported infection control duties performed by herself and ADON/WN X. DON B reported WN X completed facility floor surveillance and DON B oversee WN X and is often present to assist with weekly rounds and would expect WC X to use good infection control practices with wound care.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and sanitize food service equipment effecting 108 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased interior food service equipment illumination, and cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 05/09/23 at 09:15 A.M., An initial tour of the food service was conducted with Certified Dietary Manager (CDM) C. The following items were noted: The Victory 2-door reach-in cooler interior light bulb was observed non-functional. The 2017 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. The soda machine dispensing spout assemblies were observed being cleaned weekly instead of daily (every 24 hours). (CDM) C stated: The dispensing spouts are cleaned weekly. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. Janitor Closet: The inlet pipe of the Walk-In Cooler and Walk-in Freezer condensate drain lines were observed less than 1-inch from the flood plane level of the mop sink basin. (CDM) C indicated she would contact maintenance for necessary repairs as soon as possible. The overhead spray arm spring was observed weak, allowing the manual activated valve assembly to invade the flood plane level of the sink basin. (CDM) C indicated she would contact maintenance for necessary repairs as soon as possible. The 2017 FDA Model Food Code section 5-202.13 states: An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). Sycamore Unit (200) On 05/09/23 at 09:55 A.M., The Nourishment Room ice machine filter was observed leaking water onto the top of the ice machine. (CDM) C indicated she would contact maintenance for filter replacement as soon as possible. The 2017 FDA Model Food Code section 5-205.15 states: A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. Grand Unit (100) On 05/09/23 at 10:05 A.M., The Nourishment Room overhead plastic light lens cover interior was observed with numerous dead insect carcasses. The Nourishment Room vanity base cabinet interior was also observed soiled with paper straw wrappers and accumulated dust and dirt deposits. The 2017 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. On 05/09/23 at 10:10 A.M., The Nourishment Room refrigerator appliance light bulb mounting bracket was observed broken and loose-to-mount. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. On 05/09/23 at 10:15 A.M., The Nourishment Room refrigerator appliance light bulb was observed without tough coating to prevent glass breakage. The 2017 FDA Model Food Code section 6-202.11 states: (A) Except as specified in (B) of this section, light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; or unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. On 05/11/23 at 08:00 A.M., Record review of the Policy/Procedure entitled: Dietary Cleaning and Sanitation dated 11/19/2021 revealed under Policy: It is the policy of this facility to maintain the sanitation of the kitchen through proper cleaning and sanitizing stationary food service equipment and food-contact surfaces to minimize the growth of microorganisms that may result in food contamination. Food-contact surfaces are washed, rinsed, and sanitized: (1) after each use, (2) before switching preparation to another food type, and (3) when the tool or items being used may have been contaminated.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 108 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, decreased illumination, and cross-connections between the potable (drinking) and non-potable (non-drinking) water supplies. Findings include: On 05/10/23 at 09:25 A.M., A common area environmental tour of the facility was conducted with Director of Maintenance E and Housekeeping and Laundry Supervisor D. The following items were noted: Grand Unit (100) Occupational Therapy/Physical Therapy: Therapy Storage Room: The two overhead light lens covers were observed soiled with accumulated dust and dirt deposits. Clean Utility Room: One of two overhead light lens covers were observed loose-to-mount. Housekeeping and Laundry Supervisor D stated: I am going to contact (maintenance staff name) now. Sycamore Unit (200) The emergency exit door was observed with an ill-fitting threshold seal sweep, creating an opening between the metal threshold plate and the threshold seal sweep. The observed opening measured approximately 1-2 inches long. Red Cedar Unit (300) Cart Storage Room: 3 of 4 overhead light assemblies were observed non-functional. Nursing Station: 2 of 4 overhead light assemblies were observed non-functional. Spa: The hand sink (hot and cold) water supply was observed non-functional. Soiled Utility Room: The waste hopper faucet assembly and atmospheric vacuum breaker were both observed leaking water. The waste hopper faucet handles were also observed out-of-adjustment. On 05/10/23 at 12:45 P.M., An environmental tour of sampled resident rooms was conducted with Housekeeping and Laundry Supervisor D. The following items were noted: 127: Low water pressure was observed at the hand sink faucet assembly. 235: The Heating Ventilation Air Conditioning (HVAC) wall mounted unit filters were observed soiled with accumulated dust and dirt deposits. Housekeeping and Laundry Supervisor D indicated she would have maintenance clean the soiled filters as soon as possible. 330: The flooring carpet was observed separated at the seam, adjacent to the Bed 1 headboard. 342: The Bed 2 overbed light assembly pull string extension was observed missing. 352: The Bed 2 seven inch-wide desk fan was observed soiled with accumulated dust and dirt deposits. 354: The flooring carpet was observed separated at the seam, adjacent to the Bed 1 headboard. The flooring carpet was also observed torn and separated at the seam, adjacent to the Bed 2 headboard. 355: The Bed 1 overbed light assembly pull string extension was observed missing. The restroom hand sink faucet assembly was also observed non-functional. The hand sink faucet assembly water supply was additionally observed dripping water and could not be completely shut off. 357: The restroom drywall surface was observed etched, scored, particulate, adjacent to the entrance door. The damaged drywall surface measured approximately 12-inches-wide by 24-inches-long. 358: The drywall surface was observed etched, scored, particulate, adjacent to the Bed 2 headboard. The damaged drywall surface measured approximately 12-inches-wide by 24-inches-long. On 05/15/23 at 08:00 A.M., Record review of the Policy/Procedure entitled: Housekeeping Services dated 02/22/2023 revealed under Policy: To promote a sanitary environment. (I) Frictional Cleaning (A) Thorough scrubbing will be used for all environmental services that are being cleaned in guest/resident care areas. (B) Mop heads, cleaning cloths and cleaning solutions will be changed routinely and regularly and when obviously soiled. Mop heads and water are to be changed after each contact isolation room cleanup. On 05/15/23 at 08:30 A.M., Record review of the Policy/Procedure entitled: Maintenance and Repairs of Equipment dated 11/19/2021 revealed under Policy: It is the policy of this facility that all malfunctions and need for repairs are reported to the Maintenance Department and the Administrator in a timely manner. Record review of the Policy/Procedure entitled: Maintenance and Repairs of Equipment dated 11/19/2021 further revealed under Procedure: (4) Preventative maintenance will be completed for major equipment at regular intervals. The Dietary Manager or Dietitian and Maintenance Department will be responsible to coordinate these projects. On 05/15/23 at 09:00 A.M., Record review of the Direct Supply TELS Work Orders for the last 30 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on observation, interview, and record review, the facility failed to ensure updated and accurate advance directive information was in place for four residents (Resident #2, #13, #78 and #94) of five reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings Include: Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 (Revised [DATE]), revealed that, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: (a) The declarant, the declarant's patient advocate, or another person who, at the time of the signing, is in the presence of the declarant and acting pursuant to the directions of the declarant. (b) The declarant's attending physician. (c) Two witnesses [AGE] years of age or older, at least 1 of whom is not the declarant's spouse, parent, child, grandchild, sibling, or presumptive heir. (3) The names of all signatories shall be printed or typed below the corresponding signatures. A witness shall not sign an order unless the declarant or the declarant's patient advocate appears to the witness to be of sound mind and under no duress, fraud, or undue influence. Further review of this Act revealed, Sec. 4. A do-not-resuscitate order executed under section 3 or 3a shall include, but is not limited to, the following language, and shall be in substantially the following form: DO-NOT-RESUSCITATE ORDER This do-not-resuscitate order is issued by _______________________________________, attending physician for _________________________________________. (Type or print declarant's or ward's name) Use the appropriate consent section below: A. DECLARANT CONSENT I have discussed my health status with my physician named above. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import. _______________________________________ _______________ (Declarant's signature) (Date) _______________________________________ _______________ (Signature of person who signed for (Date) declarant, if applicable) _______________________________________ (Type or print full name) B. PATIENT ADVOCATE CONSENT I authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Patient advocate's signature) (Date) _______________________________________ (Type or print patient advocate's name) C. GUARDIAN CONSENT I authorize that in the event the ward's heart and breathing should stop, no person shall attempt to resuscitate the ward. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. _______________________________________ _______________ (Guardian's signature) (Date) _______________________________________ (Type or print guardian's name) _______________________________________ _______________ (Physician's signature) (Date) _______________________________________ (Type or print physician's full name) ATTESTATION OF WITNESSES The individual who has executed this order appears to be of sound mind, and under no duress, fraud, or undue influence. Upon executing this order, the declarant has (has not) received an identification bracelet. ______________________________ ______________________________ (Witness signature) (Date) (Witness signature) (Date) ______________________________ ______________________________ (Type or print witness's name) (Type or print witness's name) THIS FORM WAS PREPARED PURSUANT TO, AND IS IN COMPLIANCE WITH, THE MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT. Review of the facility, Advanced Directives Policy, revised ,d+[DATE], reflected, .Procedure .All Advanced Directives (including guardian documentation and out of state forms) will be reviewed by the Admissions Department when received prior to or on admission. The Social Services Department will review Advanced Directives after admission and start advanced care planning .If the advanced directive document is found to be insufficient, the resident responsible party and/or the party claiming to be a healthcare legal decision maker will be notified and the document will be placed on file and the medical record noted that the advance directive was not sufficient .If the advanced directive document is found to be sufficient, a copy of the advance directive will be made and placed in the miscellaneous section of the resident's chart .For court appointed Guardians/Conservators, a copy of the guardian appointment orders or documents will be placed in the miscellaneous section of the resident's chart .Mental illness or a diagnosis of dementia alone, even having a legal guardian, does not necessarily mean that the resident is not of sound