Every finding on record at The Villa at Green Lake Estates

This citation pertains to intake #2714636 Based on interview and record review, the facility failed to report an allegation of abuse/neglect for one resident (R906) of two residents reviewed for abuse/neglect/mistreatment. Findings include:On 6/9/26 a concern submitted to the State Agency (SA) was reviewed which alleged R906 was neglected by facility staff on 1/7/26. On 6/9/26 the medical record for R906 was reviewed and revealed the following: R906 was initially admitted to the facility on [DATE] and had diagnoses including Obesity and Heart failure. A review of R906's MDS (minimum data set) with an ARD (assessment reference date) of 1/9/26 revealed R906 needed assistance from facility staff with most of their activities of daily living. R906's BIMS score (brief interview of mental status) was 14 indicating intact cognition. A review of R906's progress notes revealed the following: 1/7/2026 at 07:00 . pt (patient) was refusing care, using aggressive language towards staff, removing brief to urinate and defecate on bed. Contacted 911 with false allegations about CNAs (Certified Nursing Assistants) (police report # [police report # and name of responding officer]). refusing to use call light for assistance and saying no one came to change him but wouldn't allow staff to change him when rounding. pt (patient) was refusing care and stating the staff were ignoring his requests to be change but pt did not use call light to call for assistance and refused to use the call light at all. Made false allegations of neglect and called 911 and said the staff were abusing him by neglecting him . 1/7/2026 at 09:17 *IDT (Interdisciplinary Team Note) .Writer spoke with [R906] regarding potential care concerns. [R906] informed writer about concerns regarding two elderly women he claimed provided care to him the night before. [R906] went on to say they changed his bed and cleaned water he had spilled on himself. He told them he had to have a bowel movement, and they replied that they couldn't help with that, but that they would let his nurse and CNA know. [R906] stated he waited too long but could not recall approximate wait time. [R906] stated he then contacted the police because he believed he had been forgotten. Writer was informed earlier in the morning that [local police department] arrived at the facility at approximately 6:33am. [R906] stated that the male aide was 'running his mouth to the cop' while [R906] was giving his statement. [local police officer] departed the facility at approximately 6:38am. Writer asked [R906] if he would like to provide any further details regarding why he contacted the police rather than using his call light for assistance. [R906] stated he believed the staff were blocking his light from working.1/7/2026-encounter Date of Service: 01/07/2026 Visit Type: Initial Consult .Details: .Psychiatric Evaluation .The patient was observed in the dining area and was agreeable to meeting with the provider. Privacy and confidentiality were maintained. He was alert and oriented to person, place, and time. Initially, he appeared guarded and visibly upset regarding events that occurred overnight. The patient reported that he felt neglected by staff overnight, stating that he remained incontinent for several hours and felt his needs were not addressed, which prompted him to contact emergency services. He expressed significant frustration and anger related to this perceived lack of care. Nursing documentation indicates that staff attempted to provide care during overnight rounds, but the patient was refusing assistance at times, using aggressive language, and making repeated calls to emergency services with allegations that staff were not responding to the call light. Facility administration is aware of the situation. During the interview, the patient was irritable and anxious when discussing these events, and some confusion was noted, particularly in his interpretation of staff interactions. Despite this, he was able to provide coherent information and did not demonstrate psychotic thought content. He denied auditory or visual hallucinations and denied suicidal or homicidal ideation. No aggressive behavior was observed during the evaluation. The patient reports that he normally sleeps well at home but has not been sleeping since admission, which he attributes to distress over the overnight incident .On 6/9/26 at approximately 9:17 a.m., the facility Administrator (Abuse Coordinator) was interviewed pertaining to the allegations of R906 alleging they were neglected/abused on 1/7/26. The Administrator reported they did not report the allegations to the State Agency but did complete an investigation. The Administrator was asked why they did not report R906's allegations to the SA, and they indicated they did their investigation and did not find the allegations were substantiated. The Administrator was queried if allegations of neglect and abuse should be reported State Agency for review, and they reported again that they had done an investigation into the allegations and felt they were unsubstantiated.On 6/9/26 at approximately 10:53 a.m., Nurse A was queried regarding the progress note they had written on 1/7/26 in R906's medical record pertaining to the allegations of abuse/neglect. Nurse A reported they were the Nurse for R906 at the time the allegation made and that R906 was reporting he was being neglected by the CNA's that were assigned to their room because they were not helping him with changing his brief. Nurse A reported R906 was not using their call button for assistance but was calling out for the aide to help. He ended up calling the police because he felt he was being ignored by the staff and neglected. Nurse A indicated they tried to go into R906's room, but they would only let the Nurse in because he was angry at the aide. Nurse A indicated they filled out a statement pertaining to R906's allegations of neglect and handed to the administrator so they could do what they needed to do. On 6/9/26 a facility document titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property was reviewed and revealed the following: Purpose: It is the practice of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

This citation pertains to intake 3013247Based on observation, interview and record review the facility failed to provide appropriate catheter care for one resident (R913), of two residents reviewed for catheters. Findings include:Clinical record review revealed R913 was admitted to the facility on [DATE] for long term care with a medical history of prostate cancer, neuromuscular dysfunction of the bladder and required a Suprapubic (SP) indwelling urinary catheter (surgically placed urinary catheter inserted directly through the abdomen). A Brief Interview of Mental Status (BIMS) conducted on 5/11/26 indicated R913 had moderate cognitive impairment.The State Agency received a concern that alleged the facility failed to provide appropriate and adequate catheter care according to the residents plan of care and physician orders. On 6/8/26 at 10:20 AM, Family Member F was contacted by phone confirming the allegations and said they would be at the facility after 1:00 PM to visit with R913.Clinical record review of R913's care plan initiated on 3/25/26 included interventions to place a T-drain gauze (pre-cut gauze designed to fit around tubing), maintain a closed drainage system, monitor for decreased urine output, monitor patency of the catheter, and notify the provider of abnormal findings.A nursing progress note dated 6/8/26 at 6:16 AM, authored by Registered Nurse (RN) G, documented R913 had urine leaking around their catheter from the suprapubic site and they would notify the physician.An attempt to interview RN 'G' via telephone was conducted on 6/8/26 at 10:47 AM and 6/9/26 at 9:41 AM. Voice messages were left, no return call for an interview was received by the end of this survey.On 6/8/26 at 10:20 AM, Medical Director (MD) D was interviewed by phone. They were asked if anyone from the facility had made them aware of R913's leaking catheter and they indicated no one had. During the interview, MD D reviewed the on-call service notes from 6/8/26 and further confirmed no provider was contacted. When asked if they were notified, what would the instruction be for R913? MD D said R913 had a complicated Urology history and was seen by their Urologist on 6/2/26 at which time they had the SP catheter exchanged. MD D further said they would have instructed nursing to call R913's Urologist and follow their recommendations.On 6/8/26 at 2:03 PM, R913 gave permission for observation of their SP catheter site with Family Member 'F' present. It was observed R913's waistband and abdominal area of their pants was wet as well as wetness observed on their incontinence brief. An odor of urine was present. The insertion site was observed with no T-drain gauze dressing, and the tubing and collection bag were observed dry with no urine in them. Family Member 'F' was observed speaking in a frustrated tone the staff did not notify them of the leaking and R913 should have to be sent to urology.On 6/8/26 at approximately 2:10 PM, FM F was followed to the nurse's station and observed with frustration informing Unit Manager Licensed Practical Nurse (LPN) E that R913 was wet with urine and there is leaking from the SP catheter. FM F was also observed telling LPN E R913 needed to be cleaned and they (FM F) would be calling the Urologist and R913 would probably have to be sent out to the ER (emergency room).On 6/9/26 at 8:38 AM during a clinical record review with the Director of Nursing (DON), they confirmed R913 had to be sent to the hospital on 6/8/26 around 5:30 PM to have their SP catheter assessed by their Urologist. At the time of the record review with the DON, they were informed MD D was not contacted per the nursing documentation in the 6/8/26 progress note at 6:16 AM, and they acknowledged the concern.

This citation pertains to Intake Number: 2714799 Based on interview and record review, the facility failed to ensure a physician's order was in place for an abdominal binder and implement effective interventions to prevent dislodgement of a feeding tube for one (R907) of one resident reviewed for tube feeding, resulting in a hospital transfer to reinsert the feeding tube. Findings include:A review of a complaint submitted to the State Agency revealed an allegation that R907 had multiple episodes of feeding tube dislodgement and the facility did not continue the use of an abdominal binder that was placed in the hospital. A review of R907's clinical record revealed R907 was admitted into the facility on 5/5/25, readmitted on [DATE], and discharged on 12/16/25 with diagnoses that included: vascular parkinsonism, hemiplegia, and aphasia. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R907 had severely impaired cognition, no behaviors, and received 51 percent or more of fluid and nutrition via a feeding tube. R907 was transferred to the hospital on [DATE] and 11/28/25 due to feeding tube dislodgement. A review of R907's care plans revealed a feeding tube care plan with the following intervention initiated on 10/21/25 and resolved (discontinued) on 11/26/25: Abdominal binder as tolerated. A review of R907's Physician's orders revealed no order for an abdominal binder. A review of a Care Plan Progress Note dated 10/24/26 noted, Abdominal binder in place. A review of a General Note dated 10/8/25 revealed, Aide observed resident's peg (Percutaneous Endoscopic Gastrostomy) tube (feeding tube surgically placed into the stomach to deliver nutrition) pulled out and notified writer .Notified on call provider. Provider gave order to send resident out to hsp (hospital) for peg tube replacement . A review of progress notes from 10/20/25 revealed R907's feeding tube was dislodged and replaced in the facility with placement verified by X-ray. A review of a Health Status Note dated 11/28/25 revealed, At approximately 1130 (AM) writer enters resident's room reconnect resident to his continuous TF (tube feeding) after CNA (Certified Nursing Assistant) gets him dressed and for the day and place him in his w/c (wheelchair). Writer observes peg tube dislodged from abdomen. Medical Director notified and gives orders to transfer resident to (hospital) non emergency . On 6/8/26 at 1:31 PM, an interview was conducted with the Director of Nursing (DON). When queried about what was required to be in place in order to utilize an abdominal binder, the DON reported a care plan and physician's order. The DON was asked to provide information about when R907's abdominal binder was implemented and why (per the progress note that mentioned it was in place on 10/24/25), clarification about whether there was a physician's order, and why the abdominal binder was discontinued per the care plan on 11/26/25. The DON reported she was not the DON at that time but would look into it. On 6/8/26 at 3:56 PM, the DON followed up and reported the abdominal binder was added to R907's care plan on 10/21/26 after the feeding tube was dislodged and they replaced it in the facility. The DON reported on 11/26/25, the facility had to resolve all the care plans and start new ones due to a change in the system library which was a result of a change in ownership. However, a new care plan intervention for the abdominal binder was not put into place. The DON reported she did not find a physician's order for the abdominal binder and there should have been one. The DON said there was a lot of communication via email regarding R907's abdominal binder, but it should be documented in the medical record. The DON reported she would follow up with any additional information. On 6/9/26 at approximately 1:00 PM, the DON reported she was unable to provide any additional information about when the binder was supposed to be implemented, if it was implemented, or why it was discontinued. When queried about what was in place to prevent the third feeding tube dislodgement on 11/28/25 (since 10/8/25), the DON was unable to offer a response.

Based on observation, interview, and record review the facility failed to properly assess for safety, implement timely and effective interventions, and provide adequate supervision with a safe environment for one (R900) of four Residents reviewed for falls/accident hazards, who was identified as high fall risk (history of fall with injury), wanderer, with severe cognitive impairment resulting in multiple falls on the staircase or with the step of the staircase, and multiple facial fractures, a laceration requiring closure, loss of consciousness, hospitalization, and unnecessary pain (using the reasonable person concept). Findings include: This citation pertains to intake # 2626141.Immediate Jeopardy (IJ) was identified on 10/8/25 at 10:00 AM.The IJ began on 9/17/25.The Administrator was notified of the IJ on 10/8/25 at 10:00 AM. A plan for removal was requested at that time to remove the immediacy.The IJ was removed on 10/8/25 based on the facility's implementation of an acceptable plan to remove the immediacy and onsite verification.Although the immediacy was removed, the deficient practice was not corrected and remained isolated with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency (SA).On 9/23/25, a complaint was submitted to the SA that alleged that the facility failed to involve the Power of Attorney (POA) in care decisions or care planning, the facility did not prevent a fall from a staircase twice causing injury. It was also alleged the facility used restraints and the facility failed to follow the residents plan of care. On 10/7/25 at 9:21 AM, an interview was conducted with the Power of Attorney (POA) for R900 via phone. They were asked if they had any additional information that they would like to add to the complaint submitted to the SA. The POA reported that they had a detailed report which included pictures, hospital documents, and email communication with the facility team. In addition, the POA reported that R900 wandered throughout the facility. R900 needed a locked down unit (a secure, specialized unit often used for residents with Dementia or Alzheimer's Disease) and had been trying to coordinate care with the Social Worker (SW) D for over a year to find an appropriate placement. The POA also reported that the facility chose a hospice company for R900 and did not include them in any of the planning about hospice care. The POA reported that they did not receive any call from the facility and they were notified about the services by the hospice provider. The POA mentioned that the fall from the open stairwell happened on 9/17/25, causing multiple injuries and a significant decline to their loved one's overall health. The POA also mentioned that the administrator reviewed the incident via video from 9/17/25 and saw R900 fall from the stairwell, and that the resident is no longer at the facility.On 10/7/25 at 9:47 AM, a follow-up interview was conducted with the POA via phone and asked if they were made aware of the fall for R900 on 10/3/25 from bed. The POA stated, Oh my goodness! It was another fall, no one called me, I can send you my call log right now. I want to cry, are you serious?.On 10/7/25 at 10:43 AM, an interview was conducted with the Assistant Director of Nursing (ADON) during an observation of R900's room. R900 was observed lying on their bed with a wedge underneath the sheet and a pillow stuffed under them on the opposite side. R900's bed was positioned where one side of the bed was placed against the wall. R900 was lying on a mattress that appeared like a regular mattress. The ADON was then asked if R900 had a perimeter mattress (as stated in R900's care plan). The ADON verified the mattress and stated, no. It must be noted that R900's care plan for fall prevention included perimeter mattress dated 9/9/24. The ADON was then asked about R900's fall on 9/17/25, and asked why there was not a progress note of the incident and why a late entry progress note was completed (five days later) the day after R900 returned from the hospital. The ADON was queried where the vitals were recorded from the incident and if the SA was notified of the accident since there were major injuries involved. The ADON reported that the nurse on duty during the 9/17/25 fall could not log into the Electronic Medical Record (EMR) system, so they (ADON) had completed a late entry progress note. The ADON added that they were unaware that there were not any current vitals in the EMR from the incident. The ADON reported that they would follow up to find out if the incident was reported to the SA. A review of medical records revealed that R900 was originally admitted to the facility on [DATE] with a readmission date of 9/22/25. R900's medical diagnoses included fracture of left femur (thigh bone), Alzheimer's disease, wandering, and confusional arousal. According to the minimal data set assessment (MDS) dated [DATE], R900 had a Brief Interview for Mental Status score (BIMS) of 99, indicative of severe cognitive impairment and was completely dependent on facility staff for mobility and transfers. It should be noted, the MDS dated [DATE] revealed the Resident needed assistance from facility staff for transfers and mobility, but was able to assist with those tasks.A discharge summary from the hospital dated 9/21/25 also revealed that R900 sustained multiple facial fractures and a laceration of the left eyebrow. Further review of R900's medical record revealed a progress note dated 6/1/25 that read, Patient was alerted {sic}that patient was observed falling and hit her head on the (stair) steps nurse came to assess patient was bleeding from back of the head and neck distended ambulance was called supervisor was notified director of nursing was notified along with family spoken with doctor patient is being transported from ems (emergency medical services) to .hospital daughter states she will meet her there. A progress note dated 9/17/25 read in part, Resident was observed going up the third floor stairs. She was redirected to come back down and lost her footing, causing her to fall unto{SIC} the floor. Resident landed on her left side, bumped her head causing a brief lost in level of consciousness. Approx (approximately) 4 cm (centimeter) laceration was observed to left brow with noted bleeding.Record review also revealed a fall evaluation dated 10/3/25 that revealed that R900 had an unwitnessed fall from the bed. It reported that resident was on the floor laying on their right side. There was no nursing progress note in the medical record, there were no vitals completed/documented for the incident. On 10/7/25, at 11:33 AM, an interview with the Director of Nursing (DON) was conducted and they were asked about falls for R900 and what interventions were put into place. The DON reported that R900 did not fall down the stairs on 6/1/25, but they had hit their head on the stairs; transferred to emergency room; and obtained staples to the back of the head. Upon return, R900 was recommended to have a soft helmet as tolerated. The fall on 9/17/25 was on the stairs and R900 was sent to the hospital for further evaluation. The DON was then asked if R900 had their soft helmet on during the fall on 9/17/25 as recommended in their care plan (implemented on 6/2/25). The DON replied No. The DON was queried about the fall out of bed on 10/3/25-why a perimeter mattress was not on R900's bed at the time of the fall and there was not one in place as of this morning. The DON reported that they would investigate why R900 did not have a perimeter mattress. The DON also reported that they did not submit a Facility Reported Incident (FRI) because the Medical Director had stated it was a pathological fracture (a broken bone that happens from an underlying disease with minimal or no trauma) from osteoporosis (weak bones). The DON was asked, how did R900 obtain a pathological fracture from osteoporosis if the hospital paperwork, and the facility stated injuries were from the impact of a mechanical fall down the stairs (it must be noted that R900 did not have a diagnosis of osteoporosis in the EMR and they were not listed on hospital discharge summary). The DON did not provide any further explanation. The DON was asked how they planned to keep other ambulatory residents safe from the unsecured staircase located in the hallway on the second floor. The DON reported that they usually did not have issues with residents in the staircase prior to this incident and now the team would work on a solution. On 10/7/25 at 1:54 PM, an interview with Nurse B was completed. Nurse B confirmed that they were assigned to care for R900 and the fall incident on 10/3/25 happened during their shift. They were asked about their documentation for the fall incident and their assessment/vitals. Nurse B reported that they did everything for the incident, but they did not document what they did.On 10/7/25 several attempts were made to contact Nurse E via telephone with no answer or call back.On 10/7/25 at 3:07 PM), an observation was made of the actual staircase/stairwell in which R900 fell on. The staircase was open for anyone to walk up or down the stairs. There was nothing to deter those that were cognitively impaired and able to attempt to use the stairs.The IJ that began on 9/17/25 was removed on 10/8/25 when the facility took the following actions to remove the immediacy: Nurse management team reviewed all like residents and completed new fall risk assessments.The interdisciplinary team met and reviewed all new risk assessments and updated all current resident's plans of care accordingly.Stop sign barrier banners have been placed at the entrance way of the stair well on ascending and descending sides on the second floor to impede resident usage. Measurements for the stairwell have been taken by the Maintenance Director to research and implement and more permanent solution.