mind or not competent for the purposes of executing an Advance Directive .If there is a question about whether a resident is competent to complete an Advance Directive, an assessment of the resident's specific capacity to complete an Advance Directive should be referred to a physician before completing an Advance Directive and document in the medical record . Review of the facility, Code Status policy, dated ,d+[DATE], reflected, A Guardian can designate a ward a DNR status only when (MI Only): It does not conflict with the prior wishes of the resident/patient or Patient Advocate .Judicial review by the probate court may be initiated by the facility, in cooperation with the appropriate parties if there is confusion or disagreement about the resident's wishes or if there are any concerns regarding whether the Guardian/Conservator is acting in the best interest of the resident. The written wishes of the resident made while the resident is able to participate in medical decisions, are presumed to be in the resident's best interests . Resident #2(R2) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R2 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that included diabetic, dementia, bipolar disorder, and depression. The MDS reflected R2 had a BIM (assessment tool) that indicated her ability to make daily decisions was severely impaired, and she required two-person physical assist with bed mobility, transfers, toileting, dressing and one-person physical assist with locomotion on unit, eating, hygiene, and bathing. Review of R2 Face Sheet on [DATE] at 11:00 a.m., reflected R2's code status was DNR (Do Not Resuscitate). Review of the Electronic Medical Record (EMR), on [DATE] at 11:01 a.m., reflected no evidence of a completed, Do Not Resuscitate Order form. During an interview on [DATE] at 5:00 PM Social Service Director (SSD) L reported upon admission staff complete resident code status. SSD L reported if residents choose to be DNR a Do Not Resuscitate Order should be complete, including two witness signatures and dates. Social Service Staff (SS) P verified R2's code status was DNR and verified was unable to locate R2's completed, Do-Not-Resuscitate Order document in R2's EMR. SS P reported R2 had a guardian and would expect R2 to have completed, Do-Not-Resuscitate Order in the EMR signed by guardian. During an interview on [DATE] at 11:02 AM SS P reported located R2's Code Status form completed on [DATE] with no staff signature along with DNR order located on the crash cart. SS P reported a completed and accurate, Resident Code Status form and Do-Not-Resuscitate Order form should be located on the crash cart and in the residents' EMR. Review of the Progress Notes, dated [DATE] at 11:35 a.m., completed by SS U, reflected, This writer got a hold of resident's guardian about code status. Guardian made arrangements with social service worker to come in. Resident #13(R13) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R13 was a [AGE] year old female originally admitted to the facility on [DATE] with re-admission [DATE], with diagnoses that included hypertension(high blood pressure), diabetic(high blood sugar), legally blind, osteoporosis, chronic pain, bipolar disorder, schizoaffective disorder and depression. The MDS reflected R13 had a BIM (assessment tool) score of 15 that indicated her ability to make daily decisions was cognitively intact, and she required two-person physical assist with bed mobility, transfers, toileting, dressing and one-person physical assist with locomotion on unit, hygiene, and bathing. The MDS indicated R13 did not have behaviors. Review of the EMR on [DATE] at, 10:33 AM, reflected R13's code status was Full code by default as indicated on Face Sheet. Continued review of the Physician orders, dated [DATE], reflected Full Code. Continued review of the EMR reflected a completed, Do-Not-Resuscitate Order document, signed by R13 on [DATE]. Review of R13's Care Conference notes, dated [DATE], reflected, Social worker called resident's guardian outside of care conference time. Resident is requesting to be DNR. Guardian is working on this to fulfill. During an interview on [DATE] at 4:41 PM, SS U reported R13's current code status was Full code by default. SS U reported R13 wishes to be DNR but had a guardian. SS U reported guardian had said had to get two physicians to sign off to be DNR according to the guardian group policy. SS U reported R13 was deemed incompetent to make medical decisions [DATE] and had court appointed guardianship. SS U was queried about the delay between [DATE] and current ([DATE]) and reported had communicated with the guardian group several times with no follow up and verified was not present for R13's care conference and unsure last time guardian had visited R13. SS U reported did not document reported communication in R13's medical record. SS U reported Social Services should function as residents advocate. SS U verified notes in R13's EMR that reflected on [DATE] R13 continued to wanted code status to be changed to DNR. SS U reported if resident deemed to lack capacity and was Full Code resident could not change code status without responsible party consent. SS U verified R13 had a completed, Do-Not-Resuscitate order form, signed by R13, dated [DATE] in the EMR (prior to R13 being deemed to lack capacity). During an interview and record review on [DATE] at 11:05 a.m., SS P reported R13 had court appointed guardian and provided current guardianship documents with highlighted areas. Review of the highlighted Guardianship documents, dated [DATE], reflected, Full guardianship of R13. The document reflected, Having filed an acceptance of appointment, and you have all of the below listed powers and duties, and all those allowed under the law(as indicated by checked box) .the power to give the consent or approval that is necessary to enable the ward to receive medical or other professional care, counsel, treatment, or service . During an interview and observation on [DATE] 1:18 PM, R13 was laying in bed, appeared calm and able to answer questions without difficulty. R13 reported recent room change related to very nagative roommate and reported was effecting her own mental health. R13 reported her code status was DNR that meant if her heart stopped she did not want CPR to keep her alive. R13 reported she had a court appointed guardian and stated name and reported had not shown up for last two care conferences and was unsure why. Resident #78(R78) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R78 was a [AGE] year-old male admitted on [DATE], with diagnoses that included hypertension (high blood pressure), diabetic (high blood sugar), dementia, cerebral vascular accident, and depression. The MDS reflected R78 had a BIM (assessment tool) score of 6 that indicated his ability to make daily decisions was moderately impaired, and he required two-person physical assist with bed mobility, transfers, toileting, dressing, hygiene and bathing and one-person physical assist with locomotion on unit and eating. Review of R78's, Do-Not-Resuscitate Order, on [DATE] at 10:21 AM, reflected the document was signed by R78's responsible party on [DATE] with two witness signatures that were undated. During an interview on [DATE] at 5:15 PM, SS P verified R78's DNR document was missing witness dates. SS P reported documents should be complete including all required signatures and dates, reviewed by unit managers, and returned to Social Service Department for review then added to EMR. During an interview on [DATE] at 11:06 AM, SS P reported plan of action to have R78's responsible party complete a new order. SS P reported completed facility audit after [DATE] interview with surveyor and identified additional incomplete documentation and corrections were made. Resident #94(R94) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R94 was a [AGE] year-old male admitted on [DATE] with re-admission [DATE], with diagnoses that included hypertension (high blood pressure), diabetic (high blood sugar), anemia, malnutrition, obstructive uropathy, stage 4 pressure ulcers, and anxiety. The MDS reflected R94 had a BIM (assessment tool) score of 11 that indicated his ability to make daily decisions was minimally impaired, and he required two-person physical assist with bed mobility, transfers, toileting, dressing, hygiene and bathing and one-person physical assist with locomotion on unit. Review of the EMR on [DATE] at 11:35 AM, reflected R94 had physician order for DNR, dated [DATE], Face sheet, dated [DATE] indicated, No CPR/DNR. Continued review of the EMR reflected completed, Resident Code Status document, dated [DATE] that reflected Full Code. Continued review of R94's medical record reflected, Michigan Do-Not-Resuscitate Order, dated [DATE], signed by R94's family with no witness signatures or dates. Continued review of R94's EMR reflected no evidence R94 had been deemed incapable of making own medical choices. Review of the Social Work Progress Note, dated [DATE], reflected R94's code status as Full Code. During an interview on [DATE] at 5:07 PM, SS P reported R94's code status was DNR and reported had been completed by Hospice services [DATE]. SS P reviewed R94's DNR order in the EMR and verified document was missing two required witness signatures. During an interview and record review on [DATE] at 8:34 AM, SS P provided, complete Resident Code Status form, signed by R94, dated [DATE]. SS P also provided completed, Do-Not-Resuscitate Order, dated [DATE], signed by R94 along with two witnesses. SS P reported both documents were located on the crash cart and verified had not been part of the EMR and was working to correct that. SS P reported documents should have been part of the medical record.

Based on observation, interview, and record review, the facility failed to 1. label open multi-dose tuberculin vial with open date in 2 of 2 medication room and 1 of 4 medication carts reviewed for labeling, dating and expiration of medications; and 2. Dispose of expired over the counter medication after manufacture expiration dates, resulting in the potential for medications given to residents to have decreased potency, reduced strength, effect, and medication errors. Findings include: Medication vials should always be discarded whenever sterility is compromised or questionable. In addition, the United States Pharmacopeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals: ?If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. ?If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer ' s expiration date. The manufacturer ' s expiration date refers to the date after which an unopened multi-dose vial should not be used. The beyond-use-date refers to the date after which an opened multi-dose vial should not be used. The beyond-use-date should never exceed the manufacturer ' s original expiration date. Retrieved from http://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html During an observation on [DATE] at 1:30 PM, Registered Nurse (RN) BB reported had worked at facility for about 6 months. RN BB unlocked the Grand #3 medication cart with an opened box of Allegra with manufacturer expiration date of ,d+[DATE] was noted. RN BB verified medication had expired last month. During an observation and interview on [DATE] 145 PM, RN BB unlocked the Grand Medication room. An opened undated multi-dose bottle of Tuberculin was observed in the refrigerator. RN BB reported nights administered TB and was aware of two residents who received dose last night and verified open undated and reported should be labeled with open date and good for 30 days. RN BB reported was unsure when opened. During an interview on [DATE] at 3:45 PM, RN Yreported had worked at the facility for six years. RN Y was queried what the facility process was if new bottle of Tuberculin serum was opened and reported would have to check and follow up with surveyor. During an interview on [DATE] at 4:40 PM, Director of Nursing (DON) B reported would expect multi-dose bottles of tuberculin serum to be dated when opened and disposed of within 30 days. During an observation and interview on [DATE] at 3:24 PM, Licensed Practical Nurse (LPN) CC unlocked Sycamore medication room. Observed open undated multi-dose vial of Tuberculin bottle in refrigerator. LPN CC verified bottle was open and undated and reported should be dated when opened.

Based on observation, interview and record review the facility failed to develop and implement comprehensive care plans for 1 (Resident #88) of 22 reviewed for comprehensive care planning, resulting in R88 fall from elevated bed and fractures that required hospitalization and surgical intervention. Findings include: Resident #88(R88) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R88 was a [AGE] year old female admitted to the facility on [DATE] and recent re-admission 3/26/23 post fall with fracture and surgical repair 3/26/23, with diagnoses that included hypertension (high blood pressure), anemia, kidney disease, bipolar disease, anxiety, major depression, displaced fracture of lateral condyle of left femur(3/21/23), displaced fracture of medial condyle of left femur(321/23), and periprosthetic fracture around internal prosthetic left knee joint(3/21/23). The MDS reflected R88 had BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she required two-person physical assist with bed mobility, transfers, dressing, toileting and one person physical assist with hygiene, locomotion, and bathing. During an observation and interview on 5/08/23 at 9:40 AM, R88 was laying in elevated bed(above hip level). R88 reported had recent fall with injury to left hip knee and ankle and reported unsure where fall occurred. R88 appeared well groomed and appeared pleasantly confused. Review of R88 Electronic Medical Record(EMR) Nursing Progress Note, dated 3/21/23 at 6:25am, reflected, Resident yelling Help, Help. Went into resident s room, resident sitting up on floor on right side of bed. Left leg bent under left hip resident unable to extend left leg having pain in left leg. Resident able to move other extremities. Did not move resident called 911 right away and [named provider]. Called the notified [named] friend. Review of the EMR, dated 3/26/23, reflected R88 return to the facility on [DATE] after hospital admission for closed fracture left distal femur and 3/22/23 left retrograde femoral nail to periprosthetic femur fracture. Requested R88 Incident Accident Report for 3/21/23 fall with complete investigation on 5/10/23 at 4:29 pm via email sent to Director of Nursing (DON) B. Review of provided Incident/Accident(I/A) reported, provided by DON B on 5/10/23 at 4:46pm reflected I/A report, post fall evaluation and Progress Note with no evidence of staff interviews or witness statements or staff schedules. During an interview on 5/10/23 at 5:50pm DON B reported R88 fall was not witnesses so no witness statements other than nurse who competed I/A report. Review of the Fall Incident/Accident form, dated 3/21/23 at 5:35 a.m., reflected R88 had an unwitnessed fall from bed with incident description, Resident yelling Help, Help. Went into residents room, resident sitting up on floor on right side of bed. Left leg bent under left hip resident unable to extend left leg having pain in left leg. Resident able to move other extremities. The report reflected resident description, Resident states I rolled out of bed, I can't move my left leg. The report reflected, R88 was alert and oriented and reported pain 10 out of 10 on pain scale. The report included, Predisposing Environmental Factors, with marked area, Bed height not appropriate. Notes included, ER reports noted with left femur fracture, did go in for surgical repair, plan to return to facility when stable. Review of the Care Plans, dated 11/2/23 through 3/21/23(date of fall), reflected, [named R88] has an ADL self-care performance deficit and requires assistance with ADL's and mobility r/t: UTI .Bed mobility: resident requires extensive assist of 2 staff to reposition and turn in bed .Resident to have enabler bars to improved resident ability to perform bed mobility. Date initiated: 11/3/22 Date revised 11/11/22 .TRANSFER: Resident requires total assist of hoyer mechanical lift to transfer. Date initiated: 11/3/2022 .[named R88] is at risk for fall related injury and falls R/T: Date initiated 11/2/22 . Keep the resident's environment as safe as possible with: even floors free from spills and/or clutter; adequate lighting; call light within reach, commonly used items within reach, avoid repositioning furniture and keep the bed in the appropriate position. Date Initiated: 11/02/2022 . During an observation on 5/11/23 at 2:08 PM, observed R88 laying in elevated bed above hip level with scoop mattress in place and eyes closed. During an interview on 5/11/23 at 9:58 AM, Director of Nursing(DON) B reported R88's fall with fracture on 3/21/23 was not reported to the state of Michigan because R88 was alert and oriented at time and could say how it happened. During an interview and observation on 5/11/23 at 3:30 pm, Certified Nurse Aid (CNA) DD reported familiar with R88 and often works on that unit. CNA DD reported R88 often confused including prior to 3/21/23 fall from bed including R88 history of seeing kittens under bed. CNA DD reported present on day shift on 3/21/23 after R88 fall but arrived for shift prior Emergency Medical Service transport. CNA DD reported assisted R88 off the floor with several other staff to gurney. CNA DD reported R88's bed should have been in low position. CNA DD reported after fall education to keep R88 bed in low position, and reported that meant between knees and hip level (top of mattress) and perimeter mattress to prevent falls. CNA DD entered R88 room and verified R88 bed was elevated at a height greater than hip level and verified was positioned too high and reported should be lower. CNA DD reported R88 had history of elevating bed really high and adjusted head of bed on own as well as height. CNA DD reported fall precautions on Kardex and reported low bed position should be below knees and reported Registered Nurse (RN) Y was also present at the time of R88 fall for day shift. CNA DD reported R88 required check and change every 2 hours and Hoyer for transfers prior to 3/21/23 fall with one to two person assist for position changes. During an interview on 5/11/23 at 3:40 PM, RN Y reported working at the facility for about six years and was familiar with R88. RN Y reported worked day shift on 3/21/23 and had arrived after R88 fall but was present to assist EMS staff transfer R88 off floor onto gurney. RN Y reported staff know resident care needs by reviewing Kardex to see interventions for safety. RN Y entered R88 room and verified bed in low position which meant knees to hips and reported had last observed R88 about 1pm for medication pass. During an interview on 5/11/23 at 4:40 PM, DON B reported R88 fall on 3/21/23 was not reported to the state of Michigan because R88 was able to report what happened and reported complete investigation was not completed for that reason. DON B verified R88 Care Plan was not being followed because R88 bed was found to be elevated greater than hip level at the time of the fall. DON B reported was present at the time of the fall and responded to R88 room and observed bed elevated above hip level position. DON B reported did not ask R88 if she had elevated bed to elevated height and reported was unsure who had left bed positioned at inappropriate level(as indicated on I/A report).

During observation, interview, and record review the facility failed to ensure residents receive showers according to their plan of care for one resident (#51) of three residents reviewed for hygiene and grooming, resulting in missed showers and the potential for inadequate hygiene and feelings of embarrassment. Findings Included: Resident #51 (R51) Review of the medical record revealed R51 was admitted to the facility 01/27/2021 with diagnoses that included fracture of left femur, type 2 diabetes, polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body), pain in left and right hand, insomnia, anxiety, abnormal posture, lack of coordination, Charcot's joint (bone and joint change that occur secondary to loss of sensation) of left foot and ankle, Charcot's joint of right foot and ankle, hypertension, depression, morbid obesity, and pain in left hip. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD of 02/04/2023 demonstrated R51 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15. Section G0120A: bathing of the MDS, with the same ARD, demonstrated that 51 required physical help in part of bathing activity. During observation and interview on 05/08/2023 at 08:58 a.m. R51 was observed lying in bed. R51's was observed in a facility gown and hair appeared to be unkept. R51 explained that she was supposed to have a shower twice per week but many times she only was offered a shower once per week. R51 explained that she had a shower in her bathroom, which was in the room. She further explained that she required assistance to get into the shower and needed some assistance with a shower. A shower was observed in R51's bathroom. During review of R51's medical record, her care plan intervention demonstrated that she required one-person extensive assistance and used a shower chair and grab bars for assistance. That intervention had a revision date of 06/25/2021. Review of R51's Point of Care Shower Schedule (POC-computerized medical record that allows care givers to document resident care that had been provided) demonstrated that R51 was to have a shower every week on Tuesday during the 12-hour day shift and every week on Friday during the 12-hour night shift. R51's POC documentation for showers demonstrated that she had not received a shower on the following Tuesdays: 04/04/2023 (documentation blank), 04/11/2023 (documentation blank), 04/18/2023 (documentation blank), 04/25/2023 (documentation blank), and 05/09/2023 (documentation blank). R51's POC documentation for showers demonstrated that she had not received a shower on the following Fridays: 04/07/2023 (documentation blank), 04/14/2023 (documentation blank), 04/21/2023 (documentation blank), and 04/28/2023 (documentation blank). In an interview on 05/10/2023 at 02:58 p.m. Certified Nursing Assistant (CNA) R explained that showers are given according to the Point of Care Shower Schedule (POC-computerized medical record that allows care givers to document resident care that had been provided). The POC will notify the CNA's which residents require a shower on that day and which shift it is to be provided. CNA R explained that there is also a shoer schedule that was in a binder at the nursing station. She explained that the POC documentation for showers would be documented as R for refused and Y for given. She further explained that the documentation should not be left blank. CNA R explained that if the shower is refused by a resident that CNAs are required to tell the nurse. In an interview on 05/11/2023 at 10:41 a.m. Registered Nurse (RN) S demonstrated a shower schedule that demonstrated R51 was to have a shower on Tuesday during the day shift and Friday during the afternoon shift. RN S explained that all resident were to have a schedule two times per week. In an interview on 05/11/2023 at 11:24 a.m. Registered Nurse (RN) Manager T explained that if showers are not completed that an alert would show on the facility dashboard. He further explained that the dashboard would demonstrate areas that were not completed or areas of concerns. RN Manager T confirmed that R51 had not received showers for the dates listed in her Point of Care Shower Schedule documentation. RN Manager T could not explain why R51's showers had not been completed for those days and shifts as listed in her Point of Care Shower Schedule.