This citation pertains to intake # 2615985 Based on interview, and record review, the facility failed to obtain laboratory services ordered by the physician/practitioner for one (R901) of two Residents reviewed for laboratory services. Findings include:A complaint received by the State Agency revealed that the facility failed to follow through with a laboratory (lab) order by the physician to rule out Urinary Tract Infection (UTI) for R901 during their stay at the facility which was also confirmed during an interview with the complainant on 10/3/25 at approximately 11:15 AM.R901 was admitted to the facility on [DATE] after hospitalization due to left ankle fracture. R901's admitting diagnoses included intellectual disabilities, pneumonia, and anxiety disorder. R901 was living in a group home prior to hospitalization. R901 had a guardian who was their family member. R901 was transferred to the hospital on 8/24/25 after a fall at the facility.Review of R901's Electronic Medical Record (EMR) revealed a physician order dated 8/18/25 that read, UA (Urinalysis - urine test to rule out infection) C&S (Culture and Sensitivity), CBC (Complete Blood Count) and BNP (B-type Natriuretic Peptide - lab test to rule out heart failure). Further review of R901's medical record revealed an interdisciplinary team note dated 8/20/25 at 12:14 that read in part, .no new orders, no new labs. There were no lab results for the tests that were ordered on 8/18/25 in R901's EMR. Review of the facility protocol on Lab and Diagnostic Test Results with a revision date of 03/2014 read in part, Assessment and Recognition: 1. The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs.2. The staff will process the test requisitions and arrange for tests.3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility.An interview with Director of Nursing (DON) was completed on 10/8/25 at approximately 11:35 AM. The DON was queried about the facility's follow up with the lab process and the lab test results for R901 that was ordered on 8/18/25. The DON reported that the facility has missed to draw the lab as ordered for R901 and they had identified that the facility was not compliant after R901 was transferred to the hospital. The DON added that they were reviewing R901's EMR after they were transferred to the hospital on 8/24/25 and identified their non-compliance and facility had completed a Past Non-Compliance (PNC) process.During the onsite survey, Past Non-Compliance (PNC) was cited after the facility implemented actions to correct the non-compliance which included non-compliance with the facility's lab policy. Facility identified the concern on 8/24/25. An ad-hoc QAPI (Quality Assurance and Performance Improvement) meeting on 8/24/25 and the facility had a compliance date of 8/25/25. The Facility PNC report revealed that they were not incompliance with their lab policy between 8/18/25 and 8/24/25. The facility was able to demonstrate monitoring of the corrective action and maintained compliance during the survey and they were continuing their audits.

This citation pertains to complaint: 2600725.Based on observation, interview and record review the facility staff failed to follow the facility policy regarding the implementation of individualized interventions for skin protection for one (R105) of three residents reviewed for pressure wounds. Findings include: A review of a complaint submitted to the State Agency (SA) documented concerns of the lack of interventions implemented to prevent wounds in the facility. On 9/4/25 R105 was observed lying on their back in bed playing on their cellphone. An interview was conducted with the resident at that time. A review of the medical record for R105 revealed the resident was admitted to the facility on [DATE], with diagnoses that included: paraplegia, pressure ulcer of sacral region, and contracture of lower leg. R105 required staff assistance for all activities of daily living. A nursing note dated 8/29/25 at 8:13 PM, documented the following wounds . 1. Left knee- stage three pressure, 2. L (left) knee medial-stage three pressure, 3. R (right) knee medial-stage three pressure, 4. R lateral foot-stage three pressure, 5. R ankle-stage three pressure, 6. Heel-stage four pressure, 7. L buttock-stage four pressure, 8. R buttock-unstageable pressure, 9. Abdomen-full thickness surgical.This revealed multiple wounds identified on the resident upon admission. A review of R105's care plans revealed the following: The resident has potential for impairment to skin integrity r/t (related to). Interventions - Monitor skin when providing cares <sic>, notify nurse of any changes in skin appearance. Date initiated 08/23/2025. The resident has actual impairment to skin integrity (SPECIFY location) r/t. Interventions - Evaluate and treat per physicians orders, Evaluate resident for S/SX (signs/symptoms) of possible infections, Monitor IV (intravenous) site q (every)/shift and complete dressing change as ordered. Date Initiated: 08/23/2025There were no other care plans and/or interventions implemented regarding the management of R105's skin, despite the numerous wounds identified. A review of a facility policy titled Skin Protection Guideline dated 7/7/21, documented in part . Purpose: To provide evidence based practice standards for the care and treatment of skin. To ensure residents that admit and reside at our facility are evaluated and provided individualized interventions to prevent, reduce and treat skin breakdown. The first step in the prevention of PU (pressure ulcer)/PIs (pressure injury), is the identification of the resident at risk. This is followed by implementation of appropriate individualized interventions and monitoring for the effectiveness of the interventions. An admission evaluation helps identify. residents with existing PU/PIs. the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI. An individualized plan of care will be developed based on known predicting factors for skin breakdown. Interventions for prevention, removing and reducing predicting factors and treatment for skin. it is important to individualize each resident's turning and repositioning schedule. The facility staff failed to implement an adequate individualized care plan for the multiple wounds identified and for the potential to prevent the worsening of existing wounds and/or the development of new wounds. On 9/4/25 at 2:49 PM, the Director of Nursing (DON) was asked whose responsibility it was to implement the wound and skin management interventions and the DON replied the nurses. When asked about R105 current condition to have multiple identified wounds, compared to the lack of care plans and interventions implemented despite the guidance of the facility's policy, the DON stated they would review R105's care plans and follow back up. No further explanation or documentation was provided by the end of the survey.

This citation pertains to complaint: 2600725. Based on interviews and record reviews the facility failed to ensure adequate supervision and/or resident specific interventions to prevent falls for one (R103- a resident with a known history of falls with injury, developmental delay, non-compliance with care, impulsive & combativeness) of two residents reviewed for falls, resulting in injuries that required the resident to be transferred to the hospital for a higher level of care. Findings include: A review of a complaint submitted to the State Agency (SA) documented concerns of frequent falls with injury due to the lack of staffing at the facility. A review of an audit of residents transferred to the hospital revealed a concern with R103. A review of the medical record revealed R103 was admitted to the facility on [DATE], with diagnoses that included: aftercare following joint replacement surgery, severe intellectual disabilities, developmental disorder of speech and language, unspecified lack of expected normal physiological development in childhood and falls. A review of the referral packet provided to the facility by the transferring hospital documented in part, . S/p (status post) unwitnessed fall. Acute L (left) medial malleolus fracture (side of ankle) with mild subluxation of the tibia articular surface in relationship to the talus. S/p ORIF (open reduction and internal fixation) Medial Malleolus fracture L ankle with open repair deltoid ligament (7/16/25). H/o (history of) fall (3/2025) with traumatic nasal and C5/C6 fractures (neck fracture). nasal fx (fracture). Developmental delay. return to Group Home with 24/7 supervision and assistance. return to group home when appropriate. Limited rehab potential 2* (secondary) to cognitive deficit. impulsive unable to follow Wt (weight) bearing precautions, became agitated and attempted to walk to restroom needed assist to remain in bed. attempted to get (out) put again and therapist had to stay with (resident). encouraging bed mobility and distractions to keep patient secure in bed, left with bed alarm in place. Not oriented to person, Not oriented to place, Not oriented to situation, Not oriented to time. fall risk. inconsistent with following simple one step commands. Problem Solving: Impaired, LLE (left lower extremity): Non-weight bearing.A review of a nursing progress note dated 8/25/25 at 8:47 AM, documented in part . 2035 (8:35 PM) Writer called to patient's room after CENA (nurses aide) observed patient on the floor. Writer observed patient laying on the floor parallel to his bed on his chest with his face turned to the right, blood noted on left side of head, patient was responsive but, unable to assess cognition r/t (related to) patient level of mental awareness. Patient is only oriented to self, is relatively nonverbal, and unable to answer questions relating to his fall. Patient assessed, FROM (full range of motion) to all extremities, doesn't appear to have pain but, notable to fully assess. Patient moved from floor to bed where a complete assessment was done including neuro check. Once patient was on his back, it was noted that patient had more injuries than writer was previously noted while patient was still prone. Pupils were noted to unequal left pupil was smaller than right and had a sluggish response time injuries included head laceration, bruise developing on left side of face, small amount of blood noted to be coming from left nostril, small abrasion above left eye. 2100 (9:00 PM) EMS (emergency medical service) was called. Arrived at 2105 (9:05 PM). 2105 Dr (doctor) was made aware of call to EMS. 2109 (9:09 PM) DON was also notified. 2115 (9:15 PM) Ems out the door with patient and taking patient to nearest hospital and not to (hospital name) as per Dr's request.Prior to the fall incident on 8/25/25, the progress notes revealed the following:A nursing note dated 7/22/25 at 4:25 PM, . Pt (patient) arrived A&Ox1 (alert and oriented time one) and stable no confusion ablet to understand but unable to speak complete sentences. Pt combative wont always allow ppl (people) to touch him. fracture on LLE (left lower extremity). Surgery was done on LLE and had cast on leg.A nursing note dated 7/22/25 at 5:34 PM, . Resident has weight bearing restriction. left leg fracture. resident needs assistance with ADL's. Resident uses assistive device/s: Wheelchair.A nursing note dated 7/22/25 at 7:22 PM, . HIGH risk for falls.A nursing note dated 7/22/25 at 7:30 PM, . An Initial Care Management meeting was held. Discharge Plan. The resident will require supervision for safety; A caregiver is required 24 hours per day. Caregiver assistance is not available.A care management noted dated 7/29/25 at 9:56 AM, . An Ongoing or Discharge Care Management meeting was held. Non-compliant with NWB (non-weight bearing), LLE r/t cognition.A therapy note dated 8/1/25 at 11:04 AM, . IDT (interdisciplinary team) met to discuss. Non-compliant with NWB to casted LLE r/t cognition.A physician note dated 8/5/25 at 3:11 PM, . LLE CAM boot in place. Difficulty w (with)/command following, difficulty w/interview and exam. Difficulty w/ROS d/t cog (cognitive) delay. D/W (discussed with) therapy staff, patient non compliant w/WB precautions. non ambulatory at this time.unable to follow commands accurately. cog delay at baseline. Walking difficulty s/p mechanical fall w/acute left med (medial) malleolar fracture w/ORIF, Hx (history) of unsteady gait w/ frequent falls. Fall prec (precautions), NWB LLE-non compliance observed.A therapy note dated 8/6/25 at 11:56 AM, . LLE NWB expect for transfers per Dr. (doctor) non compliant with NWB to casted LLE r/t cognition.A nursing note dated 8/7/25 at 7:21 PM, . Resident A&Ox1-2 with difficulties making needs known and following commands. Resident refused x3 to allow staff to place surgical boot on foot. refused getting into bed. Resident became very agitated and yelling. Resident refusing to be changed. Resident sitting in w/c (wheelchair).A physician note dated 8/14/25 at 1:09 PM, . Difficulty w/command following, difficulty w/interview and exam. Difficulty w/ROS d/t cog delay. D/W therapy staff, patient continues to be non compliant w/WB precautions. Walking difficulty s/p mechanical fall. unsteady gait w/frequent falls. Fall prec, NWB LLE- non compliance observed.A nursing note dated 8/15/25 at 3:44 PM, . IDT met to discuss. LLE NWB expect for transfers per Dr. non compliant with NWB to casted LLE r/t cognition. Care plans and interventions in place and deemed appropriate at this time.A therapy note dated 8/20/25 at 12:14 PM, . IDT met to discuss. Resident attended follow up ortho apt <sic> (appointment), LLE upgraded to WBAT (weight bearing as tolerated) with CAM boot. Care plans and interventions in place and deemed appropriate at this time.A review of the care plans revealed the following: . has actual / potential for an ADL self-care performance deficit r/t L. ankle fx. initiated 7/22/25. Goal- The resident will demonstrate the appropriate use of WC (wheelchair) to increase ability in mobility. Interventions Bathing: Physical Assist. Bed Mobility: Physical Assist. Toileting: Resident requires physical assistance with toileting. Transfers: Resident requires physical assistance. Encourage the resident to use bell to call for assistance. has impaired cognitive function or impaired though processes r/t Developmentally delayed. Goal. Interventions to maintain the highest quality of life. Interventions. Cue, reorient and supervise as needed. at risk for falls r/t L. ankle fx. hx of falls implemented 7/22/25. Interventions. bed in low position when in bed. Encourage resident to stay properly hydrated, educate that dehydration increases risk for falls, Evaluate gait and ambulation capabilities, identify abnormalities, Monitor pain and alleviate using non-pharmacological interventions and medications as ordered, Non-skid socks/footwear, Provide opportunity for physical activity (such as ambulation, self propel w/c, chair exercises, etc.), review resident medications associated with fall risk, such as diuretics, anti-epileptics, hypnotics, analgesics, and antidepressants. Discuss possibility of dose reduction with MD (medical doctor) if appropriate, Anticipate and meet the resident's needs, PT (physical therapy) to evaluate and treat as ordered or PRN (as needed). has an alteration in musculoskeletal status r/t Walking difficulty s/p mechanical fall. Interventions- Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance, Encourage /supervise/assist the resident with the use of supportive devices., Follow MD orders for weight bearing status. See MD orders and/or PT treatment plan, Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness, Monitor for any side effects to NSAIS such as GI bleeding or renal impairment, Monitor for fatigue. Plan activities during optimal times when pain and stiffness is abated, Monitor/document for risk of falls. Educate resident/family/care givers on safety measures that need to be taken in order to reduce risk of falls.A review of a facility policy titled Accidents dated 6/29/21, documented in part . Purpose: To ensure the environment is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents through a systemic approach. Avoidable Accident means that an accident occurred because the facility failed to: Identify. and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices. identify and implement measures to reduce the hazards/risks as much as possible. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, are plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident. Supervision/Adequate Supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision needed. This determination is based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. IMPLEMENTATION OF INTERVENTIONS- Implementation refers to using specific interventions to try to reduce a resident's risks from hazards in the environment. Resident-directed approaches may include implementing specific interventions as part of the plan of care.The above documentation indicates the facility failed to implement adequate supervision and/or effective resident specific interventions to prevent falls for a resident who was identified as developmentally delayed, who was unable to retain education/instructions/directive, who was consistently observed to display non-compliance to the current plan of care, physician/staff directive, with noted combativeness and impulsiveness. This information was also provided in the referral by the transferring hospital and the facility failed to implement adequate interventions for the safety of this resident. On 9/4/25 at 1:36 PM, the Director of Nursing (DON) was interviewed and asked whose responsibility it was to obtain information to develop safe and adequate care plans for the residents and the DON stated the admitting nurse. The DON stated the plan of care is also reviewed during the interdisciplinary team morning meetings and upon admission. The DON was then asked about the fall incident that occurred on 8/25/25 with R103. The DON stated the details noted in the nurses note regarding the fall and stated in part . He was sent out to the hospital and we haven't been able to get any updates from the hospital. When asked if the family of R103 had updated them with R103's condition, the DON replied . Yes, they stated he was on a ventilator and in critical care. When asked about the documentation in the referral provided to the facility and the multiple notes documented by the facility staff regarding the cognitive impairment, impulsiveness, impaired safety awareness and non-compliance and the inability to effectively educate the resident, the DON stated the resident was non-compliant with assistance and staff had witnessed the resident trying to transfer themselves, however stated it was the resident's first fall at the facility. The referral documentation that noted the resident to be a high risk, history of falls with major injury and the need for adequate supervision including the use of alarm devices was reviewed and compared to the facility's plan of care and lack of interventions implemented for adequate supervision and resident specific interventions to ensure the safety of R103. The DON stated staff was told verbally to increase monitoring of the resident. When asked what increased monitoring meant for R103, considering the other residents in the facility were rounded on every two hours (per the DON), the DON did not have a response. The DON stated there was a lot of traffic walking by R103's room, considering where R103's room was located. The DON was asked if that was considering all shifts, especially on the evening and nights when less staff are in the building and the DON did not have a response. The DON was asked if the facility staff had completed an investigation for the fall and asked the root cause identified. The DON replied they had completed an investigation. The DON was asked to provide the investigation for review. A review of the investigation provided by the DON documented in part . Resident admitted with severe intellectual disability and developmental disorder of speech and language. BIMS (brief interview for mental status) score 0 (which indicated severely impaired cognition). Between approximately 7:15 pm and 7:30 pm, during a brief change in the shower room, the resident's daytime CNA (certified nursing assistant) requested assistance from the on-coming CNA due to the resident's history of combative behavior. The resident declined to use the grab bar for stability. The additional CNA provided assistance, and the brief change was completed with out incident. The resident was then assisted back to his room and helped into bed, with the call light placed within reach. At approximately 9:00 pm, a CNA entered the resident's room to take vitals and discovered the resident on the floor, lying on his left side in the prone position. Fall occurred unwitnessed, despite interventions earlier in the evening. Modified Interventions to the Plan of Care. Reinforce use of safety interventions (grab bar, two-person assist as needed). Fall prevention strategies reinforced with staff, including placement of call light and increased observation during evening hours (none of which were documented on the residents care plans). Summary of Factual Investigative Findings. At approximately 9:00 . The resident was discovered on the floor by staff during routine vitals checks. Post-fall assessment revealed injury, EMS was called, and the resident was transferred for hospital evaluation. No further explanation or documentation was provided by the end of the survey.