Based on observation, interview and record review, the facility failed to notify the resident and/or resident's representative of the facility policy for bed hold for three (Resident #22, #64, and #317) of four residents reviewed for hospitalization resulting in the potential of residents and/or representatives to be uninformed of the bed hold policy. Findings include: Resident #22 Resident # 22 (R22) was readmitted to facility 2/10/2023 with diagnoses including chronic diastolic heart failure, dysphagia, obstructive sleep apnea, chronic obstructive pulmonary disease, venous insufficiency, lymphedema, and atrial fibrillation. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/23/23 reflected Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 15 (cognitively intact). Section G of MDS revealed that R22 required two-person extensive assist for bed mobility and toilet use, was independent with eating after set-up and that transfer activity did not occur over the entire 7-day look back period. Review of the Discharge MDS dated [DATE] revealed that R22 had an unplanned discharge to an acute care hospital and that his return to the facility was anticipated. In an observation and interview on 5/08/23 at 9:34 AM, R22 was observed lying in bed, on back, in facility gown with oxygen in place per nasal cannula. R22 stated that he was hospitalized a few months back for either an infection in the lungs or urine and could not recall whether bed hold information was provided or reviewed prior to or during his hospitalization . R22's Resident At Risk progress note dated 2/8/23 at 10:18 AM stated, .Resident was sent out to the hospital today for acute neurological change, resident hallucinating, shaking, eyes rolling back into head, slurred speech. NP (Nurse Practitioner) at bedside and gave orders to send to ER (emergency room ) . R22's Physician Order dated 2/8/23 at 9:30 AM stated, Send to ED (emergency department) for evaluation and treatment for AMS (altered mental status) and neurological changes. Resident #64 Resident # 64 (R64) was readmitted to facility 4/20/2023 with diagnoses including chronic obstructive pulmonary disease, pulmonary nodule, wedge compression fracture of first lumbar vertebra, borderline personality disorder, post-traumatic stress disorder, anxiety disorder, schizoaffective disorder, bipolar type, and alcohol dependence in remission. Review of the MDS with an ARD of 3/31/23 reflected BIMS score of 14 (cognitively intact). Section G of MDS revealed that R64 was independent with bed mobility, transfers, toilet use, and eating. Review of the Discharge MDS dated [DATE] revealed that R64 had an unplanned discharge to an acute care hospital and that her return to the facility was anticipated. In an observation and interview on 05/09/23 at 8:03 AM, R64 was observed sitting at the edge of the bed, awaiting breakfast, with oxygen in place per nasal cannula. R64 stated that she had been in and out of the emergency room several times since admission, admitted to the hospital at least twice, and was provided the facilities bed hold policy in an envelope prior to being sent to the emergency. Per R64, the bed hold policy was not reviewed nor did she sign a related document prior to the transfer to the hospital nor was she contacted during the hospitalization regarding a bed hold. R64's Behavior Note dated 4/17/23 at 12:23 PM stated, .guest complained of R (right) sided back and RLE (right lower extremity) pain, and diarrhea, she was persistent she needed to be sent out as her pain treatments were not helping. Writer notified NP and UM (unit manager) of transfer and guest is being sent to (name of local hospital). Resident #317 Resident # 317 (R317) was readmitted to facility 5/2/2023 with diagnoses including pneumonia, venous thrombosis and embolism, methicillin resistant staphylococcus aureus infection, muscle weakness, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, acquired absence of right leg above knee, peripheral vascular disease, and congestive heart failure. Review of MDS with an ARD of 4/18/23 reflected BIMS score of 15 (cognitively intact). Section G of MDS revealed that R317 required one-person limited assist for bed mobility, two-person extensive assist for transfer and toilet use and was independent with eating after set-up. Review of the Discharge MDS dated [DATE] revealed that R317 had an unplanned discharge to an acute care hospital and that his return to the facility was anticipated. In an observation and interview on 5/08/23 at 11:13 AM, R317 was observed sitting in a bedside recliner chair with oxygen in place by nasal cannula. R317 stated that he was hospitalized approximately one week prior for a lung infection, was informed of and in agreement with the recommendation for hospitalization and was provided a lot of paperwork at time of hospital transfer and that the facilities bed hold policy may have been included. Per R317, the bed hold policy was not reviewed nor did he sign a related document prior to the transfer to the hospital nor was he contacted during the hospitalization regarding a bed hold. R317's Nurses Notes dated 4/23/23 at 5:58 AM stated, .Guest was send out to (name of local hospital) r/t (related to) hypoxia . R317's Physician Order dated 4/23/23 at 1:22 AM stated, send out to (name of local hospital) r/t SOB (shortness of breath), hypoxia. In an interview on 5/9/23 at 4:31 PM, Director of Nursing (DON) B stated that in preparation for a resident transfer to the hospital, an order was received from the primary care physician or on call physician unless there was an emergent situation. Per DON B a resident face sheet, medication list/medication administration record, recent lab work, recent progress notes as well as a change in condition and transfer form were included in the transfer packet. DON B stated that the transfer packet also included a copy of the facilities bed hold policy which was provided to each resident at the time of transfer and that the admissions team followed up with the resident or representative within 24 hours of transfer to review the bed hold policy and determine whether they wanted to hold the bed. In an interview on 5/10/23 at 10:27 AM, Admission Director Q stated that she had been employed at the facility for 8 years and on the admissions team for 5 years. Per Admissions Director Q, when a resident was transferred to the hospital, the resident or responsible party, if warranted, would be contacted to review the facilities bed hold policy and offer a bed hold within 24 hours of the transfer. Admission Director Q referenced each individual resident's medical record and stated that R22 was hospitalized from 2/8/23 to 2/10/23, R64 from 4/17/23 to 4/20/23, and R317 from 4/23/23 to 5/2/23 and confirmed that neither R22, R64, or R317 nor their responsible party were contacted to offer a bed hold. Per Admission Director Q, R22, R64, and R317 were long term care residents with straight Medicaid and that a bed hold would only be offered to these residents when the facility occupancy was above a certain percentage. In an interview on 5/10/23 at 10:49 AM, Nursing Home Administrator (NHA) A stated that all residents/responsible parties were notified of the facilities bed hold policy within the admission contract, were provided the bed hold policy in a packet sent with them at the time of a hospital transfer, and that the admission director contacted the resident or responsible party within 24 hours of transfer to the hospital to review the bed hold policy for acceptance or declination and that, when complete, would be documented within the administrative notes section within the individual residents electronic medical record. NHA A further stated that the facility was responsible for reviewing the bed hold policy with all residents that were sent to the hospital including a Medicaid resident or their representative and confirmed that payer source was not taken into consideration as a bed hold should be offered to all residents. On 5/10/23 at 11:01 AM, NHA A reviewed the facilities bed hold policy with Admission Director Q at which time Admission Director Q confirmed that she did not contact, review, or obtain a bed hold for any long-term care resident that was straight Medicaid. Upon NHA confirming that all resident's or their responsible parties needed to be contacted within 24 hours of hospital transfer, regardless of payor source, Admission Director Q stated, I didn't know that. This was a misunderstanding on my part. I'm going to start calling everyone. Review of the facility policy titled Bed Hold Policy with a 2/14/22 effective and revised date stated, .Procedure: 1. During admission into the facility the Admission Director or designee will explain and provide a copy of the Notice of Bed Hold. 2. Within 24 hours of a hospital transfer the Admission Director or designee will contact the Resident and/or Responsible Party regarding the possible length of transfer and offer a bed hold. 3. Document bed hold offer and Resident or Responsible Party decision in the AR section of the medical record .

Based on observation, interview and record review the facility failed to provide indwelling urinary catheter care for one resident (#96) of four residents reviewed for indwelling urinary catheter care resulting in urinary tract infection for resident #96 and the potential to cause infection in 15 other residents with an indwelling or external urinary catheter. Finding Included: Resident #96 (R96) Review of the medical record revealed R96 was admitted to the facility 01/16/2023 with diagnoses that included encephalopathy (brain disease that alters brain function), atrial fibrillation, dysphagia (difficulty swallowing), unstageable pressure ulcer of sacrum, adult failure to thrive, hypertension, hypothyroidism (low thyroid hormone), insomnia, vascular dementia, mood disturbance, and anxiety. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD of 04/23/2023 demonstrated R96 had a Brief Interview for Mental Status (BIMS) of 99 (cognitively unable to complete the review) out of 15. Section H0100A: Appliances of the MDS, with the same ARD, demonstrated that R96 had an indwelling urinary catheter. During observation and interview on 05/09/2023 AT 02:59 p.m. R96 was observed lying in bed. A urinary catheter drainage bag was observed hanging on the side of her bed. The urine in the catheter collection tubing and the collection bag was observed to be light yellow with white sediment present. R96's daughter G was at her bedside. R96 did not answer questions but acknowledged that her daughter G could answer questions. R96's daughter G explained that R96 had a urinary catheter because she had pressure ulcer on her sacrum. R96's daughter G explained that R96 had a urinary tract infection in April of 2023 but that is was resolved at this time, after receiving antibiotics. During review of R96's medical record it was revealed that R96 had a urinary analysis with a [NAME] and sensitivity test, collected on 04/04/2023 and reported 04/13/2023, that demonstrated R96's urine contained Klebsiella Pneumoniae greater that 100,000 colony -forming unit (CFU)/ milliliter (ml). R96's medical record revealed that on 04/12/2023 she was started on Ceftriaxone Sodium (antibiotic for urinary tract infection) intravenous reconstituted one gram (GM) intravenously every 12 hours for five days. During review of 96's Point of Care (POC-computerized medical record that allows care givers to document resident care that had been provided) for indwelling catheter care demonstrated that R51 was to have a shower every week on Tuesday during the 12-hour day shift and every week on Friday during the 12-hour night shift. R51's POC documentation for indwelling catheter care demonstrated was not completed, on three shifts, for 04/072023, 04/08/2023, 04/09/2023, and 04/10/2023. In an interview on 05/10/2023 at 03:53 p.m. Certified Nursing Assistant (CNA) R explained that indwelling urinary catheter care is performed during each shift and is performed by the Certified Nursing Assistants that are assigned to the resident. CNA R' explained that once the urinary catheter care is completed it is charted in the residents Point of Care (POC). In an interview on 05/10/2023 at 02:42 p.m. Director of Nursing (DON) B explained that indwelling catheter care is to be completed every shift. She explained that the Certified Nursing Assistants (CNA) was responsible for the indwelling catheter care and would document completion of the task in the residents Point of Care (POC). DON B reviewed R96 POC indwelling catheter care for April 2023. DON B could not explain why indwelling urinary catheter care was not completed, for R96, as identified on R96's POC. DON B explained that R96 had a urinary tract infection (UTI), that was identified 04/13/2023. She explained that R96 was started on an antibiotic at that time and the UTI was resolved at the time of interview. DON B explained that R96's UTI was an facility acquired urinary tract infection.