R37 On 6/30/25 at 10:15 AM, R37 was observed lying in bed. R37 reported he was not feeling well at that moment and was going to the hospital. When queried about the care in the facility, R37 reported he wore a Life Vest (a wearable cardioverter defibrillator vest that continuously monitors for life-threatening irregular heart rhythms and automatically delivers shock treatment to save a person's life, if needed). R37 reported the vest was not removed because he was to wear it at all times. R37 reported the vest did not fit properly and was very tight which caused a big wound on the trunk of his body where the vest made contact with his skin. R37 reported the facility ordered a new vest, but he never received it. R37 reported the wound was painful and uncomfortable. An observation of the wound to R37's torso was not conducted as R37 left for the hospital shortly after the above interview and did not return prior to the end of the survey. A review of R37's clinical record revealed R37 was admitted into the facility on 6/10/25 with diagnoses that included: ischemic cardiomyopathy (damaged heart muscles that cannot pump blood properly). A review of a Minimum Data Set (MDS) assessment revealed R37 had intact cognition and no unhealed pressure ulcers or other skin impairments. A review of a Nursing Evaluation completed for R37 on admission on [DATE] revealed no documentation of skin impairment to R37's trunk/torso. A review of R37's Physician's Orders revealed an order for weekly skin check every Tuesday with a start date of 6/17/25. An order dated 6/12/25 revealed, Monitor every shift. Patient is to wear LifeVest at all times EXCEPT when showering/vigorous cardiac rehab . A review of a Skin Observation assessment dated [DATE] revealed no skin impairment to R37's trunk/torso was identified. A review of R37's progress notes revealed the following: An IDT (Interdisciplinary Team) Note dated 6/11/25 documented, .Skin rash under breast present upon admission. It should be noted that a skin rash under R37's breast was not documented on the admission Nursing Evaluation or Skin Observation form completed on 6/10/25. Further review of R37's Physician's Orders revealed no treatment orders to address the rash mentioned in that note. Further review of R37's clinical record revealed no further documented assessment of the rash, including the size, appearance, and where it was located (under left or right breast). There was no mention of R37's vest being too tight, as reported by R37. A Physician/PA (Physician Assistant)/NP (Nurse Practitioner) - Progress Note dated 6/11/25 revealed no documentation of any skin impairments. A Skin/Wound Note dated 6/18/25 documented, During shower this am an abrasion was observed under left abdominal fold r/t (related to) life vest. Skin also red moist and has mild order <sic> (odor). After shower area cleansed. Antifungal powder and camalseptine <sic> (an ointment used as a moisture barrier to calm skin irritation) applied. Treatment in place. All necessary parties notified. Further review of R37's Physician's Orders revealed an order dated 6/18/25 for Wound Treatment: Left Abdominal Fold Abrasion: 1. Cleanse area with NS (normal saline) 2. Pat Dry Apply Camalseptine <sic> and Antifungal powder and ABD (abdominal pad) for cushion .every day shift for Wound Care . A review of a Physician/PA/NP Progress Note dated 6/18/25 did not document any skin abnormalities or that R37's life vest did not fit properly. A review of a Weight Change Note dated 6/19/25 revealed R37 gained 4.5 pounds since admission nine days prior. It was noted R37 took a diuretic for edema and weight fluctuations were expected. A review of a consultation completed by the contracted wound care provider dated 6/20/25 revealed, .Wound Assessment(s) .Wound #1 Abdomen - LUQ is an acute Partial Thickness Abrasion .Initial wound encounter measurements are 1.5cm length x 13cm width with no measurable depth .There is a Scant amount of sero-sanguineous drainage (a combination of clear fluid and blood) noted .Wound bed has 100% pink, granulation, 20% slough (non-viable yellow, tan, gray, green or brown tissue) .Additional Orders .ABD DIRECT, OFFLOAD AREA NO ADHESIVE .Avoid direct pressure to wound site .OFFLOAD VEST OFF SITE . It should be noted that according to the State Operations Manual (Rev 229; Issued 4/25/25), if slough is present but does not obscure the depth of tissue loss, it is considered Full-thickness Skin loss and a Stage 3 Pressure Ulcer related to a medical device. A review of a Wound Assessment Details Report completed by Licensed Practical Nurse (LPN) 'O' on 6/27/25 revealed documentation that R37's wound was a Stage 1 facility acquired pressure ulcer (Intact skin with a localized area of non-blanchable erythema) that measured 13cm x 0.5 cm. The photo included on the assessment showed a linear wound with areas of full-thickness tissue loss, slough and scattered black, scab-like areas. A review of a consultation completed by the contracted wound care provider dated 6/27/25 revealed, Wound #1 Abdomen - LUQ is an acute Partial Thickness Abrasion .measurements are 0.5cm length x 13cm width x 0.1 cm depth .Wound bed is 90%, pink, granulation, 10% slough; no eschar . It should be noted in the photo taken on 6/27/25, there were scattered black, scab-like areas. A review of a IDT Note dated 6/25/25 revealed, .Life vest in place, (company name) contacted for new vest . On 7/2/25 at approximately 8:15 AM, an interview was conducted with the Assistant Director of Nursing (ADON). When queried if the facility had a Wound Care Coordinator, the ADON reported there was a nurse who rounded with the contracted wound provider once a week and the Director of Nursing (DON) was ultimately the person who oversaw wounds in the facility. On 7/2/25 at 11:53 AM, an interview was conducted with the DON. When queried about how R37 got the wound to his LUQ, the DON said it was from rubbing from the life vest. When queried about how often R37's skin was monitored due to having a medical device (life vest) that was reportedly too tight according to R37, the DON reported at least weekly, but with the vest they should be checking every shift, if not more. At that time, the following was requested from the DON: Interventions in place upon R37's admission into the facility, interventions implemented upon identification of skin breakdown to prevent further breakdown or worsening of the existing wound, and when the new life vest was ordered. The DON said she would look into it. On 7/2/25 at 2:00 PM, a follow up interview was conducted with the DON. The DON reported R37's skin was not checked more frequently because the vest was only to be removed for showers. The DON reported due to the life vest, they were unable to put additional protective interventions in place. At that time, any Wound Assessment Detail Reports conducted prior to 6/27/25 were requested. On 7/2/25 at approximately 2:45 PM, the ADON reported R37 was admitted with some skin impairment to his LUQ. At that time, any documentation of the skin impairment on admission and any physician's orders to treat the area at that time were requested. No additional information was provided prior to the end of the survey. The ADON further reported R37 was fitted for the life vest at the hospital and could only be fit every three months per the life vest company. At that time, it was requested a second time to provide the date the life vest company was contacted to enquire about a better fitting vest. No additional information was provided prior to the end of the survey. The ADON was asked to provide the hospital discharge records, as they were not accessible in the medical record. The records were not provided prior to the end of the survey. A review of R37's care plans did not include any care plans related to R37's medical device related wound to the LUQ and did not include a care plan related to checking R37's skin underneath the left vest. A review of a facility policy titled, Prevention of Pressure Ulcers/Injuries revised 1/2019 read in part, .Risk Assessment .Areas of impaired circulation due to pressure fro positioning of medical devices .CNA's (Certified Nursing Assistants) will inspect the skin on a daily basis when performing or assisting with personal care or ADLs (activities of daily living) .General Preventive Measures: 6. Routinely screen and document the condition of the resident's skin for any signs and symptoms of irritation or breakdown. 7. Immediately report any signs of a developing pressure ulcer to the supervisor. 8. The care process should include efforts to stabilize, reduce or remove underlying risk factors .Risk Factor - Friction and Shear .Monitor the placement of splints and casts to assure they are not placing friction on the resident's skin . Based on observation, interview and record review, the facility failed to document accurate skin assessments, ensure timely identification of pressure ulcers, and implement effective interventions to prevent the development and worsening of a pressure ulcer, for two (R68 and R37) of two residents reviewed for pressure ulcers resulting in R68 acquiring multiple pressure ulcers first identified as Unstageable (obscured full-thickness skin and tissue loss) and/or Stage 3 (full-thickness skin loss) pressure ulcers and R37 acquiring a medical-device related pressure injury with full-thickness skin loss. Findings include: R68 On 6/30/25 at 10:30 AM, R68 was observed lying in bed. R68 was asked if he had any wounds or sores on his body. R68 explained he had wounds, some he had when he was admitted and some he acquired at the facility. R68 was asked if he could turn himself. R68 explained he could not turn himself, staff had to turn him. Review of the clinical record revealed R68 was admitted into the facility on 1/27/25 and readmitted [DATE] with diagnoses that included: quadriplegia, injury of cervical spinal cord and major depressive disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R68 was cognitively intact. Review of R68's skin impairment care plan revealed interventions that read in part, .Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration (excessive moisture exposure) etc. to MD (medical doctor). Date Initiated: 02/27/2025 . Monitor skin when providing cares [sic], notify nurse of any changes in skin appearance Date Initiated: 01/27/2025 . Review of R68's wound notes from a consultant Wound Care Provider revealed: 2/14/25 .Wound #3 Right Elbow is an acute Stage 3 Pressure Injury Pressure Ulcer . Initial wound encounter measurements are 2.4cm (centimeters) length x 1.2cm width .There is a Scant amount of sero-sanguineous (blood serum and red blood cells) drainage . Wound bed has 70%, pink, granulation (new connective tissue formed during the healing process), 30% eschar (dead or devitalized tissue, and may appear scab-like) . General Notes: Patient has a history of Stage 3 on elbow based on previous records at different facility . Wound #4 Left Scapula is an acute Stage 3 Pressure Injury Pressure Ulcer . Initial wound encounter measurements are 1.4cm length x 4cm width . 20% slough (non-viable yellow, tan, gray, green or brown tissue) . General Notes: Patient has a history of a stage 3 ulcer on L (left) scapula based on previous records . 2/28/25 .Wound #5 Right Ischial (lower part of the buttocks) is an acute Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer . Initial wound encounter measurements are 3.4cm length x 2cm width . There is a Scant amount of sero-sanguineous drainage . 100% slough . 4/4/25 .Wound #7 Left Ischial is an acute Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer acquired on 03/30/25 . Initial wound encounter measurements are 3cm length x 1.8cm width . There is a Scant amount of sero-sanguineous drainage . Wound bed has 40%, pink, granulation, 60% eschar . Review of R68's progress notes revealed no documentation of skin impairment prior to the Consultant's wound notes on 2/14/25, 2/28/25 and 4/4/25. Including between 3/30/25 and 4/4/25. Review of R68's Skin Observation documentation revealed no identification of a new skin impairment. On 7/2/25 at 10:09 AM, the Director of Nursing (DON) was interviewed and asked how often skin checks should be completed. The DON explained the Skin Observation should be done weekly. The DON was asked why of the 22 weeks R68 had been at the facility, only nine Skin Observation's had been completed. The DON offered no explanation. The DON was also informed of the nine Skin Observations completed, none had identified any new skin impairment. The DON made no reply. The DON was asked about R68's wounds being identified when they were at Unstageable or Stage 3. The DON explained Wounds #3 and #4 were called Stage 3 because they had been at a Stage 3 prior and had reopened. The DON was informed the Consultant had documented that fact, however was asked why Wound #3 was documented as having granulation tissue and was 30% eschar and Wound #4 had 20% slough, which indicated both wounds had been present for a while. The DON offered no explanation. The DON was asked about Wound #5 that was first documented by the Consultant as an Unstageable with 100% slough. The DON offered no explanation. The DON was asked about Wound #7 in which the Consultant had documented was acquired on 3/30/25 but there was no documentation found in R68's record. The DON offered no explanation. The DON was asked if there were pictures of R68's wounds prior to the most recent Consultant's visit. The DON had the ability to access prior pictures and showed the first picture of R68's Wound #7 taken on 4/4/25 which appeared to be almost completely covered in black eschar. The DON was asked if the pressure ulcer in the picture should have been identified and documented before it looked like the image in the picture. The DON agreed there should have been identification before the wound was at that extent. When asked if R68 required total assistance of staff for care, the DON agreed. The DON was asked if staff were changing, bathing and turning R68 should the wounds have been identified and documented on before they were Unstageable and/or Stage 3. The DON acknowledged the concern.

Based on observation and interviews, the facility failed to properly date (Insulin) and appropriately store medications in one out of four medication carts resulting in the potential for harm due to unsafe medication administration and decreased efficiency. Findings include: During an observation completed on the 2-West medication cart on 7/1/25 at approximately 11:30 AM with Licensed Practical Nurse (LPN) M, an opened undated Humalog (Insulin) was located on the top drawer. When questioned, LPN M reported that it should have been dated. They confirmed that that the insulin pen was open and they were unsure why it was not dated. Further observation of the medication cart revealed five unidentifiable loose pills on the drawer. They were unsure how it happened and added that management was checking the medication carts weekly. They reported that they were a new nurse. During an interview with 2nd floor unit manager (UM) I on 7/2/25 at approximately 9:15 AM, the observations from 7/1/25 were shared. UM I reported that insulin should have been dated as soon as they were opened and staff should follow the facility process when they pull medications from the packages and should not be any loose pills on the cart. They were notified of the concerns and reported that they understood the concerns. On 7/2/25 at approximately 11:45 AM, the Director of Nursing (DON) was notified of the concerns with 7/1/25 observations of the 2-West medication cart. The DON reported that staff were expected to follow their facility processes and understood the concerns. A facility provided document titled Medication Storage in the Facility with a revision date of April-2018 read in part, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: A. The provider pharmacy dispenses medications in containers that meet regulatory requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. Nurses may not transfer medications from one container to another or return partially used medication to the original container. B. Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications (such as medication aides) permitted to access medications. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. D. Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, vaginal products, etc. Eye medications are stored separately per facility policy. E. Except for those requiring refrigeration or freezing, medications intended for internal use are stored in a medication cart or other designated area. F. Medications labeled for individual residents are stored separately from floor stock medications when not in the medication cart . Expiration Dating (Beyond-use dating): A. Expiration dates (beyond-use date) of dispensed medications shall be determined by the pharmacist at the time of dispensing. B. Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date. C. Certain medications or package types, such as IV (intravenous) solutions, multiple dose injectable vials, ophthalmic, nitroglycerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. 1) Drugs re-packaged by the pharmacy staff will generally carry an expiration date (beyond- use date) as follows: (Note: the pharmacist determines the exact date based upon a number of factors as well as applicable law or regulation). When the beyond-use dating for a medication identifies a month and year, the medication can be used through the last day of the month. a. Blister-pack cards and medication vials - 12 months from the date of dispensing (where the manufacturer's expiration date is longer than 12 months). If the manufacturer's expiration date is less than 12 months, the expiration date on the label will be the manufacturer's date. b. Medications in multi-dose packaging will have a beyond-use dating of 60 days or the manufacturer's expiration date if less than 60 days. c. Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: 1. In a multi-dose injectable vial 2. An ophthalmic medication 3. An item for which the manufacturer has specified a usable life after opening D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date or regulations/guidelines require different dating .