Based on observation, interview, and record review, the facility failed to notify 1 Resident's (R 94) facility wound physician of change in condition(wound status) of 2 Residents reviewed for pressure ulcers, resulting in R 94 having delayed treatment and physician consultation related to his skin break down and infection. Findings include: Resident #94(R94) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R94 was a [AGE] year-old male admitted on [DATE] with hospital re-admission related to wound infection 2/2/23 to 2/13/23, hospital re-admission 3/21/23 with diagnosis that included wound infection and re-admission 4/18/23, with diagnoses that included hypertension (high blood pressure), diabetic (high blood sugar), anemia, malnutrition, obstructive uropathy, stage 4 pressure ulcers, and anxiety. The MDS reflected R94 had a BIM (assessment tool) score of 11 that indicated his ability to make daily decisions was minimally impaired, and he required two-person physical assist with bed mobility, transfers, toileting, dressing, hygiene and bathing and one-person physical assist with locomotion on unit. During an observation on 5/08/23 at 10:45 AM, R94 was laying on back in air mattress with eyes closed. R94 appears very thin and pale. Review of the discharge MDS, dated [DATE], reflected R94 had two stage 2 pressure ulcers(partial thickness loss of dermis) on admission 12/22/23. Review of the Admission MDS, dated [DATE], reflected R94 had two unstageable pressure ulcers, slough and or eschar(non-viable tissue), and two suspected deep tissue injuries on re-admission 1/2/23. Review of the 5-day Re-admission MDS from acute care setting, dated 2/19/23, reflected R94 had two stage 4 pressure ulcers(full thickness tissue loss with exposed bone, tendon or muscle) present on admission 2/13/23. Continued review of MDS reflected R94 two suspected deep tissue injuries not present on admission 2/13/23. Review of the Nursing Progress Note, dated 1/19/23 at 12:06 p.m., reflected, Wound rounds completed with [named facility wound physician]. Left thigh sharps debrided. Treatment order updated with changes as recommended. Plan to reassess next week.(Facility wound Physician consult note scanned into EMR 3/7/23). Review of the Nursing Progress Notes, dated 1/30/23 at 1:31 p.m., reflected, wound dressing saturated, large amount of drainage, eschar tissue sloughing off, strong odor. No mention facility wound Physician notified of change in R94's wound. Review of R94's Nurse Practitioner Progress Notes, dated 2/2/23, reflected CHIEF COMPLAINT: Change in wounds .Patient was noted with foul smelling wounds with increased purulent drainage and wound physician was inhouse and did debride thigh wound. Based on clinical presentation of wounds and collaboration with wound physician, decision was made to send patient to the hospital for evaluation and treatment of thigh and buttock wounds and need for extensive I&D .Pain Level: 6 .Pressure ulcer of sacral region, unspecified stage: Noted with increased purulent drainage from both sacral and thigh wounds, foul odor and deterioration, sent to ED for evaluation and debridement . Review of the EMR, dated 1/19/23 through 3/2/23, reflected no evidence R94's wounds were evaluated by facility wound physician during weekly rounds on 2/26/23 or wound physician was notified of worsening pressure wounds and development of two preventable facility acquired deep tissue injuries. The EMR reflected no visit notes for facility wound physician dated 2/26/23 by time of survey exit on 5/15/23. Review of R94's Nursing Progress Note, dated 2/13/23 at 11:11 p.m., reflected, Resident admitted from [named] hospital with a sacral and two L hip wounds. A&Ox3, Full code, takes meds whole, house diet, Foley in place(placed on 2/2/23), non-ambulatory,incontinent of bowel . c/o pain of both heels, L hip, and coccyx, PRN medication given, repositioned for some relief of coccyx pain . Review of R94's Nurse Practitioner Progress Notes, dated 2/14/23, reflected, CHIEF COMPLAINT: readmission from hospital . Patient readmitted after hospital stay for necrotizing fasciitis and abscess in left thigh and underwent multiple surgical debridements. Patient had coccyx wound debrideded as well and only has wound vac on thigh wound. Will continue with wound team to monitor and finished antibiotics with one dose after admission. Patient states that oxycodone is effective in treating his pain and will continue at this time .Pain Level: 6 .NECROTIZING FASCIITIS: Continues on antibiotics for one day to complete course, will continue with wound team follow and pain medication . Review of R94's Nurse Practitioner Progress Note, dated 3/17/23, reflected, .patient was started on antibiotics for wound infection. Wound on coccyx with purulent drainage and change in odor . No mention facility wound physician was notified of worsening wound changes. Review of the Infection Progress Note, dated 3/17/23 at 2:34 p.m., reflected, Guest continues on Amoxicillin-Pot Clavulanate Tablet 875-125 MG 1tablet PO Q12 hours for Wound infection for 10 Days. Guest continues to have low BP and little output. Peripheral line placed in L hand and IV fluids started. Review of R94's Nurse Practitioner Progress Note, dated 3/21/23, reflected, CHIEF COMPLAINT Change in condition . Patient was noted to have increased fatigue and decreased appetite/fluid intake. Patient agreed to another bag of IV fluids and D5 ordered. Will obtain labs and continues on antibiotics for wound infection. Patient appears weaker and initially declined going to the hospital and declined to discuss code status with SW/nursing. Contacted by DON later in the day and decision was made to send to Ed for further evaluation and likely will need IV antibiotics . Review of R94's Progress Note, dated 4/18/23 at 4:33 p.m., reflected, Resident arrived from [named] Hospital on hospice, [named} hospice nurse in and assessed resident. Notified hospice nurse of red drainage noted in foley. Notified unit manager of dressings to BLE and wound nurse to assess tomorrow . Review of R94's Progress Note, dated 4/27/23 at 11:03 a.m., reflected, Resident readmitted from hospital on hospice services with multiple skin integrity concerns. Resident with bilateral heel unstageable pressure ulcers, coccyx is stage 4 with wound vac in place. Left thigh with stage 4 ulcer wound vac present on admission, vac discontinued during wound rounds on 04/20/23. Resident with venous ulcer to right calf with tx in place. Continue with wound physician evaluation for comfort and wound management . Review of R94's Skin/Wound Progress Note, 4/27/23 3:38 p.m., reflected, Wound rounds completed with Dr [named facility wound physician] Wound vac to sacrum dc'd. New orders in place. Plan to reassess next week. (Same day Progress Note reflected wound vac had been discontinued on 4/20/23.) Review of the Treatment Administration Record, dated 4/1/23 through 4/30/23, reflected R94's wound vac was discontinued 4/27/23. Review of R94's Skin/Wound Progress Note, dated 5/4/23 at 11:03 a.m., reflected, Late Entry:Note Text: Wound rounds completed with [named facility wound physician]. Left thigh and bilat heels are improving. Right trochanter deteriorating, sacrum stable .No change to treatment orders. Plan to reassess next week. On 12/26/2022, the resident weighed 156 lbs. On 04/30/2023, the resident weighed 138 pounds which is a -11.54 % Loss. Review of Hospice Start of Care Documentation, dated 4/18/23, reflected R94's weight was 135 pounds. Continued review of the documents reflected, .Reason for hospice referral/admission: Patient sent to emergency room with recurring infection leading to sepsis. Patient has multiple [NAME] [wounds] on bilateral lower extremities sacral region and his left hip. Increasing confusion and worsening vital signs. Patient has recurring aspiration leading to change in diet. Is bed bound continuous losing weight . During an interview on 5/10/23 at 10:00 AM, WN X reported bilateral heels and right trochanter were facility acquired pressure ulcers and reported R94 was admitted with sacral and left hip and right calf wounds. WN X reported after admission R94's left hip wound rapid declined and was admitted to the hospital and diagnosed with necrotizing fasciitis after 2/13/23 hospital admission. WN X reported wound measurements taken on every Thursday at wound rounds with facility wound physician and use of camera that determines measurements. During an interview on 5/11/23 at 10:22 AM, WN X and Unit Manager (UM) T entered R94s room after WN X gathered supplies reported today was wound rounds and facility wound physician M was no able to be present this week. During an observation and interview on 5/11/23 at 11:36 am, WN X reported process for wound documentation that included after rounds sit and document same day off phone pictures and paper notes. WN X verified no written notes taken during R94 wound care. WN X reported usually only herself and facility wound physician for rounds unless CNA staff needed for positioning. WN X reported prints off wound notes and provides facility wound physician copy at the following week (Thursday) wound rounds. WN X reported the wound physician then dictates those prior week notes, sends out of the country for dictation and she can obtain notes between 2-3 weeks post actual wound care monitoring. WN X reported measure weekly with picture including height, width and depth. WN X reported depth was observed by eye because she was able to see changes and verified did not obtain manual depth of wounds including R94 sacral wound and reported could start to add to notes. WN X reported did not see that R94 had a dressing on the left posterior calf area and had no knowledge of open area to the left lower leg and WN X asked this surveyor if there was a dressing in place. WN X entered R94's again, observed undated border dressing on R94s posterior left calf. WN X removed border dressing with alginate over appear that appeared very dry but intact at that time. WN X reported unsure why treatment in place with no order and reported may have been in place for protection. Review of the weekly wound notes, dated 12/26/23 through current (5/11/23), reflected R94 had no evidence of depth measurements including wounds with without eschar or significant slough. Continued review of weekly wound round physician notes reflected the same for the visit notes prior to 3/16/23. Review of the EMR reflected no evidence of facility wound physician notes after 3/16/23. Review of R94's skin Care Plan, dated 1/11/23, reflected, [named R94] has actual skin impairment and is at risk for further impaired skin integrity/pressure injury: pressure injuries to - sacrum, left thigh, bilateral heels r/t Hx Necrotizing fasciitis to thigh ulcer, hx of debridement to sacral and thigh ulcers injuries .Goals .Will remain free from complications from pressure, dated 1/11/23 .Interventions . Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician. Date Initiated: 12/22/2022 . During an interview on 5/11/23 at 1150 PM, Director of Nursing (DON) B reported would expect physician documentation to be in resident charts(EMR) within seven days. DON B reported would expect wounds to be measured weekly including length, width and depth measurements and reported depth must be taken manually because the camera does not obtain depth. DON B reported nursing staff are not expected to eye ball wound depth. DON B reported not aware physician was provided copy of nurse wound notes seven days after actual observation to dictate then sent out and reported was aware of long delay but not aware physician going by nurse notes. DON B reported infection control duties performed by herself and ADON/WN X. DON B reported WN X completed facility floor surveillance and DON B oversee WN X and is often present to assist with weekly rounds and would expect WC X to use good infection control practices with wound care.

This citation pertains to intake MI00132479. Based on interview and record review, the facility failed to promptly notify the physician in a change of condition in one of three residents reviewed for medication orders (Resident #3), resulting in delayed transfer to the hospital and re-hospitalization due to sepsis. Findings include: Resident #3 (R3) R3's Minimum Data Set (MDS) dated [DATE], revealed she admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS, a brief performance-based cognitive screener for nursing home residents) score of 12 (08-12 Moderate Impairment). R3's Hospital Discharge Summary dated 9/28/22 revealed she was alert and orientated to person, place and time; and had the diagnoses of Giant Cell Arteritis (inflammation of blood vessels), vision loss in the right eye, history of stroke, essential hypertension (high blood pressure that was not the result of a medical condition) and type II diabetes mellitus. R3 had presented to the emergency roiagnom on [DATE] due to a loss of vision in her right eye and scalp tenderness. R3 was discharged from the hospital to the nursing home on 9/28/22 with the plan to return to her home following rehabilitation. In review of R3's September and October 2022 Medication Administration Record (MAR), Norvasc 5 milligrams (mg), Cozaar 100 mg and Metoprolol Tartrate 100 mg daily were prescribed to treat high blood pressure. Weights and Vital Signs (VS) Summary report indicated on 10/02/22 R3's Blood Pressure (BP) at 7:45 AM was 130/67 millimeters of mercury (mm Hg), R3's October 2022 MAR indicated Clonidine 0.1 mg was ordered on 10/02/22 for one dose only due to high blood pressure. In review of R3's care plans, there was no care plans regarding high blood pressure. Post Discharge Plan and Summary dated 10/13/22 revealed R3 was alert and orientated to person, place, and time; her short term and long-term memory were okay, she had met her maximum potential, was independent with ambulation and toileting, was continent of bowel and bladder. In review of R3's Physical Therapy Discharge Summary, R3 was discharged from therapy on 10/15/22 and planned to discharge home from the nursing on 10/16/22; the same document revealed a change of condition was noted two to three days prior to the 10/15/22 visit. Upon arrival for therapy on 10/15/22, R3 was observed in bed with a cold pack on her stomach reported her stomach was hurting. R3 was very lethargic, slow to respond, and demonstrated increased effort to sit up. R3 attempted to don her pants but had to stop due to fatigue and low energy. R3 was not able to eat breakfast or her lunch on 10/15/22. The same note revealed R3 wanted to discharge home the next day, on 10/16/22. Therapist indicated was concerned regarding safety due to change in status. The same evaluation indicated R3's change of condition status, discharge safety and not eating were reported to the nurse. In review of R3's progress notes, there was no indication the physician was notified of R3's change of condition on 10/15/22. Weights and VS Summary report indicated on 10/15/22 R3's BP at 8:40 PM was 163/83 mm Hg and was 178/114 at 9:59 PM. The last blood pressure in R3's medical record was recorded on 10/15/22 at 9:59 PM. In review of R3's progress notes, there was no indication the physician was notified of R3's blood pressures on 10/15/22. The American Heart Association website at http:// www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings, indicated blood pressure numbers of less than 120/80 mm Hg were considered within the normal range and if blood pressure readings exceed 180/120 mm Hg and if any symptoms such as headache, chest pain, nausea/vomiting or dizziness, to call 911 immediately. The same website also instructed contact a health care professional immediately if readings were unusually high and were not experiencing any other symptoms of target organ damage such as chest pain, shortness of breath, back pain, numbness/weakness, change in vision or difficulty speaking, as it could still be a hypertensive crisis. Nurses Note on 10/15/22 at 4:30 PM indicated Zofran for nausea and vomiting had been administered; there was no mention of R3's change of condition reported by therapy or if a head-to-toe nursing assessment was completed. Nurses Note dated 10/16/22 at 3:42 AM indicated the nurse had spoken with on call about R3's change in condition and was encouraged to push fluids and give Zofran as needed and if condition worsens let them know. R3 said stomach pain had subsided and had gotten resident to drink fluids as writer goes in her room. The same noted indicated the nurse had advised the nurse assistant to do the same every time they come in contact with her. The same note did not include how much fluids were accepted or if blood pressures from the night before had been reported to the physician on call. There was no mention of any head-to-toe nursing assessment or if vital signs were obtained. There were no VS documented in R3's medical record since 10/15/22. Licensed Practical Nurse (LPN) P was interviewed on 1/18/23 at 1:00 PM and did not remember what was reported to the physician on 10/16/22. Nurse Practioner (NP) N was interviewed on 1/18/23 at 12:20 PM and stated 10/15/22 was on the weekend and the nurse would have contacted the physician on call. NP N was not able to confirm if R3's abnormal blood pressures from 10/15/22 were reported to the on physician, and that text to the physician only was saved for 30 days. NP N stated if she was notified regardingt R3's blood pressures on 10/15/22 (163/83 and 178/114), she would have ordered clonidine for sure. Nurses Notes dated 10/16/22 at 12:23 PM indicated Director of Nursing (DON) B Spoke with the nurse practioner in regard to R3's declining condition, new orders were received for IV start and 1 Liter bolus of normal saline (NS). Certified Nursing Assistant (CNA) O was interviewed on 1/18/23 at 12:55 PM and stated she worked on 10/16/22 and recalled R3 had been there a few weeks kept declining. CNA O stated she noted a decline in R3's physical and mental capacity. In the morning at the start of her shift, she noted R3 was incontinent of bowel and bladder, was not able to walk, and complained of a lot of pelvic pain. CNA O stated R3 requested an ice pack for her pain. CNA O stated she reported concerns regarding R3's condition twice and told the nurse she needed to be sent to the hospital. The last time she reported to the nurse R3 needed to transfer to the hospital was around noon, and she was transferred 1-2 hours after that. Nurses Notes dated 10/16/22 at 2:30 PM revealed DON B arrived at facility and was met by R3's emergency contact, whom had concerns. R3's emergency contact was informed that orders had been received to postpone discharge and to start IV fluids. Upon entrance to the room, R3 was lying in bed noted to have mottling (bluish-red lace-like pattern under the skin caused by a disturbance of normal blood flow) to both upper and lower extremities, feet, and chest. No capillary refill (method for detecting changes in blood flow that can lead to shock) was noted on her toes, she was alert and talking. DON B indicated in the same note she was unable to obtain a pulse oximetry reading (arterial oxygen saturation), started oxygen at 4 liters via nasal canula (oxygen delivery device), then increased to 10 liters via non-re-breather mask (typically delivered 70 to 100 percent oxygen). DON B's same note indicated she conversed with R3 in regard to her code status and explained that the mottling was a symptom of her body shutting down, resident was a full code, she indicated she wished to remain a full code. Writer explained to resident, that she would need to be transferred to hospital for evaluation and resident agreed. DON B indicated in the same progress note she had completed transfer paperwork and called 911. Emergency Medical Services (EMS) indicated they were already on their way as family had called. EMS arrived and R3 left the nursing home facility at 2:15 PM. In review of R3's medical record, including the transfer record, there were no vital signs documented on 10/16/22. On 1/18/23 at 11:43 AM DON B was interview and stated she came into the facility on [DATE] to start R3's IV. The IV did not get started, R3 was transferred to the hospital. DON B stated R3's vital signs were obtained prior to transfer, but did not know what they were, and confirmed vital signs were not included in transfer assessment details.