Based on interview and record review the facility failed to ensure coordinated hospice service visits for one resident (R9), of one resident reviewed for end of life care, resulting in the potential for unmet end of life care needs. Findings include: On 7/2/25 at 12:57 PM, a review of R9's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: dementia, acute respiratory failure, high blood pressure, and Alzheimer's disease. Continued review of the record revealed they admitted to Hospice Services on 2/10/25. On 7/2/25 at 8:40 AM, 10:10 AM, 11:25 AM and 11:40 AM requests were made for the facility to provide R9's Hospice staff visit schedule with the defined discipline of whom was visiting (nurse, aide, social services, spiritual staff, etc). On 7/2/25 at 1:54 PM a copy of the visit schedule was provided, however the copy provided was grainy and difficult to read. The schedule included names of contracted hospice staff but it did not indicate the discipline of whom was visiting as requested. The schedules and Hospice progress notes for nurses revealed a nurse visit on 4/22/25 and the next one occurring on 5/2/25, 10 days later. The notes further indicated a Hospice nurse visit on 5/13/25, another visit in May that was not dated, and the next visit occurring on 6/12/25, revealing only three nurse visits in a one month period. Continued review of the notes for the Hospice Aide visits was conducted and revealed one visit in February 2025, four visits in March 2025, three visits in April 2025, no visits for May 2025 and four visits for June 2025. On 7/2/25 at 10:00 AM, an interview was conducted with Social Worker 'D'. They were asked who monitored to ensure Hospice staff were performing their scheduled visits and said they did not know but would find out. Social Worker 'D' did not follow up with who was responsible for ensuring the provision of Hospice services by the end of the survey. On 7/2/25 at 11:40 AM, an interview was conducted with the Director of Nursing (DON) regarding the provision of Hospice services and oversight. The DON indicated the Hospice staff and facility staff should be following the care plans. At that time, the DON was asked about the absence of a facility initiated care plan for R9's Hospice services and said they should have one in place. A review of a facility provided policy titled, Hospice Program was conducted and read, .10. In general it the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs .13. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility .

Based on observation, interview, and record review, the facility failed to provide 80 square feet per resident in multiple resident rooms for 26 of 42 resident rooms (#'s: 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, and 213, ), resulting in the potential for inadequate space and resident dissatisfaction. Findings Include: On 7/1/25 at approximately 11 AM, a review of the facility bed count information sheets and observations of Medicare/Medicaid resident rooms measurements provided by the facility administrator revealed the following: ROOM# SQ. FT. # OF BEDS 101 149.46 2 102 148.4 2 103 148.4 2 104 148.4 2 105 148.4 2 106 148.4 2 107 148.4 2 108 148.4 2 109 148.4 2 110 149.46 2 111 149.46 2 112 149.46 2 113 149.46 2 201 149.46 2 202 148.4 2 203 148.4 2 204 148.4 2 205 148.4 2 206 148.4 2 207 148.4 2 208 148.4 2 209 148.4 2 210 149.46 2 211 149.46 2 212 148 2 213 148.4 2 Individual and group interviews conducted with residents revealed no complaints regarding the size of their room. The health and safety of the residents were not affected by the room size. During an interview with the facility administrator on 7/2/25 at approximately 1:20 they were queried about the room waiver and their plans. The administrator reported that there were no plans for any expansion of the North halls, or make them in to single rooms. There were plans for some aesthetic changes to the rooms. They added that they would discuss with their corporate team.

Based on observation, interview and record review the facility failed to ensure treatment in a dignified manner for two residents (R#'s 17 and 70) of two residents reviewed for dignity, resulting in the potential for embarrassment. Findings include: On 6/30/25 at 11:29 AM, Certified Nursing Aide (CNA) 'B' was observed transporting R70 in their geri-chair. CNA 'B' was observed pulling the geri-chair in a forward motion as R70 was seated in the chair facing rearward. On 6/30/25 at 1:20 PM, an interview was conducted with CNA 'C' in the hallway outside of R17's room. CNA 'C' was asked if it was normal for R17 to have slept all morning and remain sleeping into the afternoon. CNA 'C' said sometimes it was her normal and some days she could be, moody. On 7/1/25 at 11:40 AM, an interview was conducted with the facility's Director of Nursing (DON) regarding language use and appropriate wheelchair transports. The DON said wheelchairs should not be pulled in a forward motion with the resident facing backward and staff were expected to treat residents in a dignified manner. A review of a facility provided policy titled, Quality of Life-Dignity was conducted and read, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .

Based on observation, interview, and record review the facility failed to maintain an effective grievance resolution process to ensure prompt resolution of resident concerns for one (R56) of one resident reviewed for grievances, and seven of eight residents who wished to remain anonymous who attend the resident council interview. Findings include: On 6/30/25 at 10:45 AM, R56 was observed seated in a wheelchair in her room. When queried about the care in the facility, R56 reported she has had clothes and other belongings stolen from her room. R56 reported she caught another resident going through her drawers, the resident took one of her shirts out of the drawer, threw it on the bed, and the next morning R56 noticed a blue and purple shirt were missing. R56 said she has talked to a staff member who no longer worked at the facility about her concerns. Additionally, R56 reported her cellular phone charging cord was taken from her room while she was at therapy. R56 said it was found with a staff member. R56 reported she reported her concerns about her missing items to the Administrator, but has not received any follow up about what the facility was going to do about it. When queried about what was reported to the Administrator, R56 explained she went to the hospital a few months ago and when she returned, the luggage she had in her closet was unzipped and a purse, a wallet, and one hundred dollars was missing from it. R56 also reported a lavender blanket that had velvet on one side and lamb's wool on the other side. A review of R56's clinical record revealed R56 was admitted into the facility on 4/11/24 and readmitted on [DATE] after a hospitalization. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R56 had intact cognition. On 7/1/25 at 10:35 AM, all grievance and/or concern forms with any associated investigation or follow up for R58 since the last survey was requested from the Administrator. At 12:11 PM, the Administrator reported there were no grievances or concern forms on file for R56. On 7/1/25 at 12:35 PM, an interview was conducted with the Administrator. When queried about the facility's grievance process and how resident concerns were recorded, tracked, and resolved, the Administrator reported if a resident or family member expressed a complaint to anyone in the facility, they were asked if they wanted to file a formal grievance. If they want to file a grievance, then they were asked to complete a grievance form and the protocol was followed. If they said they did not want to file a formal grievance, the concern was discussed in morning meetings and the concern was looked into, but not documented. The Administrator further explained that staff are assigned to certain residents to complete quality rounds to see if they have any concerns. If concerns were brought up in quality rounds they were jotted down on the form and the resident was asked if they wanted to file a formal grievance. The Administrator was asked about any concerns reported to him by R56. The Administrator said R56 reported she was missing a black purse but did not wish to file a grievance. The Administrator reported they looked into the concern, but since R56 did not want to file a grievance, there is no documented investigation or follow up. The Administrator denied knowing anything about R56's missing blanket, wallet, or one hundred dollars and said there was nothing recorded on the inventory list that showed R56 had a black purse brought into the facility. The Administrator reported family denied knowing about a purse. However, the Administrator did not have any documented investigation or follow up to that concern. When queried about how the facility monitored for patterns of concerns if they were not documented, the Administrator did not offer a clear response. The Administrator followed up and said there was a progress note in R56's clinical record in April that said R56 did not express any concerns about financial safety. When queried about whether that was related to R56's concern about her missing purse, the Administrator said it was not and R56 reported the missing purse prior to that note. No documentation was provided to show what was done to try to resolve R56's concern about missing items, including a significant amount of money. On 7/2/25 at 9:30 AM, an interview was conducted with eight residents who either always or sometimes attended the resident council meetings. When queried about how the facility handled concerns or grievances either from the resident council or individually, multiple residents laughed. One resident said, They don't! It was explained by a resident that during resident council, the Activities Director recorded the concerns that were brought up, but some things remained ongoing concerns without any resolution. When asked to describe any concerns they felt were not resolved by the facility, seven of eight residents in attendance expressed issues with getting their clothing back from laundry in an appropriate manner. One resident said she labels all of her clothing with her name, but it often did not come back to her from laundry. Two other residents agreed that clothing does not always come back from laundry. Another resident said she had to remind the laundry staff all the time to bring back her clothing. Another resident expressed dissatisfaction with how her underwear was brought back on hangers underneath her other clothing. When queried about how long the issues with laundry had been going on, one resident said, It's ongoing. It has been going on for a long time. When queried about whether the facility provided a reasonable explanation for why concerns were not resolved, one resident said they do not get an explanation. At that time, the group was asked if they knew how to file a grievance individually if they had a concern about care and services in the facility. One resident said they will just tell their concern to whomever. Another resident said, you can express your concern, but it never seems to get fixed. Another resident said, One hand doesn't know what the other hand is doing. A review of a facility policy titled, Grievance Guideline with an effective date of 11/28/27 revealed, in part, the following: .The objective of the grievance guideline is to ensure the facility makes prompt efforts to resolve grievances a resident may have. The intent of the grievance process is to support each resident's right to voice grievances (e.g. those about treatment, care, management of funds, lost clothing, or violation of rights) and to assure that after receiving a complaint/grievance, the facility actively seeks a resolution and keeps the resident appropriately apprised of its progress toward a resolution .The facility will train and designate an individual who is responsible for .Receive and track all grievances through to their conclusion .lead any necessary investigations by the facility .Work with facility staff utilizing root cause analysis processes for resolution of the grievance or concern .Complete written grievance resolutions/decisions to the resident involved .A grievance or concern can be expressed orally to the Grievance Official or facility staff or in writing using a grievance form .Any employee of this facility who received a complaint shall immediately attempt to resolve the complaint within their role and authority. If a complaint cannot be immediately resolved the employee shall escalate that complaint to their supervisor and the facility Grievance Official .The Grievance Officer will maintain a log of all grievances for a period of 3 years .

Based on observation, interview, and record review, the facility failed to report injuries of unknown origin to the Administrator/Abuse Coordinator for one (R38) of four residents reviewed for abuse. Findings include: On 6/30/25 at approximately 9:40 AM, it was reported by another resident that R38 often wandered into her room, has gotten into her bed, and threw water on her one time. On 6/30/25 at approximately 10:00 AM, R38 was observed ambulating in the hallways of the second floor unit. R38 was observed standing very closely in other people's space. When spoken to, R38 talked non-sensically. On 7/1/25 at 10:45 AM, R38 was observed wandering the second floor unit, up and down each hallway. At approximately 10:51 AM, R38 entered another resident's room and approached their bed. The other resident yelled, No! Get out! Get out and go to your room! R38 was observed trying to get into the bed of the other resident who was not in the room at that time. At approximately 10:53 AM, a staff member redirected R38 into their own room and closed the door. A review of R38's clinical record revealed R38 was admitted into the facility on 9/20/19 with diagnoses that included: metabolic encephalopathy (2024), dementia with behavioral disturbance, and Alzheimer's disease. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R38 had severely impaired cognition, wandering behaviors, and required supervision/touching assistance for walking. A review of R38's progress notes revealed the following: An Incident Note dated 3/9/25 at 5:05 PM (written on 3/10/25) that read, CNA (Certified Nursing Assistant) reports to writer that resident has a large bruise to the back of the right leg. Writer assess area and area was non painful to palpation. Earlier in the shift. Writer witnessed resident climb in the bed throwing both feet over foot board hitting the area where bruise is located. Ice applied to are to minimize swelling, left leg assessed for bruising as well and none noted at this time . A Health Status Note dated 3/10/25 at 10:03 AM that read, While standing at cart writer heard residents room door open accompanied by a noise upon observation resident was observed behind door holding the handle. when asked what occurred resident was unable to give a clear description. no other abnormalities seen in room. during end of shift resident began to developed a bruise to left eyebrow .DON (Director of Nursing) notified . On 7/1/25 at 10:34 AM, all incident reports with associated investigations for R38 for the past sex months were requested from the Administrator. A review of incident reports provided by the Administrator for R38 revealed the following: A Skin incident report dated 3/9/25 at 1:00 PM noted, CNA reports to writer that resident has a large bruise to the back of the right leg. Writer assess area and area was non painful to palpation. Earlier in the shift. Writer witnessed resident climb in the bed throwing both feet over foot board hitting the area where bruise is located. Ice applied to are to minimize swelling, left leg assessed for bruising as well and none noted at this time . It was documented in the incident report that the incident was not witnessed and R38 was unable to give a description of what happened. There was no associated investigation provided with the incident report. A Skin incident reported dated 3/10/25 at 12:00 AM noted, While standing at cart writer heard residents room door open accompanied by a noise upon observation resident was observed behind door holding the handle, when asked what occurred resident was unable to give a description .during end of shift resident began to developed a bruise to left eyebrow . It was documented R38 was unable to give a description and the incident was not witnessed. It should be noted that the incident report was completed by a different staff member than the progress note. There was no associated investigation provided with the incident report. On 7/2/25 at 9:00 AM, the Administrator was asked to confirm if there were any associated investigations into the 3/9/25 and 3/10/25 incidents for R38. The Administrator reported there was no additional investigations for either date. On 7/2/25 at 1:09 PM, an interview was conducted with the Administrator/Abuse Coordinator. When queried about the facility's protocol for injuries of unknown origin, the Administrator reported if it could not be determined what happened, the injury was reported to the Administrator as soon as possible. Once it was reported to the Administrator, they started looking into what happened and if they were unable to determine the cause, it was reported to the State Agency. The incidents with R38 (bruise to back of leg on 3/9/25 and bruise on eyebrow on 3/10/25) were reviewed with the Administrator. When queried about whether those bruises should have been reported to him since R38 had a history of wandering, was not able to say what happened, and nobody witnessed the injuries directly, the Administrator reported they should have been reported to him so an investigation could be started to determine if it was an injury of unknown origin and if so, then reported to the State Agency. A review of a facility policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, dated 11/28/27, revealed, in part, the following: .Injuries of Unknown Origin: AN injury should be classified as an injury of unknown source when both of the following conditions are met: .The source of the injury was not observed by any person or the source of the injury could not be explained by the resident .The injury is suspicious because of the extent of the injury of the location of the injury .or the number of injuries observed at one particular point in time or the incidence of injuries over time .Investigation of injuries of Unknown Origin or Suspicious injuries must be immediately investigated to rule out abuse .The facility will ensure that all alleged violations .including injuries of unknown source .are reported immediately .or not later than 24 hours if the vents that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials .in accordance to State law through established procedures .

Based on interview and record review the facility failed to develop an integrated hospice care plan for one resident (R9) of one resident reviewed for hospice services resulting in the potential for unmet end of life care needs. Findings include: A review of R9's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: acute respiratory failure, high blood pressure, Alzheimer's disease and dementia. A review of a hospice contract indicated they admitted to hospice services on 2/10/25. A review of R9's hospice documentation revealed a care plan developed by the hospice company, however; a review of R9's facility care plans did not reveal a care plan for hospice services nor outline the coordination between the hospice company and the facility. On 7/2/25 at 11:40 AM, an interview was conducted with the facility's Director of Nursing (DON). They were asked if R9 should have a facility care plan that indicated R9 was on hospice and included interventions and coordination between the facility and the hospice company and the DON said they should have had one. A review of a facility provided policy titled, Careplan Standard Guideline dated 11/28/17 was conducted and read, .The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: 1. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being .

Based on observation, interview and record review the facility failed to ensure dressing changes were completed as documented for one (R55) of two residents reviewed for Skin Conditions. Findings include: On 6/30/25 at 10:03 AM, R55 was observed lying in his bed. A gauze dressing dated 6/25 was observed on R55's left wrist. R55 was asked what the dressing was for. R55 explained he must have hit his wrist on something, and the nurse had wrapped it up. R55 was asked if he knew how often the dressing was changed. R55 explained it had been a couple of days since it had been changed. Review of the clinical record revealed R55 was admitted into the facility on 8/20/24 with diagnoses that included: diabetes, Parkinson's disease and heart disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R55 was cognitively intact. Review of R55's progress notes revealed a Skin Observation note dated 6/15/25 at 6:50 PM that read, CNA (Certified Nursing Assistant) alerted writer that resident arm was bleeding. Writer assessed arm resident stated he did not know how it happened. Left lower arm bleeding moderately due to resident [NAME] [sic] on blood thinners and small cut noted. Arm was cleaned with NS (normal saline), TAO (triple antibiotic ointment) applied andwrapped [sic]. Resident denied any pain. Review of R55's June 2025 Treatment Administration Record (TAR) revealed an order for Cleanse left lower arm with NS, apply TAO, and cover with dry dressing every day shift for skin tear Start Date 06/16/2025. The TAR was marked as completed, indicating the treatment was done, on 6/25/25, the date on the dressing. The TAR was also marked as completed on 6/26/25, 6/27/25, 6/28/25 and 6/29/25. On 6/30/25 at 12:53 PM, the Director of Nursing (DON) was interviewed and asked to verify the date on R55's left wrist dressing. The DON verified the date was 6/25. The DON was informed the TAR had been marked off every day since 6/25/25. The DON had no explanation. The DON was asked if the TAR could be marked as completed if the treatment was not done. The DON explained the TAR should only be marked as completed after the treatment was done.

This citation pertains to Intake Number: MI00151566 Based on observation, interview, and record review, the facility failed to provide adequate supervision and implement effective interventions to prevent accidents and failed to assess and determine the root cause of a fall for three (R13, R38, and R72) of six residents reviewed for accidents and supervision, resulting in R13 eloping from the facility, R38 repeatedly entering other residents' rooms and the potential for avoidable accidents. Findings include: R13 On 6/30/25 at 10:13 AM, a resident was observed in R38's room and attempted to get into R38's roommate's bed. At that time, Licensed Practical Nurse (LPN) 'P' was asked if the resident in the room was R38's roommate. LPN 'P' reported the resident was R13 and they should not be in that room. At that time, LPN 'P' asked another staff member to get R13 out of the room. A review of R13's progress notes revealed the following: On 1/5/25, R13 was aggressive, combative, attempted to push other residents in their wheelchairs, was pushing on the door leading to the stairs, and was unable to be redirected. On 6/5/25 at 6:52 PM, it was documented R13 refused to be changed, was consistently trying to leave the floor, and eloped and walked down the stairs from 2nd floor to basement and stated, 'she didn't want to come back' while hitting the nurse and other staff . A review of R13's clinical record revealed R13 was admitted into the facility on [DATE] with diagnoses that included: adjustment disorder with mixed anxiety and dementia with behavior disturbance. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R13 had severely impaired cognition and no behaviors including wandering. R13 required supervision/touching assistance while walking. On 7/1/25 at 10:35 AM, all incident reports with associated investigations for R13 for the past six months were requested from the Administrator. A review of an investigation conducted by the facility regarding R13 revealed the following: An incident report dated 6/5/25 at 3:39 PM that noted, Resident observed having exit seeking behaviors. She then is seen at door causing alarm to sound but is redirected. Another alarm sounds and resident is in stairwell. Maintenance assistance alerts staff and tries to redirect resident however resident gets combative and proceeds to push her way through the door leading outside. Resident remained combative stating, 'I want to go for a ride father'. She was then guided into the building via wheelchair. It was documented R13 was located in rear of facility. A typed summary (unsigned and undated) noted, At approximately 3:56pm on June 5th, the 2 North stairwell door alarm sounded. A CNA (Certified Nursing Assistant) attending to the residents on that hall silenced the alarm approximately 30 seconds after the alarm was triggered .At approximately 3:57 (pm) the North stairwell exit door alarm was triggered. The assistance maintenance director (Maintenance Assistant - MA 'Q') immediately entered the stairwell and encountered the resident and began to attempt to redirect her back to the building. (R13) was combative and argumentative about returning to the building. The Maintenance Director (MD 'R') witnessed this occurrence and called a 'Code White' over the PA system. All staff responded appropriately and promptly. Nursing staff arrived with a wheelchair and escorted (R13) back into the building at approximately 3:59pm .The CNA that silenced the door alarm without checking the surroundings was educated and provided disciplinary action . An undated statement written by MA 'Q' documented, I (MA 'Q') was moving a bed to (room number) while I heard North stairwell alarmed. I proceeded to run down the north stairwell to outside. I intercepted the resident. I stood between them and the street while (Regional Maintenance Director, RMD 'S') called for assistance. I stayed in front of her until help arrived and was able to take her back inside. An undated, signed statement, written by Licensed Practical Nurse (LPN) 'M' documented, I had just come back to the floor when the alarm went of <sic> and then it had went silent. Minutes later the basement alarm went off and maintenance staff left the floor and told us it may be resident. We all went assist with getting her from outside and bringing her back up. An Employee Discipline Form for CNA 'T' dated 6/5/25 read, CNA responded to door alarm at 3:55 pm on North hall. Alarm was disengaged by CNA without properly checking stairwell or investigating who set alarm off. A review of a Wander/Elopement Risk Evaluation dated 6/1/25 for R13 revealed R13 was at risk to wander/elope. It was documented R13 was physically able to leave the building on their own, independently mobile, ambulatory, cognitively impaired, attempted to exit the unit or facility, made repetitive statements about 'going home' and/or packing belongings, and wandered aimlessly about the facility. A review of R13's care plans revealed a care plan initiated on 2/20/25 and 6/1/25 (four days prior to R13 exiting the building) that noted, (R13) is an elopement risk/wanderer. The only intervention in place prior to 6/5/25 was on 2/20/25 and it noted, Staff aware of residents wander risk. Further review of R13's progress notes revealed On 7/1/25 at 2:08 PM, an observation of the north stairwell was conducted. The North stairwell was located at the end of the North hallway on the second floor. The door required a code to open the door without setting off an alarm or if the handle was pressed for 15 seconds, the door would open and an alarm would sound which required a code to disengage. To get to the door that exited to the outside of the building, there were two flights of stairs that went down to another emergency exit that required a code or 15 second delay which would set off the alarm. Once outside, the door will not open without a code. Upon exiting the door, there was a grassy and wooded area straight ahead which had a steep drop off. To the right of the door was a shed with large equipment outside of it and a sidewalk which led to the employee parking lot. The parking lot, which was at a decline, led to a street. On 7/2/25 at approximately 1:10 PM, an interview was attempted with MA 'Q'. The Administrator reported they went home ill. At that time, an interview was requested from RMD 'S' and the Administrator reported MD 'R' was the person who responded to the door alarm when R13 left the building. On 7/2/25 at 1:22 PM, an interview was conducted with MD 'R'. When queried about what happened with R13 on 6/5/25, MD 'R' reported they were working on the second floor with MA 'Q' when they heard the alarm go off for the maintenance door in the basement that led to the outside. MA 'Q' explained when the alarm went off, it announced which door was breached. MA 'Q' ran down the hallway and MD 'R' went the opposite way through the maintenance door. MD 'R' reported RMD 'S' was outside of the building and MA 'Q' stopped R13 in the parking lot and MD 'R' called a 'Code White and said it was not a drill. RMD 'S' called the receptionist and informed them R13 was out of the building. According to MD 'R', R13 was combative and had known behaviors where if she saw a car, she went toward it. Nursing came out and calmed her down and got her back inside via wheelchair. On 7/2/25 at 1:33 PM, an interview was conducted with RMD 'S'. When queried about what happened with R13 on 6/5/25, RMD 'S' reported he was outside working on the generator when he saw MA 'Q' coming behind R13 out of the corner of his eye. Then MD 'R' was behind them and went in and called a code. MA 'Q' was holding R13's arms and RMD 'S' called the receptionist for assistance from a nurse. Then a nurse came out and all the staff came out and they took over and got R13 back inside. R38 On 6/30/25 at approximately 9:40 AM, it was reported by another resident that R38 often wandered into her room, has gotten into her bed, and threw water on her one time. On 6/30/25 at approximately 10:00 AM, R38 was observed ambulating in the hallways of the second floor unit. R38 was observed standing very closely in other people's space. When spoken to, R38 talked non-sensically. R38 was not wearing shoes and was observed wearing a soft helmet. On 6/30/25 at 1:45 PM, an interview was conducted with R38's resident representative (RR) who reported R38 had a fall while wandering around the unit. RR reported R38 walked up and down the small flight of stairs leading to the third floor, lost balance and hit her head on the stairs. R38 was transferred to the hospital where she required stitches. RR reported R38 had dementia and appeared to be weaker than before. RR wondered if something could be done to prevent R38 from accessing the stairs. On 7/1/25 at approximately 8:30 AM, R38 was observed entering another resident's room during medication pass. On 7/1/25 at 10:45 AM, R38 was observed wandering the second floor unit, up and down each hallway. Multiple staff were observed talking amongst themselves at the nurse's station. A wet floor sign was observed tipped over and laid across the end of the 2 North hallway. R38 was observed walking up and down the hallway and stepped over the sign. R38 was not wearing shoes and was not wearing a helmet as observed the previous day. On 7/1/25 at approximately 10:51 AM, R38 entered another resident's room and approached their bed. The other resident yelled, No! Get out! Get out and go to your room! R38 was observed trying to get into the bed of the other resident who was not in the room at that time. At approximately 10:53 AM, a staff member heard the other resident yelling and redirected R38 into their own room and closed the door. On 7/1/25 at 10:55 AM, R38 was observed lying in bed and appeared to be sleeping. The door to R38's room was difficult to open and required considerably force to push it open. A review of R38's clinical record revealed R38 was admitted into the facility on 9/20/19 with diagnoses that included: metabolic encephalopathy (2024), dementia with behavioral disturbance, and, Alzheimer's disease. A review of a MDS assessment dated [DATE] revealed R38 had severely impaired cognition, wandering behaviors, and required supervision or touching assistance for walking. A review of R38's care plans revealed a care plan initiated on 11/25/24 that noted, .tends to wander without purpose into other resident's rooms . An intervention initiated on 11/25/24 noted, Document 30 minutes checks post wandering into a resident's room. A review of R38's full clinical record revealed no progress notes or documentation by the CNAs in the Behavior Task of R38 being found in two residents' rooms on 7/1/25. 30 minute checks were not documented in the clinical record as specified on R38's care plan. On 7/2/25 at 8:15 AM, an interview was conducted with Registered Nurse (RN) 'U'. When queried about where 30 minute checks for R38 were documented after she was found in other residents' rooms, RN 'U' reported she did not know and would have to check with the manager. RN 'U' said she would do a skin check if R38 was found in another resident's room in case someone hit her. RN 'U' stated, I work midnights so you will have to check with the managers. On 7/2/25 at 8:20 AM, an interview was conducted with the Assistant Director of Nursing (ADON). When queried about what was in place to prevent R38 from wandering into other resident's rooms, the ADON reported the staff were supposed to redirect her when wandering. When queried about the 30 minute checks and where they were documented, the ADON reported that if the nurse was alerted, they would document on a form kept at the nurse's station. The ADON checked the first floor nurse's station and there were no forms for R38. The ADON reviewed R38's clinical record and reported there were no documented wandering behaviors or alerts in the clinical record. The ADON reported the CNAs documented behaviors in their tasks and the nurses should document in the progress notes in order to track behaviors and implement new interventions, if needed. On 7/2/25 at approximately 8:30 AM, an interview was conducted with second floor unit manager, LPN 'I'. When queried about where R38's 30 minute checks were documented, LPN 'I' said there was nobody on 30 minute checks on the second floor. LPN 'I' was not aware R38 was found in two different residents' rooms on 7/1/25. A review of R38's incident reports for the past six months revealed R38 tripped over a wheelchair in the hallway and fell on 5/25/25, fell near the steps near the nurse's station on the second floor and hit her head resulting in bleeding and a hospital transfer on 6/1/25, and fell while wandering back and forth on the hallway on 6/3/25. On 7/2/25 at approximately 12:03 PM, an interview was conducted with the Director of Nursing (DON). When queried about what was done to look into R38's wandering behaviors to prevent her from entering other residents' rooms, the DON did not offer a response. When queried about what was in place to prevent falls while wandering for R38, the DON reported after the last fall they implemented a soft helmet. When queried about why R38 had not been wearing the helmet, the DON reported she may have refused. When asked where that would be documented, the DON reported she did not know. A review of a facility policy titled, Safety and Supervision of Residents, dated July 2027, revealed, in part, the following, .Implementing interventions to reduce accident risks and hazards shall include .Ensuring that interventions are implemented .Documenting interventions . A review of a facility policy titled, Missing Person/Elopement, revised 1/2020, revealed, in part, the following, .Should an alarm on one of the external exits to the facility be sounded, staff shall immediately respond to determine the cause of the alarm . R72 Record review revealed R72 was a long-term resident of the facility, admitted on [DATE]. R72's admitting diagnoses included catatonic schizophrenia, major depressive disorder, and muscle weakness. Based on the Minimum Data Set (MDS) assessment dated [DATE], R72 had Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition, despite their diagnoses. R72 needed partial (<50%) to substantial (>50%) staff assistance with their mobility and transfers. R72 also had a legal public guardian. A complaint received by the State Agency revealed that R72 had a fall in the room and did not get timely assistance from the staff. An initial observation was completed on 7/1/25 at approximately 11:10 AM. R72 was observed lying on their bed. They had a facility provided (hospital) gown on. An interview was completed during this observation. R72 verbalized that they were in a nursing home and they wanted to go home. When they queried if they had any falls, R72 reported that they had one fall when they tried to get up and walk. R72 added that they had waited for 45 minutes to get help and staff assisted them to bed after. Review of R72's Electronic Medical Record (EMR) revealed a note dated 3/4/25 titled Behavior narrative note that read, Patient found lying parallel to her bed during rounds prior to dinner. She stated that she was just sitting. Writer asked multiple times if she had fallen and she stated 'no, I slid down to the floor'. Focused assessment performed prior to being transferred back to bed by staff . There was no evidence of any post incident assessment in the EMR. There was no evidence of any notification to R72's physician and legal guardian of the incident. A request for an incident and accident report with facility investigation for R72's incident from 3/4/25 was sent via e-mail to the facility administrator on 7/1/25. The facility administrator replied back on 7/2/25 and reported that they did not have an incident report or investigation/root cause analysis for the event. Review of R72's progress notes from admission to current date did not reveal any ongoing behaviors as noted under the progress notes dated 3/4/25. R72's care plan for falls and behaviors did not reflect any updates on or after 3/4/25. An intervention dated 1/30/25 under fall care plan read Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter and/or remove any potential causes if possible . An intervention under psychotropic medication use read monitor resident for safe ambulation, encourage proper footwear when up . dated 3/7/25. An interview with a Certified Nursing Assistant (CNA) N who was assigned to care for R72 was completed on 7/2/24 at approximately 8:45 AM. CNA N reported that they had been working at the facility for approximately four years and they usually worked in the set where R72 was residing and were familiar with resident's routine. CNA N was queried if they exhibited any behaviors and they reported that had preferred to stay in their room doing their own routine. When questioned if R72 had any falls, CNA N added that they recalled having one incident a couple of months ago, not on their shift; had heard from other staff, but they were not very sure. An interview with the Assistant Director of Nursing (ADON) was completed on 7/2/25 at approximately 10:30 AM. They reported that they had been in the role for approximately a month. The ADON was queried about the facility process if a resident was observed on the floor and reported that they had slid to the floor. They reported that would be considered as a fall and they would complete an assessment, incident report and complete an investigation. They were questioned about R72's incident and rationale for why it was documented as a behavior note and why there was no incident report and investigation not completed. The ADON reported that they were unable to provide any further explanation and agreed on the concerns. They are addressing these concerns now with their team. An interview with LPN O was completed on 7/2/25 at approximately 10:50 AM. LPN O was assigned to care for R72 on 3/4/25 and had completed the behavior narrative note. They were queried about the incident and their focused assessment. They reported that they had added that under behavior as they were instructed by the management. When asked further they added that any self-reported incidents were documented under behavior narrative note and they were asked to show in the EMR where they had documented their focused assessment. LPN O added that they assessed the resident but there was no other documentation. When questioned further on their rationale they reported that they understood the concern. On 7/2/25 at approximately 11:40 AM, the Director of Nursing (DON) was interviewed regarding the facility process. The DON reviewed the EMR for R72 and reported that the incident on 3/4/25 was a fall event and the staff should have followed their facility processes. They added they would check for the reports (incident and investigation) and would report back later. Later, the DON confirmed that they did not have any further information and agreed with the concern. A facility provided document titled Fall Evaluation Safety Guideline with a revision date of 11/28/17 read in part, Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention to: 1. To achieve each resident's maximum potential of physical functioning 2. To prevent or reduce injuries related to fall. 3. To enhance resident dignity and self-worth 4. To rehabilitate residents to their fullest potential of function Falling is an unintentional change in position coming to rest on the ground floor or onto the next lower surface. The fall may be witnessed, reported by the resident or an observer or identified when a resident is found on the floor or ground. Falls include any fall regardless of which setting it may have occurred. An intercepted fall occurs when the resident would have fallen if he or she or someone else had not caught him or herself. Any failure to maintain an appropriate lying, sitting or standing position resulting in a resident's sudden, unintentional relocation either to the ground or into contact with another object below his or her starting point defines falling. The intent of this guideline is to ensure this facility provides an environment that is free from hazards over which the facility has control and provides appropriate supervision to each resident as identified through the following process: i. Identification of hazards and risks ii. Evaluation iii. Implementation iv. IV. Monitoring v. Analysis Fall Evaluation: A fall evaluation is used to identify individuals who have predicting factors for falls. This evaluation is completed upon admission, quarterly, annually and with a significant change in condition. Fall prevention is achieved through an IDT1 approach of managing predicting factors and implementing appropriate interventions to reduce risk for falls .