This citation pertains to MI 842 Based on interview and record review, the facility neglected to implement interventions to prevent falls for one (Resident #2) of three reviewed for falls resulting in Resident #2 being lowered to the floor and sustaining fractures, hospitalization , and surgery. Findings include: Review of the medical record revealed Resident #2 (R2) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed R2 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating she was cognitively intact. The MDS revealed R2 required extensive assistance of two staff members for transfers and ambulation. Review of the ADL (Activities of Daily Living) Self Care Performance Deficit Care Plan initiated 11/6/19, revealed R2 required extensive two-person assistance for transfers and ambulation. Review of the At Risk for Fall Related Injury and Falls Care Plan initiated 11/6/19, revealed encourage (R2) to wear appropriate footwear as needed and encourage (R2) to wear non-skid footwear when out of bed, assist as needed initiated 11/7/19. R2's Care Plans did not indicate she refused to use a gait belt. Review of the Incident and Accident Report dated 1/3/20, revealed at 7:45 AM CNAs (Certified Nursing Assistants) transferring bed to shower chair, guest started feeling weak and was lowered to floor. Sitting on floor back against bed, knees bent, legs to (left) side, c/o (complained of) (left) knee pain. The Incident and Accident Report revealed R2 sustained bilateral distal femur fractures. Review of the POS [REDACTED]. Review of the SBAR (Situation, Background, Appearance, Review) Communication Form dated 1/3/20 revealed guest lowered to floor during a transfer from bed to shower chair, guest legs became weak and required being lowered to floor, now with increased pain to BIL (bilateral) knees .Xray of L (left) knee, and later orders given for xray to R (right) knee. X ray results of L knee show distal femur fracture. Practitioner notified, orders given to transfer to ER for eval and tx (evaluation and treatment). Review of the Radiology Results Report dated 1/3/20, revealed R2's left knee had an acute fracture involving left distal femur with modest displacement. Review of the Physician's Note dated 1/3/20, revealed patient with fall early in the morning onto knees. Patient complaining of left knee pain initially then right knee pain. Patient with previous TKA (total knee arthroplasty/replacement) of her right knee. Patient had a left TKA scheduled until stroke which brought patient here. Patient with some minor swelling and tenderness over site .Patient with weakness, poor gait stability and poor safety awareness. X-ray ordered .Patient with fall, contusion of bilateral knees x-rays performed which showed acute fracture of left distal femur with displacement. Patient sent out to ER for urgent evaluation of this . In an interview on 3/13/20 at 10:41 AM, Certified Nursing Assistant (CNA) D reported when her and CNA E attempted to transfer R2 from bed to the chair, her condition changed and we had to lower her down. CNA D reported R2 never used a gait belt because R2 had refused a gait belt in the past. When asked how R2 was transferred without the use of a gait belt, CNA D stated we held her hand. R2 reported she received education that a gait belt had to be used even if the resident refused. CNA D reported she told the nurse that R2 refused the gait belt. In an interview on 3/13/20 at 1:21 PM, CNA E stated we turned (R2 in bed), had her feet hanging off the bed, asked if she was ready and she said no. We gave her a couple minutes. We were ready to stand her up. Said 1, 2, 3. She didn't really stand up for us. We put her down, gave her a couple minutes and tried again and she wasn't really helping us stand up. We asked her to straighten her legs. She was barely past a 90-degree angle standing up. We were already turning her to get her in the shower chair. The options were for her to stand up or lower to the floor. It wasn't possible to get her on the bed. She wasn't able to stand up. Kept staying my knee, my knee, and slowly lowered her to the floor. When asked how R2 was lowered to the floor, CNA E stated we were both under her arms and we lowered her sitting on her bottom. CNA E reported they were able to pivot R2 during the second transfer attempt. CNA E stated when we started to turn her, that's when she started to get lower and lower and reported R2 first complained of knee pain during the second transfer attempt. CNA E reported a gait belt was not used and R2 was barefoot. When asked why a gait belt was not used, CNA E reported she thought R2's kardex (care guide) indicated she was an extensive one person assist. CNA E reported she thought it was safe to use two people instead of a gait belt. CNA E reported neither her nor CNA D attempted to put a gait belt on R2 that day. CNA E reported she did not hear R2 refuse a gait belt. CNA E stated I now know that any time we transfer, we are to use a gait belt. CNA E reported R2 was barefoot because she didn't have any socks in her room. CNA E reported socks were available, but they were rushing and forgot. When asked if it would have helped if a gait belt and gripper socks were in place, CNA E Stated yes, yes, it definitely would have helped. CNA E reported she received education that gait belts needed to be used for all transfers and gripper socks should be in place. In an interview on 3/13/20 at 11:18 AM, Registered Nurse (RN) F reported she was not told nor aware of R2 refusing a gait belt. RN F reported staff usually used a gait belt when transferring R2. RN F reported when she assessed R2 after being lowered to the floor, R2 was not wearing any footwear, did not have a gait belt in place, and her left knee was swollen. RN F reported R2 was initially only complaining of pain in her left knee, therefore a left knee x-ray was done at the facility. RN F reported R2 then began complaining of right knee pain, but she was transferred to the hospital before the right knee x-ray could be done. Review of the hospital records dated 1/3/20, revealed [AGE] year-old woman with bilateral distal femur fractures after a fall. Patient requires admission to trauma service. The left knee x-ray results dated 1/3/20 revealed Comminuted distal femoral metaphyseal fracture. The right knee x-ray dated 1/3/20 revealed Comminuted distal femoral metaphyseal fracture which appears to extend into the region of the arthroplasty cup. The bilateral hip and femur x-ray dated 1/3/20 revealed Comminuted fractures involving both distal femoral metaphyses. On the RIGHT side fracture line extends into the arthroplasty device. R2's discharge [DIAGNOSES REDACTED].>Principal Problem: Pathological fracture of right femur due to secondary [MEDICAL CONDITION] Active Problems: Fall Closed displaced fracture of condyle of right femur Bilateral femoral fractures [MEDICAL CONDITION] on [MEDICAL TREATMENT] Closed fracture of left distal femur Closed fracture of right distal femur . R2 had surgery on 1/5/20 and 1/7/20. In an interview on 3/13/20 at 2:38 PM, Director of Nursing (DON) B reported R2 was lowered to the floor by two CNAs. DON B reported a gait belt was not used and footwear was not in place. DON B reported the hospital determined the right femur fracture was pathological. When asked about the left, DON B agreed the hospital paperwork did not reflect pathological fracture on the left and reported the nurse at the hospital told her both were pathological. Review of CNA D's Disciplinary Action Record Work Rules dated 1/3/20 and signed 1/6/20, revealed Failed to use a gait belt during a transfer per policy. All CNAs have been trained to properly use gait belts for all transfers. Employee also failed to assure proper footwear was on patient. Review of CNA E's Disciplinary Action Record Work Rules dated 1/3/20 and signed 1/8/20, revealed Failure to use gait belt during a transfer per policy. All CNAs have been trained to use gait belts for all transfers. Employee also failed to assure proper footwear was on patient.

This citation pertains to MI 221 Based on observation, interview, and record review, the facility failed to prevent an elopement for 1 (Resident #1) of 5 reviewed for elopement, from a total sample of 5, resulting in immediate jeopardy when Resident #1, who was a known elopement risk, left the building unbeknownst to staff on 3/24/17 at approximately 8:12 pm, and was found by a restaurant employee 0.4 miles away from the facility and the facility was then notified by the local Sheriff's department of Resident #1's whereabouts at approximately 9:55 pm. This deficient practice places 5 residents, who have been identified by the facility as an elopement risk, at risk for serious harm, injury, and/or death. Findings include: Review of the facility's Elopement Policy revised 9/2013, revealed Elopement Alarm Activation 1. If an employee hears a door alarm, he or she should: a. Immediately go the site of the alarm; b. If a resident is observed attempting to exit the facility, follow the steps outlined below for Attempts to Leave the Facility; c. If no resident is found to be exiting the facility, the employee should exit the facility, walk around the building, and ensure that a resident has not already exited the facility. 2. In situations where the alarm sounds and a resident is not found to have exited: a. Notify the charge nurse immediately, and b. Ensure that a head count is completed to ensure that all residents are accounted for. Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #1 had some difficulty in making daily decisions in new situations. Review of Resident #1's Activities of Daily Living (ADL) care plan dated 9/6/16, revealed Resident #1 was independent in the facility with wheelchair mobility. Review of the Incident and Accident Report dated 11/6/16, revealed notified by front desk receptionist that resident was observed going out front door of facility. By the time CNA (Certified Nursing Assistant) (and) nurse got outside, resident was self propelling her wheelchair backwards on sidewalk . A wanderguard was applied to Resident #1's wheelchair at that time. Review of Resident #1's Risk for Elopement care plan initiated on 11/8/16, revealed (Resident #1) is at risk for elopement and/or wandering r/t (related to) history of attempts to leave facility unattended, impaired safety awareness. Interventions included apply wanderguard per order. Check placement, function and expiration date per facility protocol. Review of the Nursing Notes revealed on 11/9/16, Resident #1 locked herself in the front lobby bathroom twice and was found in the front lobby bathroom on 11/11/16 and 12/30/16. The Nursing Note dated 1/3/17, revealed Resident #1 was found in the front lobby bathroom and CNA staff were verbally instructed to check on Resident #1 more frequently for elopement prevention . On 1/22/17, Resident #1 locked herself in the Sycamore Unit bathroom. The Nursing Note dated 2/21/17, revealed Resident #1 was wandering from 7:15 pm until 7:45 pm. The Behavior Notes dated 3/13/17, revealed Resident #1 was observed on 3/12/17 from 8:00 pm until 11:59 pm with episodes of crying and transporting herself to facility common areas, including front restrooms and pacing the hallway with her wheelchair. The Nursing Note dated 3/17/17, revealed At 0930 (9:30 am), it was reported to this nurse that resident was ramming the staff exit door Resident was sitting right by exit door .asked if she wanted to go outside, resident said yes . Review of the Incident and Accident Report dated 3/24/17 at 10:00 pm, revealed received phone call from police stating that guest was at (name of restaurant) nearby. Review of the Facility's 5 Day Summary for Elopement of (Resident #1) on 3/24/17, revealed on 3/24/17 at approximately 9:55 pm the facility received a phone call from an officer that one of our residents may be at the (name) restaurant. (Registered Nurse (RN) G), the afternoon supervisor, and nurse, (RN H) responded to the restaurant and noted that (Resident #1) was in the restaurant and in her wheelchair .Video footage review also revealed that (Resident #1) was up by the front entrance door and began pushing the front door at 20:10:49 (8:10 pm). The receptionist, (Receptionist E), had stepped into the breakroom at the same time and exited the break room at 20:11:37. (Resident #1) cleared the first set of doors while alarming at 20:12-1 min 11 seconds total time. At 20:12:41 the second door closes. (Receptionist E) is observed silencing the door alarms at 20:12:47-6 seconds after the front door closed .Root cause is that the receptionist, who was oriented to the elopement policy upon hire on 3/14/17, deactivated the keypad alarms without checking outside when she did not see a resident at the door. She is a new employee and looked around for what could have activated the door, however she did not step outside. (Resident #1) has the knowledge to know how to open the door by holding it for more than 15 seconds and waited until the receptionist stepped away to attempt to go through the door . The speed limit for the road that the restaurant is located on is 50 miles per hour. The surveyor attempted to contact Receptionist E via telephone and left voicemail's requesting return calls on 4/11/17 at 11:07 am, 4/11/17 at 1:04 pm, and 4/12/17 at 9:35 am. A return call was not received prior to the exit of the survey. Review of the Summary of Staff Interviews dated 3/25/17, revealed Receptionist E stated that she remembered going to the break room around 8pm and she went to get a soda. She did not recall if there was any other staff present at the front area or remember (Resident #1) there. She stated that she turned off the door alarm when she returned because it was going off. She stated that she did not really think about it. She stated that she has heard that alarm go off before only when the