This citation pertains to intake #MI00150133 Based on interview and record review the facility failed to ensure a stop date for antibiotic treatment for one resident (R#306) of three residents reviewed for antibiotic stewardship resulting in the resident receiving numerous additional doses of antibiotic medication. Findings include: On 3/26/25 at 12:30 PM, a review of R306's physician's orders and Medication Administration Record (MAR) for February 2025 and March 2025 was conducted and revealed Nurse Practitioner (NP) 'H' prescribed Ivermectin (antibiotic) on 2/10/25 for the treatment of possible scabies. The order indicated the medication was to be administered on day 1 (2/10/25), day 2 (2/11/25), day 8 (2/17/25), day 9 (2/18/25) and day 15 (2/24/25). It was noted the order did not include a stop date and the medication was continued to be given once daily (with the exception of a few refusals from R306) after day 15 until it was discontinued on 3/26/25. On 3/27/25 at 12:48 PM, a telephone interview was conducted with NP 'H' regarding R306's order for the Ivermectin antibiotic. They said they did not know why the medication was not stopped after day 15 but it should not have been given after that date. On 3/27/25 at 1:27 PM, an interview was conducted with the facility's Director of Nursing and they acknowledged the concern and indicated a stop date should have been included in the order. A review of a facility provided document titled, Infection Prevention and Control Manual for Antibiotic Stewardship & MDROs (multi-drug resistant organisms) was conducted and read, Stewardship involves identifying the microbe responsible for disease, utilizing evidence based definitions when indicated; selecting the appropriate antibiotic along with documentation indicating the rationale for use, appropriate dosing, route, and duration of antibiotic therapy; and to ensure discontinuation of antibiotics when they are no longer needed .

This citation pertains to intake #MI00150928 Based on interview and record review, the facility failed to ensure freedom from misappropriation for one resident, (R302) of two residents reviewed for misappropriation, resulting in a staff member stealing R302's money. Findings include: On 3/27/25 at 9:50 AM, a review of a facility reported incident folder for R302 was completed. The folder contained investigation documentation that included a summary that read, .On 2/27/25 (R302) was brought to the Administrator's office by (Nurse 'D') .(R302) was crying when she entered the office .(Nurse 'D') reported (R302) was upset because she suspected her money had been taken .(R302) confirmed she was upset because she suspected money had been taken from her. (R302) reported she had spoken to her bank after having received and reviewed her bank statement. (R302) said she noticed transactions that she did not make because they happened outside the facility. (R302) had not left the facility, other than for hospital visits, since her admission in early May of 2024. (R302) stated, 'Certified Nurse Aide (CNA) 'C' took my money! She was the only one I gave my card to.' Administrator asked for clarification regarding why (R302) thought (CNA 'C') had taken her money and how she obtained (R302's) debit cart. (R302) reported that she had given the debit card to (CNA 'C') December 31. (R302) asked (CNA 'C') to withdraw $500 from (R302's) Checking account. (R302) stated, There more <sic> charges on here than I authorized. Continued review of the summary read, .On 2/27/25 facility administrator contacted (CNA 'C') via phone and informed her that allegations of misappropriation had been made against her .(CNA 'C') said: That's fine, but it wasn't me, it was (CNA 'F'). Remember him, the tall, guy, aide? I drove him in my car to the gas station, he went to the ATM (automated teller machine), he got her cash, he went to (Grocery Store) and got her pop .Administrator spoke with (R302) later in the afternoon of 2/27. Administrator asked (R302) she remembered a CNA named (CNA 'F') .(R302) did recall the CNA. Administrator asked if (R302) had ever given (CNA 'F') her card. (R302) said, 'No, the ONLY person I gave my card to was (CNA 'C')' (R302) went on to say that (CNA 'C') used the card for things (R302) was not aware of These transactions were discovered upon review of the bank statements .Before Administrator could reach out to (CNA 'F') for comment, (CNA 'F') texted the administrator the following message: 'I had no involvement in the situation, but I also know how fast words travel. If there's anything I can clarify or any information I can provide to assist, I'd be more than willing to speak with you.' .Because (R302) denied ever giving (CNA 'F') her debit card, and (CNA 'F') reaching out, unprompted, to provide a statement after the administrator spoke with (CNA 'C') The Administrator had the impression that (CNA 'C') may be impeding the investigation by contacting potential witnesses .With the information collected from (R302), (CNA 'C'), witness statements, bank statements, and (Facility) policies, the Administrator had satisfactory information to terminate (CNA 'C's) employment . On 3/27/25 at 10:07 AM, an interview was conducted with the facility's Administrator regarding R302's missing money. The Administrator reported CNA 'C' withdrew more money than R302 asked them to and after reviewing the statements, the amount of money withdrawn compared to the amount of money CNA 'C' gave to R302 did not add up and some of the money was missing. The Administrator further reported in addition to ATM withdrawals, CNA 'C' also used the card for point of sale purchases near their home which is not near the the facility. The Administrator further reported CNA 'C' accepting R302's debit card was against the facility's code of conduct. A review of a facility provided policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property was conducted and read, .DEFINITIONS OF ABUSE AND NEGLECT .d. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident ' s belongings or money without the resident ' s consent .It is the policy of the Facility that each resident will be free from 'Abuse' .

This citation pertains to intake #MI00150133. Based on observation, interview, and record review, the facility failed to ensure appropriate infection control practices related to transmission based precautions (TBP) for two residents (R#'s 300 and 307) of six residents reviewed for infection control. Findings include: R300 On 3/26/25 at 10:05 AM, R300 was observed seated in their wheelchair near the nursing station on the second floor. An interview was attempted, however; R300 did not offer any verbal response at the attempt. An observation of R300's room revealed no signage to indicate they were on any type of TBP or an isolation caddy hanging on the door containing personal protective equipment (PPE). Additional observations of the room on 3/26/25 at 1:38 PM and 3/27/25 at 10:00 AM continued to reveal no signage for TBP or isolation caddy on the door. On 3/26/25 at 12:00 PM a review of R300's physician's orders was conducted and revealed an active order dated 2/18/25 that read, Contact Isolation for Scabies. R307 On 3/26/25 at 9:55 AM, an observation of R307's room revealed an isolation caddy with PPE hanging on the door as well as a sign to indicate R307 was on both contact and droplet transmission based precautions. On 3/26/25 at 12:03 PM, Nurse 'G', R307's assigned nurse was asked why R307 was on contact and droplet precautions. After reviewing the orders Nurse 'G' said they did not know and would follow-up, however; they never followed up with an answer. On 3/27/25 at 10:00 AM, R307's room was observed to remain with the isolation caddy, and the contact and droplet signs posted to the door. On 3/27/25 at 11:10 AM, a review of R307's active, completed, and discontinued physician's orders was conducted and did not reveal any orders for transmission based precautions. On 3/27/25 at 11:53 AM, an interview was conducted with the facility's Director of Nursing and they said R300 should no longer be on TBP and the order should have been discontinued. They further indicated R307 should have had an order and indication for contact and droplet TBP. A review of a facility provided policy titled, Guideline for Standard and Transmission-based Precautions was conducted and read, .It is the practice of this facility to follow CDC (Centers for Disease Control and Prevention) established guidelines for determining the following: Standard and transmission-based precautions to be followed to prevent spread of infections. When and how isolation should be used for a resident, including but not limited to the following: 1. Type and duration of the isolation, depending upon the infectious agent or organism involved . The policy provided did not address whether there should be an order for the use of TBP.

This citation pertains to intake #: MI00147691, MI00147358 Based on observation, interviews and record review facility failed implement an effective discharge planning process for two (R901 and R902) of two residents reviewed for transfer/discharge, resulting in psychosocial harm using the reasonable person concept for R901 who has aphasia (difficulty communicating due to damage in the brain), a language barrier, and severe cognitive impairment, was discharged to another facility, farther away from family, without approval from the resident's representative and without notification to the other facility; and R902 feeling frustrated and dissatisfied with their living situation. Findings include: R901 A complaint received from another State Agency revealed the following: (R901's name omitted) family received a call from staff notifying them that (R901's name omitted) would be transferred to (facility name omitted). The staff stated (R901's name omitted) was being transferred because he wanders into other residents' room and the residents hit him. The staff stated they could not look for him when he wanders and unable to care for him anymore. At 2:30 PM, (R901's was transferred to (facility name omitted). A review of R901's Electronic Medical Record (EMR revealed R901 was admitted to the facility on [DATE] after a hospital stay. R901's admitting diagnoses included aphasia, dementia, anxiety disorder, nutritional deficiency, and chronic obstructive pulmonary disease (COPD). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed that R901's primary language was not English and they had severe cognitive impairment. R901 had limited ability to communicate due to their diagnosis of aphasia, cognitive impairment and language barrier. R901's spouse was appointed as their Durable Power of Attorney (DPOA) to make decisions on their behalf. During initial and follow-up observations completed on 12/10/24 at approximately 9:45 AM, 10:15 AM and 1:30 PM on the 2nd floor, the surveyor observed Velcro stop signs in doorways of three residents' rooms. An unknown resident was observed walking down the hall and attempted to enter other residents' rooms during those observations. During the observation at 1:30 PM, the resident was observed with unintelligible speech. Staff redirected the resident. When queried about the stop signs on the doors, Certified Nursing Assistant (CNA) A reported they had the signs on the rooms doorways of alert residents to redirect this resident who tends to wander into other resident rooms. Further review of of R901's EMR revealed a progress note titled transfer to hospital or other facility dated 10/3/24 read in part Arabic speaking gentleman with confusion, dementia, heart disease .needs more appropriate placement. Reason for transfer: Needs a more appropriate environment. Usual mental status: alert, disoriented, cannot follow commands. Documents sent: A face sheet was sent with the patient. Medication sheet was sent with the patient and current labs were sent with the patient. A nursing note dated 10/2/24 titled recapitulation of stay read under comprehensive care plan goals, smaller facility or lock down unit needed .spouse is very supportive. A social service progress note dated 10/2/24 at 14:18 read in part, (name omitted) the marketing liaison was here to see and evaluate resident for admission to community. Resident was accepted in both locations but will prefer the (location name omitted - where R901 was discharged to) .would like to receive the resident tomorrow at 11 AM . It must be noted that the location was the preference of the liaison. Further review of R901's EMR revealed social work progress notes dated 10/2/24, that revealed that referrals were sent to these facilities by the facility social worker. Social service progress note dated 10/2/24 at 12:01 read in part, Social worker called and spoke with resident spouse (name omitted). Writer informed his wife that I will be sending referral to (facility names omitted) for more appropriate placement. She responded his confused. Spouse states will be in today to visit. An interdisciplinary (IDT) team note dated 10/2/24 read, IDT discussed the resident for wandering, confusion, and eating food off other resident trays spouse visits often. SW (Social work) is attempting to find more appropriate placement for his cognition. Labs completed on 10/1/24 with nothing remarkable except valproic acid level was low . (name omitted) NP (nurse practitioner) texted . Further review of the records did not reveal that the facility provided any opportunity and or time to discuss the discharge plans with the R901's representative and asked for their input with the plan, location of the facility, how it would be a more appropriate set up for R901's care needs etc. by the facility's social worker and or the interdisciplinary team. There was no evidence that facility had involved the R901's representative/family to develop a resident specific discharge plan to address their care needs before R901 was discharged from the facility to a new facility that was located farther away from the family. A request was sent via e-mail to facility Administrator and Director of Nursing (DON) on 12/10/24 at 2:06 PM to provide any incidents/accidents reports and investigations completed for R901 during their stay at the facility. Facility reported R901 did not have any incidents/accident reports. Further review of R901's EMR revealed a form titled My Transition Home initiated on 10/2/24 at 3:49 PM with a locked date of 10/3/24 at 9:01 AM was not signed by resident/representative. The form read phone (spouse name omitted) -unable to come. The form also read that personal belongings were sent with the resident and it was later confirmed that R901 did not have any personal belongings when they arrived at the facility on 10/3/24. An initial interview was completed with R901's representative (spouse) and R901's daughter on 12/10/24 at approximately 11:35 AM. During the interview with resident representative R901's daughter was also present. R901's spouse reported they were at a hospital receiving care and their daughter was aware of what had happened and they were very involved in R901's care. R901's spouse reported that they were very upset about the discharge. They reported that they were notified by the facility social worker that they were looking for an appropriate placement the day before. They did not know they were transferring their spouse to another facility that was located about an hour away from where they lived. R901's daughter reported that their mother visited R901 almost every day of the week and they also called to check during the day. On 10/3/24, the day of discharge from the facility, R901's representative had called in the morning to check and they were notified by a staff member that R901 was still sleeping and they did not need to come in. Later that day, at approximately 10:30 AM, R901's spouse received a call from the facility social services director (SW) B about R901's transfer to another facility. R901's spouse had requested SW B' to call their daughter. R901's daughter reported that they had received a call from SW B on 10/3/24 at 10:56 AM that they were transferring R901 to the current location. R901's daughter had notified that they were unaware of this facility location and they did not want to approve the transfer to this location. They had notified SW B that this facility was located farther away from where their mother lived and did not want to transfer to this location. They added that they had notified R901's spouse/representative and family was open to look for a facility that was closer to where the spouse resided, as they visited R901 regularly. R901's daughter stated, he may not know us but he needs us. R901's daughter added that during the conversation with SW B they were notified that R901 needed more supervision and they did not have the staff to monitor. R901's daughter reported that they thought R901 stayed at the facility after their conversation. Later that day at 3:14 PM. R901's family received a call from the Social Worker from the facility R901 was transferred to (SW C) to notify them that R901 was at their facility. SW C told the family they were unaware R901 was being transferred to their location, R901 did not arrive with any personal belongings, and R901 was not able to provide any information. R901's daughter reported they attempted to call SW B multiple times on 10/3/24 after the transfer and they were unable to reach her. R901's daughter reported that their mother and brother went to the facility a few days after discharge and picked up R901's personal belongings. It must be noted that based on information received from transportation provider R901 was dropped off at the current facility at approximately 12:45 PM. A follow up interview was completed with R901's daughter on 12/10/24 at approximately 5:35 PM. They confirmed that their mother/R901's representative did not have a meeting with the staff at the facility or administration regarding any discharge planning related to their care needs for their father. They stated that it was done behind our back and their mother/R901's representative was very upset. An interview was conducted with SW B on 12/10/24 at approximately 12:40 PM. They were queried about the discharge planning process. They reported that the discharge planning process started on day one after a resident was admitted to the facility and followed up based on the resident's functional progress, care needs and wishes of the resident/resident representative. They were queried about R901's discharge to another facility and if their discharge plan was communicated with the resident representative. SW B reviewed the EMR and confirmed that R901 needed long term care. They reported that R901 needed 1:1, was restless, high risk for falls and needed more supervision. They added that R901 had a language barrier. They confirmed they had residents who had similar needs at the facility. When queried about other interventions that were tried prior to R901's discharge from the facility, no further explanation was provided. When queried if they met with their IDT and R901's representative/family to discuss R901's care needs, provided options/plan and involved them in planning prior to the transfer on 10/3/24 they stated no. They added that they would arrange for IDT to meet with the family if they had requested for a meeting. When queried about the concerns expressed by the representative about the location of the current facility and their preferences, SW 'B' reported they were not aware and added that if a resident or resident representative did not agree with the plan they would not discharge the resident and did not provide any further explanation. SW 'B' explained they might discharge residents / petition them out to the hospital if their behavior posed a threat to themselves or other residents or staff. They added it would have been documented in their progress notes. An interview with the Unit Manager (UM) D was completed on 12/10/24 at approximately 2:40 PM. During the interview they were queried about R901 and why they discharged to another facility. UM D reported that R901 had dementia, they wandered into other resident rooms, and they moved them into a different room/unit a few days after they were admitted . They added R901 took food off plates and needed close supervision; had their sleep cycles altered, usually slept during the day; and needed smaller facility. They added they did not have any other concerns, R901's family was very supportive; and R901's spouse visited them almost every day. They were queried if they had the resident/resident representative sign their discharge summaries after staff members reviewed and they added that it was verbal and they did not sign. A follow-up interview was conducted with UM D (who had also completed the discharge summary) on 12/11/24 at approximately 12 PM. During the interview they were queried if they spoke with R901's family member and they reported that they do not recall speaking with R901's resident representative on the day of discharge. They added that the social worker followed up. UM D was queried if they or their charge nurse called the facility R901 was transferred to on the day of discharge to provide information on R901 and they stated that they did not call. If their nurse did it should be on their progress note. They added that possibly their DON might have called the other facility. An interview with SW C was conducted on 12/11/24 at approximately 10:50 AM. During the interview they were queried about the R901 and their day of admission to their facility. SW C reported that the facility staff were unaware they R901 was being transferred to be admitted to their facility. They added that R901 was dropped off at their facility lobby and staff did not who R901 was and why they were there. R901 was not able to communicate and they were not able to provide any information. R901 attempted to walk and they were trying to keep him safe while looking for additional information. R901 did not have any of their medications or personal belongings with them. After some time, they were able to locate the face sheet and they had contacted the family and eventually they came in. An interview with Licensed Practical Nurse (LPN) E was completed on 12/11/24 at approximately 11 AM. LPN E worked at the facility where R901 was transferred to and they were the nurse on the floor on 10/3/24 (when R901 was admitted to the facility). They added that they worked on the 2nd floor and they were not expecting R901. R901 was transferred to their floor closer the afternoon shift and they were trying to help the other nurse. R901 did not have any information and they were dropped off downstairs. They were not able to obtain any information from R901. A follow-up interview was conducted with SW B on 12/11/24 at approximately 11:15 AM. During the interview they were queried if they had called and spoke with any staff member at the facility where R901 was transferred prior to transfer. SW B reported that they spoke with a liaison from the organization during the onsite visit and did not speak with any staff at the facility and added someone from nursing might have called the facility. They were queried how R901 was transported form their facility and they looked up on the computer and reported that R901 was transported in a wheelchair van by one of their transportation providers and provided their contact information. They had confirmed that no one from the facility accompanied R901 during the transfer on 10/3/24. An interview with the office staff for the (TS F) transportation provider was completed on 12/11/24, at approximately 12:20 PM. The call was placed by the facility administrator from their office. TS F was queried about the specifics of transport for R901 on 10/3/24. They reviewed their documentation and reported that they had provided the transport for R901 and the pickup was scheduled at 10:30 AM on 10/3/24. It was further reported they provided transportation one other time for R901 for an appointment and the driver noted during the transport R901 attempted to take off the seat belt and was not safe. The driver recommended having a staff member to accompany R901 for any future appointments. An interview with the DON was conducted on 12/10/24 at approximately 2:55 PM. They were queried about the facility's discharge planning process. The DON reported that discharge planning started on day one after admission into the facility and it involved their IDT, resident, or resident representative based on their goals. The DON was queried about R901's discharge and if they were involved in the process and/or had a meeting with the resident's representative. The DON reported that they did not meet with the resident representative, but the social worker and unit manager were involved. They added R901 had a language barrier and they were ambulatory and the unit manager might be able to provide additional information. A follow up interview with the DON was conducted on 12/11/24 at approximately 11:35 AM. They were queried on the expectation from their team with discharge/transfer process. The DON added the nursing staff reviewed the discharge instructions with the resident/resident representative if they were onsite or via phone. The DON was queried about their expectation for their staff to call to provide report the facility residents were transferred to and medication supplies during the transfer/discharge to another facility. The DON reported that it would be the best practice for the nursing team to call and provide a report to the facility that residents were transferred to, but it did not happen consistently. Also, the facility process was not to send any medications if residents were transferred to another skilled nursing facility. When queried further on medications that R901 needed to take that day until pharmacy was able to deliver their medications at the other facility, they reported that facility might be able to use their back up if those medications were available. An interview with the facility's Administrator was conducted on 12/11/24 at approximately 12:35 PM. During the interview they were queried about their expectations for discharge planning and facility-initiated discharge process and they reported that they expected their staff to follow the discharge planning policies and to keep the resident/resident representative/guardian involved in the process. R902 A complaint received by the State Agency revealed that R902 would like to move to another facility and had requested assistance from staff. R902 preferred to be in a private room and they were not getting updates from the facility. A review of R902's EMR revealed R902 was admitted to the facility on [DATE]. R902's admitting diagnoses included Parkinsonism, bipolar disorder, arthritis, diabetes, heart failure and Chronic Obstructive Pulmonary Disease (COPD). Based on the Minimum Data Set (MDS) assessment dated [DATE], R902 had intact cognition and needed supervision to minimal assistance from staff for their mobility and Activities of Daily Living (ADLs). An observation of R902 was completed on 12/10/24 at approximately 9:55 AM. R902 was observed in the bed watching television. R902 had a shirt and sheet covering their body. R902 stated, I want to get out this place, right now and added that they had already addressed this with the facility and no follow up has been made. R902 was upset. At approximately 12:25 PM, R902 was further interviewed. R902 reported they spoke with facility staff over a month ago about transferring to a different location and have not heard anything. An e-mail was sent to the facility administrator on 12/11/24 at 9:35 AM and they were asked to provide any grievances and follow-up for R902 from 9/1/24 to 12/10/24 and was notified that they did not have any grievances. Further review of of R902's EMR revealed a social work (SW) progress notes dated 10/7/24 that noted the social worker attempted to assess the resident, the resident was upset and asked to leave them alone. A SW progress note dated 10/21/24 at 13:34 revealed that a referral to other skilled nursing facilities were made by the social worker. A SW progress note dated 10/21/24 at 14:23 revealed that social worker had called the Ombudsman and notified that referrals were sent to five facilities that R902 had requested. The note read one admission director from one facility called and notified that they did not have any beds. Further review of EMR revealed no further follow-up with R902 or any referrals that were sent. An interview with SW B was completed on 12/10/24 at approximately 12:40 PM. During the interview they were queried about the R902's request to transfer to other facilities and their discharge planning. SW B reported that they were still working on placement and they had sent referrals to facilities in October. When queried if they had called the followed up with facilities and if they had spoken with R902 and provided updates. SW B reported that they had not spoken with any other facilities and had not spoken with R902 and did not provide any further explanation. On 12/10/24 at approximately 2:10 PM, SW B provided copies of the documents that were sent to other facilities. They reported that they were faxed over. There were no fax confirmations and they added they received call back from one facility and they did not have any beds. They had confirmed that they did not call to follow up and did not provide any updates since October 2024. An interview with Admissions Coordinator (AC) G from one of the facilities where R902's referral was sent was completed on 12/10/24 at approximately 2:20 PM. They were queried if they had received R902's referral and they reported that they received a fax. They were not a provider for R902's insurance carrier so they were not able to accept the resident and reported they must have notified the facility. A review of the facility provided document titled Discharge Summary and Plan read in part, When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge .Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and includes: a. where the individual plans to reside. b. arrangements that have been made for follow-up care and services. c. a description of the resident's stated discharge goals. d. the degree of caregiver/support person availability, capacity and capability to perform required care. e. how the IDT will support the resident or representative in the transition to post-discharge care. f. what factors may make the resident vulnerable to preventable readmission; and g. how those factors will be addressed. The discharge plan is re-evaluated based on changes in the resident's condition or needs prior to discharge. The resident/representative is involved in the post-discharge planning process and informed of the final post-discharge plan . Another document provided by the facility titled, Transfer or Discharge, Facility Initiated dated 10/2022 read in part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Policy Interpretation and Implementation: Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: a. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility. b. the transfer or discharge is appropriate because the president's health has improved sufficiently so the resident no longer needs the services provided by this facility. c. the safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident. d. the health of individuals in the facility would otherwise be endangered . Facility-Initiated Transfer or Discharge 1. Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. 2. In some cases, residents are admitted for short-term, skilled rehabilitation under Medicare, but, following completion of the rehabilitation program, they communicate that they are not ready to leave the facility. In these situations, if the facility proceeds with discharge, it is considered a facility-initiated discharge. 3. A resident's declination of treatment is not grounds for discharge, unless the facility is unable to meet the needs of the resident or protect the health and safety of others. 4. The facility will document that the resident or, if applicable, resident representative, received information regarding the risks of refusal of treatment and that staff conducted the appropriate assessment to determine if care plan revisions would allow the facility to meet the resident needs or protect the health and safety of others .

This citation pertains to intake: MI00141154. Based on observations, interviews, and record reviews the facility failed to ensure a Licensed Practical Nurse (LPN) H Immediately responded to a reported change of condition for R402 who was reported to the nurse as unresponsive, resulting in delayed follow up care, delayed initiation of Cardio Pulmonary Resuscitation (CPR), delayed summoning of Emergency Medical Services and death, for one (R402) of one resident reviewed for CPR. Findings include: The Immediate Jeopardy began on [DATE], when LPN H failed to timely follow up on R402 who was reported as unresponsive. The Administrator and Director of Nursing (DON) was notified of the Immediate Jeopardy on [DATE] at 3:24 PM. The surveyor confirmed by interviews, and record reviews that the Immediate Jeopardy was removed on [DATE], but noncompliance remains as isolated due to sustained compliance that has not been verified by the State Agency (SA). Review of a complaint submitted to the SA documented in part . There was a 30 minute delay in between when a CNA (Certified Nursing Assistant- later identified as CNA D) found the decedent unresponsive and when CPR was initiated. Life saving efforts failed and the decedent was pronounced dead . The staff and this facility were negligent in beginning life saving care for the decedent (R402) and should be investigated . This complaint was submitted by the local Police Department. Review of the medical record revealed R402 was admitted to the facility on [DATE] with diagnoses that included: dementia, chronic systolic and diastolic congestive heart failure, systemic lupus, and end stage renal disease. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 8 (which indicated moderately impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of a Nursing progress note dated [DATE] at 9:27 PM, documented the following in part, . At approximately 1615 (4:15 PM) on coming CNA (later identified as CNA D) ask <sic> writer if resident normally sleeps slumped down in w/c (wheelchair), writer replies yes. At approximately 1630 (4:30 PM) another CNA (later identified as CNA E) ask <sic> writer does resident normally sleep bent over in chair. Writer replies yes and adds that resident is also a hard sleeper after dialysis and if she can assist resident back to bed I will be in to assess. At approximately 1645 (4:45 PM) Writer exits another resident's room and hears someone screaming for help. Writer proceeds up the hall accompanied by another CNA and enters room and observed what appears to be that resident is unresponsive. Resident observed to have head in lap which is not unusual behavior due to being cold after dialysis. CNA and writer assisted resident to bed and writer begins to assess resident. NO pulse noted upon palpation. Resident unresponsive to name being called and sternum friction rub. CNA remains with resident as writer checks code status and initiates code for all staff to respond. Writer returns to room and immediately and <sic> nurse manager shortly follows. CPR initiated, AED applied, 911 called and V/S (vital signs) taken every 2 min (minutes) and were unable to obtained . At approximately 1710 (5:10 PM) EMS (Emergency Medical Services) arrives and takes over CPR . Resident pronounced deceased at 1747 (5:47 PM) . The note was documented by Licensed Practical Nurse (LPN H). On [DATE] at 12:25 PM, a telephone interview was conducted with CNA D (the first CNA to have identified a change of condition with R402 on [DATE]). CNA D explained on [DATE] they had initially worked the first floor and their assignment was switched upstairs. CNA D stated they were training another CNA (CNA E) that day. CNA D stated they went into R402's room and seen that the resident was . slumped over like she was going to fall out of the chair, and I tried to wake her up. I shook her and she still didn't wake up. I raised her head and it dropped (immediately plopped) back down. I rubbed her chest, nothing . She was not responding and I ran to get the nurse (LPN H name) who is (R402's) regular nurse and told her (LPN H) that (R402 name) was not responding to me and I can't wake her up and she told me that I have to shake her hard and I told her that I did and asked her to come and check on her and she said [NAME], that's how she normally is . CNA D went on to say that LPN H knew R402 better than they did because LPN H was R402's regular nurse, so they went on to finish their checks of other residents. CNA D stated in part . I didn't have a good feeling so I sent her (later identified as CNA E) to go and see if she could wake her up . I did send her (CNA E) over there to check up on her (R402) being that I couldn't wake her up and she (R402) was not responding to me. CNA D' stated that when they were interviewed by the corporate staff, they told her that she could have done more at that time for R402, which made it seem like CNA D did not do what they were supposed to do. CNA D stated they did everything they could to wake R402 and seen that the resident was unresponsive and ran to inform the nurse. CNA D stated they felt like they did what they were supposed to do. CNA D stated when they informed LPN H that R402 was not responding LPN H did nothing. CNA D stated in part . This is what really bothers me, she (LPN H) did not move. She wouldn't budge, she didn't move when I asked her to come and see. I never had a nurse that would never come and see what I wanted . I never had a nurse that didn't move and that's the problem with (LPN H name) . On [DATE] at 1:01 PM, a telephone interview was conducted with CNA E who stated they were very upset about R402 to have been found unresponsive and the delay of LPN H's follow up of R402 condition. CNA E stated they decided to end their employment with the facility due to the incident of the delayed care for R402. CNA E was asked to recall the events on [DATE] and CNA E explained it was their second day on the floor (they were newly employed at the facility), and their assignment was switched mid-day. CNA E explained they were paired with CNA D that day. CNA E stated they found CNA D in one of the resident rooms and they asked if they needed help and CNA D asked them to go across the hall and check on R402 because . she looked like she is dead and she said the nurse said this is how she acts when she comes back from dialysis and looked at me all crazy and did not check on the resident . CNA E stated they went into R402's room and . she (R402) was slumped down all the way, her head was down to her knees . there was no pulse, so I started yelling for help . CNA E stated they went to inform LPN H. CNA E then stated they didn't understand why LPN H did not go and assess R402 when they were first informed by CNA D that the resident was unresponsive. CNA E stated they did not like the way the facility handled the situation and decided to not continue their employment with the facility. Review of a police investigation (submitted by the police department) documented the following in part . [DATE] / Interview with (CNA D name) . at approximately 1630 hrs. (hours) (CNA D last name) checked on (R402 name) in her room and found her seated in her wheelchair and laying over onto her bed. She said she tried to reposition (R402 name) in her wheelchair, and she was unresponsive. She said she went and told the nurse, (LPN H name) . and (LPN H name) said that (R402) is always like that, that she always sleeps really hard and you have to shake her to wake her up . (CNA D last name) directed (CNA E) to go check on (R402 name) across the hallway again explaining to her she had been unresponsive earlier. (CNA E last name) went to check on (R402 name), found her unresponsive without a pulse, and began yelling for help . Further review of the police investigation documented the following interview in part with CNA E, She (CNA E) said her trainer, (CNA D name), had told her sometime between ,d+[DATE] hrs. she had previously checked on (R402 name) and believed she might be deceased . (CNA E last name) told me (CNA D last name) told her she had told the nurse (LPN H name) she thought (R402 name) might be dead, and the nurse reportedly said, She's always like that, and did not go check on her (R402) . (CNA E last name) stated this was approximately 1700 hrs. and she checked on (R402 last name). She found her (R402) slumped down in her wheelchair and without a pulse . The interview went on to document how CNA E went to inform the nurse. On [DATE] at 2 PM, two attempts were made to conduct a telephone interview with LPN H, however unsuccessful. The Administration team was asked to contact LPN H so that a telephone interview could be conducted. On [DATE] at 4:22 PM, the Director of Nursing (DON) entered into the conference room with LPN H on their telephone. LPN H was asked to call the surveyor for an interview and a telephone interview was conducted shortly after. LPN H was asked to recall the date of [DATE] when R402 was found unresponsive. LPN H stated a young lady came to them and asked if R402 normally sleeps across the bed and they told the CNA (identified as CNA D) that the resident normally does sleep that way. LPN H stated they told the CNA to get R402 in their bed. LPN H stated they were with another resident when another young lady (identified as CNA E) came and asked the same question, and they asked CNA E had they put R402 in bed yet. LPN H stated they decided to check and heard the young lady (CNA E) scream and they rushed into (R402) room and saw the resident slumped in their chair. LPN H stated they checked R402's breathing and pulse and R402 was absent of both. LPN H stated they went out the room to check what R402 code status was, once identified that R402 was a full code, they yelled back down the hall for the staff to start CPR. LPN H was asked if they were informed that R402 was not responsive by CNA D and CNA E and LPN H denied being informed that the resident was unresponsive and stated both CNAs asked about how the resident was sleeping. Review of the police investigation documented the following interview in part with LPN H, . at approximately 1630 hrs. certified nursing assistant/CNA (CNA D name) came to her stating (R402 name) was seated in her wheelchair and slumped over onto her bed. (LPN H) name told (CNA D name) that is how (R402 name) sleeps sometimes. At approximately 1700 hrs. (CNA E name) came to (LPN H name) stating she had found (R402 name) slumped down in her wheelchair and unresponsive with no pulse. (LPN H name) stated she went to grab her computer cart to look up (R402 name) chart to see if she had a do-not-resuscitate/DNR order on file. She told (CNA E last name) she and (CNA D last name) should take (R402 name) out of her wheelchair and place her onto her bed . Staff members were already beginning life-saving efforts on (R402 name) when (LPN H name) entered into the room . Further review of the police report documented in part . contacted (Hospital Physician name). (Hospital Physician name) pronounced (R402's name) to be deceased on [DATE] at approximately 1747 hours (5:47 PM). On [DATE] at 2:03 PM, the Corporate Regional Director (CRD) B (who filled in for the Administrator for the first day of survey, in the Administrator absence) was asked to provide the facility's camera footage for the hallway of R402's room on the date of [DATE]. Review of a facility Verification Of Investigation regarding the death of R402 on [DATE], documented in part .SUMMARY OF FACTUAL INVESTIGATION FINDINGS . On [DATE] . At approximately 4:55 PM, Certified nursing assistant, (CNA E name) entered (R402 name) room and observed her slumped over in her chair. (CNA E name) summoned for charge nurse, (LPN H name) who enters (R402's name) room approximately 30 seconds later. (LPN H name) initiated a code blue and continued with advanced life saving measures until EMS arrived to take over . The facility investigation failed to identify, acknowledge, and document that R402 was initially found unresponsive by CNA D and reported to LPN H, before having been reported that R402 was identified as unresponsive by CNA E and reported to LPN H, for the second time. On [DATE] at 9:47 AM, the facility's Administrator, Director of Nursing (DON), CRD A and later joined by CRD B was interviewed and asked why the facility failed to identify and address the fact that CNA D initially informed LPN H of R402 to have been found unresponsive and the delay of follow up provided by LPN H, who later identified R402 absent of a pulse and not breathing and none of the Administration staff responded. The DON was then asked if LPN H should have followed up with R402 after CNA D initially informed them that R402 was unresponsive, and the DON replied that LPN H should have assessed the resident the first time after they were informed of the change of condition by CNA D. On [DATE] at 1:30 PM, the facility allowed the surveyor to review the camera footage for the hallway where R402 resided for the date of [DATE]. In attendance of the camera review was the Administrator, DON, CRD B and CRD A. The Administrator stated the camera footage was off by 22 minutes. When asked how they identified the video footage was off by 22 minutes, the Administrator explained the footage was 22 minutes faster and they verified that by reviewing the times of the other facility camera footage, the clocks on the wall from the video footage and by the time R402 was seen on the camera arriving back from dialysis on the date of [DATE]. The video footage was reviewed, and the time was displayed in the 1700's (5 PM time frame). At 17:01 CNA D is seen entering into the room of R402, shortly after CNA D is seen running from R402's room (to inform LPN H of their findings, not observed on camera). Per the Administration team there is a dead spot where they were unable to capture CNA D talking to LPN H. Further review of the video footage failed to show CNA E entering into the room of R402, however showed CNA E leaving out of the room at 17:17 (Per the Administration staff it must have been a glitch in the video footage). LPN H is observed to have entered into the room at 17:17, this is the time that LPN H confirms that R402 is without a pulse and is not breathing. CPR is then initiated minutes after 17:17. The Administrator is observed on the video footage at 17:23 arriving with the facility's Automated External Defibrillator (AED) in hand and entering into the room of R402. In total, there is a 16-to-17-minute delay from LPN H to have been initially informed by CNA D of R402 to have been identified as unresponsive and for LPN H to have responded, and more than a 17-minute delay to initiate CPR and the use of an (AED) on R402 who was identified without a pulse and was not breathing. Review of the American Heart Association 2023 Hands - Only CPR - American Heart Association International , documented in part . In a cardiac arrest, every second counts . Every minute CPR is delayed, a victim's chance of survival DECREASES BY 10% . Immediate CPR from someone nearby can double-even triple-their chance of survival . https://international.heart.org/hands-only-cpr/ Review of the fire department report documented an Alarm Date & Time of [DATE] at 16:59 (4:59 PM) . and an Arrival Date & Time of [DATE] at 17:03 (5:03 PM) . Review of a facility policy titled Notification of Changes Guideline (Revised [DATE]), documented in part . It is the practice of this facility that changes in a resident's condition . are immediately . reported to the attending physician . Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification . to ensure best outcomes of care for the resident . The facility nurse failed to immediately follow up on the concerns reported (initially by CNA D) to LPN H regarding R402 to have been unresponsive which delayed nursing follow up, the initiation of CPR and the use of the AED. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the imediacey: Element 1 Resident 402 no longer resides in the facility. Element 2 Residents who currently reside in the facility have the potential to be affected. All current residents have been assessed by a licensed nurse including current set of vitals to identify if any change of condition has been noted. No concerns were identified. Element 3 An Adhoc Quality Assurance and Performance Improvement meeting was held on [DATE] with Interdisciplinary team and medical director. Facility's Notification of Change and Cardiopulmonary Recitation guideline along with the American Medical Directors Association Acute change of Condition in the Long-Term Care Setting guideline was reviewed deemed appropriate for education. The Director of Nursing/Designee educated all licensed nurses working in the facility on the guidelines with specific attention to timely assessment of patient's noted with a change of condition, and if a resident requires such emergency care that nurses are to follow the procedure including simultaneously assess the resident for breathing and pulse for 10 seconds and if need to activate the emergency response system and CPR. The mentioned nurse received one to one education from Director of Nursing. Any assigned agency nurses will receive education prior to working their shift. American Medical Directors Association's Know it all before you call, essential clinical data collection: a guide for nurses on reporting change of condition has been added to all clinical desktops for quick access and all nurse reference. Element 4 To ensure continued compliance Director of Nursing/Designee will review clinical alerts daily for 2 weeks, then 5x weekly for 3 months to ensure timely corresponding nursing assessment. The Director of Nursing/Designee will audit residents who have had a change in condition 3x weekly for 4 weeks, then weekly for 3 months to ensure appropriate interventions and treatment are in place.