guy comes and goes with his family. She acknowledged that she should have not just turned the alarm off and went back to the desk. She also acknowledge having gone over the elopement policy during general orientation. Review of the New Employee Orientation Checklist, revealed Receptionist #1 was oriented on Elopement Policy and Drill-Explanation of each Department's Responsibility During the Drill on 3/14/17. In a telephone interview on 4/11/17 at 11:17 am, Licensed Practical Nurse (LPN) C reported on 3/24/17 she administered medications and checked the function of Resident #1's wanderguard at approximately 7:50 or 7:55 pm. LPN C reported Resident #1 stayed around the area for a couple minutes and then took off. LPN C reported she didn't think anything of it because Resident #1 enjoyed being in the front activities area. LPN C reported Resident #1 was a wander risk, but she was not aware of any previous attempts to leave the facility. LPN C reported Resident #1 only had an emotional response to wanting to go out, like crying. LPN C reported a receptionist was working in the front lobby when Resident #1 eloped from the facility. LPN C reported she was never notified by the receptionist that Resident #1 eloped or that the alarm sounded. LPN C reported she was not aware Resident #1 was missing until the local Sheriff's department called the facility. LPN C reported Resident #1 was missing for just under 2 hours. When asked if she was able to hear the wanderguard door alarm from the nurse's station on the unit, LPN C stated we couldn't that night. LPN C reported there was usually a chime and then the computer would place a red dot to show what door was alarming. LPN C stated we weren't hearing the alarms through the computer. In a telephone interview on 4/11/17 at 11:27 am, CNA D reported on 3/24/17, she was assigned to care for Resident #1 and last visualized Resident #1 between 5:00 pm and 6:00 pm and stated then after that it's just busy busy busy and I never, I didn't have time to pay attention to who was who and who was where. I was just too busy. CNA D reported she did not believe Resident #1 was an elopement risk, but reported Resident #1 had a wanderguard. CNA D reported she was not aware Resident #1 eloped from the facility until the facility received a phone call from the local Sheriff's department. Resident #1 reported she cannot hear the wanderguard door alarm from the nursing unit. CNA D stated there used to be an alert on the computer at the nurses' station, but that's been so long ago. I think it was going off all the time and after a while you get immune to it because it's guests coming in and out the front door. When asked if she could hear the alarm since Resident #1 eloped, CNA D stated not that I know of. I haven't heard any. We aren't ever up by the desk for anything more than passing by. In a telephone interview on 4/11/17 at 12:16 pm, Restaurant Employee F reported she was working at the restaurant, located 0.4 miles from the facility, the night Resident #1 entered the restaurant in her wheelchair, with her coat hanging on the back of the wheelchair. Restaurant Employee F reported she heard restaurant staff asking Resident #1 if she knew her name. Restaurant Employee F reported the she asked all the patrons in the restaurant if Resident #1 belonged with anyone there, but nobody knew her. Restaurant Employee F reported she then called 9-1-1 and sat with Resident #1 at a table until the police arrived. Restaurant Employee F reported it took about an hour to realize that Resident #1 did not belong with anyone else in the restaurant. In a telephone interview on 4/12/17 at 9:14 am, RN H reported she was working on 3/24/17 when Resident #1 eloped from the facility. RN H reported she was not aware Resident #1 was missing until the restaurant notified the facility. When asked how she could identify when a door alarm was sounding while on the units, RN H stated it's kind of hard .hard to hear from some areas. Usually the nurse from Red Cedar can hear it by the 330 numbers, the hall by the offices. That's where you hear it best. There's nothing on the units that blares an alarm. It only alerts from the front door so it's kind of hard. In a telephone interview on 4/12/17 at 10:44 am, Evening Supervisor/RN G reported she received a call from the Sheriff's Department on 3/24/17 around 9:50 pm or 9:55pm notifying her that it was possibly one of the facility's residents in a wheelchair at the restaurant. RN G reported herself and RN H went to the restaurant and confirmed the individual was in fact Resident #1. When asked if anyone in the facility knew that Resident #1 was missing prior to the phone call from the Sheriff's Department, RN G stated no, not to my knowledge. RN G reported that nobody reported to her that the front door to the facility had alarmed. When asked if she could hear the door alarms from the nursing units, RN G stated depends on where you're at on the units. We have monitors on the units and they will beep when the call lights or door alarm goes off, have to look at the monitor to know which is going off. RN G reported had she heard a distinct door alarm sound on the night of 3/24/17, she would have went straight to the door, turned the alarm off, checked to see if she could locate what set the alarm off, and check outside. RN G reported if she could not determine what set the alarm off, she would have come inside and called a code white to start the elopement process. In an interview on 4/11/17 at 11:46 am, Director of Nursing (DON) B reported Resident #1 was witnessed leaving the building in November and that was why the wanderguard was placed. DON B reported she did not recall the incident of Resident #1 ramming the staff exit door on 3/17/17. DON B reported Receptionist E should have responded to alarm and if didn't see anyone, she should have gone outside and looked and if couldn't figure out why alarm was sounding, she should have initiated a code white. In an interview on 4/11/17 at 12:04 pm, Nursing Home Administrator (NHA) A reported if Receptionist E had followed policy, Resident #1 would have been found right outside the doors. NHA A reported the door alarm sounds at the nurses' station, but it's the same sound as the call lights. An observation on 4/12/17 at 8:26 am with Nursing Home Administrator A on the Red Cedar Unit, revealed a low pitched beeping alarm sounding at the nurses' station and a red circle blinking on a map which was displayed on the computer monitor, indicating a call light was activated. NHA A was on the phone with the front office staff and then instructed DON B to activate the wanderguard system at the front lobby door. DON B activated the wanderguard system. The alarm sound at the nurses' station did not change. The only difference was a red blinking square appeared at the location of the front door on the map displayed on the computer monitor at the nurses's station. All alarms were then canceled and no call lights were activated. The Surveyor entered the Red Cedar Unit Spa and activated the bathroom call light. This triggered an alarm sound at the nurses' station. NHA A then instructed DON B to again activate the wanderguard system at the front lobby door. Again, the alarm sound at the nurses' station did not change. The alarm from the front lobby door could not be heard from the nurses' station of the Red Cedar Unit. NHA A reported the front door is an egress door which can be pushed for 15 seconds and then the lock releases. Another observation at this time, revealed DON B approaching the front lobby door with the wanderguard bracelet in her hand. When she was within 1-2 feet of the door, the overhead small light changed from green to red, indicating the wanderguard bracelet was detected by the front door and the front door locked. At this time, DON B began pressing on the bar of the door. Short beeps immediately sounded. DON B continued to press for 15 seconds while the short beeps continued. After 15 seconds, the front door lock released, DON B was able to open the door, and the alarm changed to a constant beeping alarm sound. In an interview on 4/12/17 at 8:26 am, when asked how staff at night (when front office staff and receptionists were not in the building) could distinguish between a call light and a door alarm, NHA A reported that usually residents were not out of their rooms at night. In a second interview on 4/12/17 at 10:24 am, NHA A and DON B reported that during the facility's Quality Assurance meeting on 3/27/17, the facility identified that the alarm sound system had room for improvement. NHA A reported the facility requested an upgrade to install a totally different audible alarm for the wanderguard doors which will be significantly loud and different. Review of the Field Service Proposal dated 3/28/17, and from the alarm company, revealed Needs/Problems Identified: Customer requests addition of audible alarm at each of three nurse stations that will only sound during a door alarm. In a telephone interview on 4/12/17 at 11:06 am, Regional Service Manager M from the alarm company reported he was aware of the facility's proposal and the technician began work on Monday 4/10/17. Regional Service Manager M reported the technician was scheduled to return to the facility on [DATE] to complete the work requested on the proposal. Regional Service Manager M stated this is to give them an audible alarm at the nurses stations for just the doors. NHA A was presented with Immediate Jeopardy Notification on 4/11/17 at 3:29 pm due to the facility's failure to prevent the elopement of Resident #1 on 3/24/17 at approximately 8:12 pm, unbeknownst to staff, and was found by Restaurant Employee F 0.4 miles away from the facility. The facility was notified by the local Sherriff's department of Resident #1's whereabouts at approximately 9:55 pm. This deficient practice places 5 residents, who have been identified by the facility as an elopement risk, at risk for serious harm, injury, and/or death. A corrective action plan was requested from the facility to remove the immediate jeopardy. Immediate Jeopardy was removed on 4/12/17 when the facility had the following in place: 1) On 3/24/17, Resident #1 was assessed for signs and symptoms of injury upon return to the facility and was placed on 1:1 supervision, which has continued at this time. Resident #1 sustained no adverse effects from the elopement. 2) On 3/24/17 at 11:55 pm, all wander guard activated doors were checked for function by the Director of Maintenance 3) On 3/24/17, all residents with wander guards had the function and placement of their wander guards rechecked by their charge nurses. All wander guards were double checked for expiration and this was completed by the charge nurses on 3/24/17. There were no identified issues. 4) Between 3/24/17 and 3/26/17, residents who had not had an elopement risk assessment completed in the last 72 hours had their elopement risk re assessed by their charge nurses. The assessments were reviewed by the DON and this occurred between 3/25-3/26. One new resident was identified at risk per the assessment and had a wander guard placed and had her plan of care updated. 5) All staff have been reeducated on the Elopement Policy by the DON and/or Administrator. Education was started on 3/24/17 and continued throughout the weekend into the following week to ensure all staff have been reeducated. Casual staff will not work until they receive the Elopement Education. We currently have 99% compliance with facility staff reeducation. The receptionist was terminated on 3/27/17 and had not worked since the event occurred on 3/24/17. 6) On 3/25/17, residents that are at risk for elopement have had their plan of care reviewed and updated as appropriate by the DON 7) On 3/25/17, elopement books were reviewed and updated as appropriate to ensure compliance with policy and procedure by the DON 8) On 3/25/17, elopement drills were conducted on all three shifts with discussion of any identified opportunities for improvement with the teams involved. 9) On 3/25/17 and 3/26/17, residents determined to be at risk for elopement were reviewed to ensure placement of name ID bands per policy by the DON with orders updated for nurses to validate the ID band is on resident every shift. 10) On 3/26/17, a representative from the alarm company completed an inspection of the wander guard system and door locks and found the system to be functioning appropriately and without concerns. 11) An Ad Hock QAPI meeting was held on the night of 3/24/17 which included the DON, NHA, Director of Maintenance, and the evening supervisor. The Elopement Policy and Procedure was reviewed and found to be appropriate. An additional QAPI meeting was held in the am of 3/27/17, events were reviewed as well as P&P and action plan. The action plan will be forwarded to the Medical Director on the am of 3/27/17. 12) Random elopement drills will be conducted weekly for the next four weeks, then monthly. Drills will be completed by the maintenance department and results of drills will be forwarded to the QAPI committee for review and recommendation. Any identified issues will be immediately addressed. 13) A care conference was held with Resident #1 and her guardian to determine appropriate placement in light of the recent elopement. This took place on 4/3/17 after he had returned from vacation. He is agreeable to seek alternate placement in a secure facility. 14) The facility consulted alarm company on 3/28/17 and an upgrade was approved by the facility's operations director on 3/29/17. The work is scheduled to be completed on 4/13/17. The facility will have a staff member present at the front door at all times until the system has been upgraded to a new audible sound. Although the Immediate Jeopardy was removed on 4/12/17, the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the State Agency.