This citation pertains to intake: MI00139836. Based on interviews and record reviews the facility failed to ensure physician orders were transcribed and implemented as ordered by the Physician Assistant, ensure abnormal laboratory results were reported to the physician, ensure an EKG and echocardiogram was completed as ordered by the physician, and ensure the appropriate mode of transportation services were activated to transport the resident to the hospital for one (R909) of one resident reviewed for a change of condition, which resulted in the delay of care including the administration of antibiotics, treatment and medical services and required the resident to be transferred and admitted to the hospital for a higher level of care. Findings include: Review of the medical record revealed R909 was admitted to the facility on [DATE], with a readmitted [DATE] and diagnoses that included: rhabdomyolysis, quadriplegia, lack of coordination and anoxic brain damage. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 (which indicated intact cognition) and required staff assistance with all ADLs. Review of a Physician Assistant progress note dated 8/28/23, documented in part . Patient is being seen at nursing's request. Nursing reports that patient was complaining of right lower quadrant abdominal pain last evening. Patient is seen currently lying in bed. He states that he is feeling short of breath . It is noted during exam that patient has intermittent cough appears to be guarding when he coughs. Patient is admitting to lower abdominal pain . Patient is appearing uncomfortable . Will get stat abdominal x-ray. Will get stat laboratory studies . Although patient is not tachypneic he is having episodes of decreased 02 saturations between 89 and 90%. We will get stat chest x-ray. Nursing is advised to apply 02 2 L (liters) via nasal cannula for 02 saturations less than 90% . Although patient has history of chronic pain and is on multiple controlled medications it is unusual for him not to be requesting an increase of both medications given the discomfort he is currently exhibiting. Patient will require close monitoring . Review of the medical record revealed an order for the administration of the oxygen to maintain a 90% saturation level was never transcribed and implemented as documented by the Physician Assistant. Review of a Nursing note dated 8/29/23 at 8:20 AM, documented in part . Xray report possible Bowel obstruction. MD (Medical Doctor) notified. New orders in place Dextrose-Sodium Chloride Intravenous Solution 5-0.45% (Dextrose w (with)/Sodium Chloride), Use 80 ml (milliters)/hr (hour)intravenously every shift for bowel rest for ileus for 2 Days . 12 lead ekg (electrocardiogram) - r/o (rule out) pericarditis, STAT (immediate) for r/o pericarditis - pleuritic chest pain, Pt (patient) is NPO (nothing by mouth) status . Review of a Physician note dated 8/29/23, documented in part . Review of abdominal x-ray is significant for an ileus . Patient indicates that he does not have abdominal pain but rather pain that began midsternal and has now moved to the right side of his chest and subcostal area . after awaking him he is breathing more quickly and shallowly. Pain seems as if it may be pleuritic. In questioning a possible pericarditis. I will initiate treatment with ibuprofen and check an EKG and echocardiogram looking for signs of pericarditis. We will also note any potential signs of right heart strain on the EKG as pulmonary embolism is also on the differential, albeit lower. If diagnostics are consistent with a pericarditis, we will also consider initiation of colchicine . Review of the physician orders revealed on 8/29/23 at 7:57 AM, a 12 lead ekg was ordered STAT and at 8:00 AM, an echocardiogram was ordered. Review of the medical record revealed no results of an EKG or echocardiogram to have been completed. Review of a Nursing note dated 8/29/23 at 7:16 PM, documented in part . writer is unable to successfully start iv (intravenous) on patient. Writer calls <sic> (third party name) to start iv . Review of the laboratory results collected on 8/28/23 at 6:37 PM and reported to the facility on [DATE] at 9:27 PM, documented multiple abnormal values, which included a [NAME] Blood Cell Count (WBC) of 17.1 (Reference Range- 3.5-10.6) which indicated a possible infection or inflammation in the body. Review of the medical record, Physician/Physician Assistant/Nurse Practitioner notes revealed no acknowledgment of the review of the laboratory results and/or the abnormal WBC count. Review of a Nursing note dated 8/30/23 at 8:29 AM, documented in part . Remain NPO (nothing by mouth) as ordered for bowel obstruction and is to start IV fluids via peripheral line. RN (Registered Nurse, RN Name) unable to start line. F/u (follow up) done with (third party name) RN . NP (Nurse Practitioner name) notified and order <sic> to start resident on Hypodermoclysis until peripheral insertion . Review of a Nursing note dated 8/30/23 at 11:25 AM, documented the third-party RN to have initiated a peripheral line in the right upper arm. Review of a Physician Assistant progress note dated 8/30/23, documented in part . Patient was seen recently in regards to feeling short of breath and abdominal pain . Patient has been placed n.p.o. An IV was unable to be established yesterday and patient was started on hydrodermoclysis <sic>. A midline IV has just been placed .Patient states he is not feeling any better. He continues to appear to be guarding with deep inspirations . Patient states that he feels like he has a fever although his temperature has been normal . Patient seen laying in bed appearing somewhat uncomfortable . Review of a Discharge/Transfer nursing note dated 8/31/23 at 8:41 AM, documented in part . Patient having abd (abdominal) pain and experiencing SOB (shortness of breath). Patient had recent ABD (abdominal) X Ray and Doctor wants patient sent out to rule out ABD obstruction . Transportation has been called and awaiting for arrival. Patient to be sent to (hospital name) . This note was documented by Licensed Practical Nurse (LPN) B. On 10/10/23 at 11:24 AM, LPN B was interviewed via telephone. LPN B was asked the presentation of R909 on 8/31/23 when they transferred the resident to the hospital and LPN B replied in part . I had literally just got on shift and did my rounds. I was concerned in what I was told in report, so I said let me check on him and when I went in there he was short of breath . He was short of breath and using his accessory muscles to breathe . When asked if the resident had on oxygen, LPN B replied No, everything was happening so fast that their thought process was to get the resident out to the hospital. LPN B was asked what transportation services they called to transfer the resident to the hospital and LPN B replied they called 911. Review of the record did not document which transportation services were called to transport R909 to the hospital. On 10/10/23 at 11:40 AM, the Director of Nursing (DON) was interviewed and asked the facility's protocol when a physician orders medications, treatments, or oxygen to be administered, the DON was asked if it was the physician or nurses' responsibility to transcribe and implemented the orders and the DON replied it was both. The DON stated the physicians, nurse practitioners and physician assistants will usually put in their own orders, or they may give a verbal to the assigned nurse. The DON was then asked why the oxygen orders were never ordered as directed by the physician assistant on 8/28/23 and the DON stated they would look into it and follow back up. The DON was then asked how the facility obtains the results of the labs ordered on the residents and the DON stated the results are sent through a portal to the electronic medical system in the residents' record. The DON stated if the labs are critical the laboratory will call the facility and inform the nurse. When asked whose responsibility it is to report to the physician any abnormal laboratory results for a resident with a recent change of condition the DON replied the nurse assigned to the resident. The DON was asked about the lab results for R909 that was provided to the facility on [DATE] that was never acknowledged or followed up by the facility's staff and clinicians and the DON stated they would look into it. The DON was also asked to provide the results of the EKG and echocardiogram that was ordered on 8/29/23. The DON was then asked to provide documentation on what transportation services was called to transport R909 to the hospital. At 1:38 PM, the DON returned and stated they did not see the oxygen order transcribed or implemented as ordered and documented by the physician assistant. The DON stated the EKG and echocardiogram were not done as ordered due to the facility on going issues with the third-party company. The DON stated they were not able to provide an explanation on why the labs were not documented as reviewed and reported to the physician. The DON then provided documentation of an actual wheelchair and specialty transport company (name withheld) that utilizes vans and minivans for wheelchairs and large party accommodations as the mode of transportation used to transport R909 to the hospital. The DON was asked why 911 was not called to safely transport the resident that was observed to be in distress and the DON stated initially the nurse (LPN B) did not feel that it was necessarily appropriate. The DON was informed of the interview conducted with LPN B to have described the distress that R909 was in when they observed the resident and the DON then stated they were unsure on why the nurse called the transportation services instead of 911 and the nurse had not been back to the facility since for them to follow up on this. The DON was then asked to provide any additional information or documentation that pertained to the above concerns. Review of a facility policy titled Laboratory, Radiology, and Other Diagnostic Services Guideline dated 6/1/20, documented in part . Purpose: To ensure laboratory, radiology and other diagnostic services meet the needs of residents, that results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis, and treatment . Our facility is responsible for quality and timeliness of the services . The facility failed to follow their policy and ensure the laboratory results were reported to the provider and failed to ensure that the ordered EKG and echocardiogram was completed. Review of the transportation documentation provided revealed LPN B had not called 911 for transport of a distressed resident, but indeed called a transportation company to transfer the resident to the hospital. Review of a facility policy titled Notification of Changes Guideline revised 7/24/19, documented in part . A significant change in the resident's physical, mental, or psychosocial status that is a deterioration in the health, mental or psychosocial status in either life threatening conditions or clinical complication . In life threatening conditions activate the emergency response system immediately . This indicated R909 who was observed to have shortness of breath and utilizing their accessory muscles to breathe should have been transported to the hospital by the emergency response system, via 911 utilizing the Emergency Medical Services (EMS) who are qualified and trained medical personnel and who have the necessary equipment to safely transport the resident to a higher level of care to ensure timely treatment. Review of the hospital Internal Medicine History and Physical note dated 8/31/23 at 4:19 PM, documented in part . He states for the last 2 weeks he has experienced stabbing sensation over the right lower chest when he talks or takes a deep breath . He says has <sic> been couching with the feeling of sputum production but has not been able to get it out . PHYSICAL EXAM . In mild distress . Unable to inspire fully due to pain. Poor air movement . WBC (white blood cell count) 15.9 . HI (High) . CT (computerized tomography) Abd (Abdomen)/Pelvis: Large consolidations and loculated effusions at the right base empyema cannot be excluded . Chest x-ray: Interval development patchy airspace opacities in portions of the right mid and lower lung field since prior evaluation. Pneumonia is suspected until proven otherwise . CT Thorax: Pneumonia with a small, loculated right pleural effusion. Decreased image resolution limits evaluation for empyema . Impression and Plan Pneumonia, right middle and lower lobe, Right sided loculated pleural effusion . Cefepime (antibiotic) 2 g (grams) and linezolid (antibiotic) 600 mg in ED (Emergency Department) (Patient with parapneumonic effusion, empiric antibiotics started with IR thoracentesis (a procedure that uses imaging guidance and a needle to help diagnose and treat pleural effusions) with fluid analysis pending . Further review of the hospital record revealed the resident was admitted to the Intensive Care Unit (ICU) and had a VATS (Video-assisted thoracic surgery) procedure with a chest tube implemented for drainage. No further explanation or documentation was provided by the end of the survey.

Based on interview and record review the facility failed to timely assess, monitor and follow physician orders for one R72 of one resident reviewed for hospitalization resulting in a decrease in R72's condition (sepsis) and hospitalization . Findings include: A review of R72's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: bipolar disorder, depression, dementia and atrial fibrillation. R72 was discharged to the hospital on 2/15/23. Review of R72's Minimum Data Set (MDS) indicated the resident had a Brief Interview for Mental Status (BIMS) score of 6/15 (severely cognitively impaired) and required extensive one to two person assist for most activities of daily living. Continued review of R72's clinical record documented, in part, the following: 2/13/23 -Physician Progress Noted (authored by Physician Assistant (PA) H: .Patient seen recently due to weight loss and increased agitation .UA (urinalysis) C & S (culture and sensitivity) was ordered but has yet to be completed. Have discussed with nursing need to collect urine specimen via straight cath . *It should be noted that review of physician orders for R72 revealed an order dated 2/10/23 - Order Summary: Type of Lab cmp (comprehensive metabolic panel), Mg (magnesium), cbc (complete blood count) w/diff. As documented in PA H's note above there were no lab results until 2/15/23 in R72's clinical record pertaining to the 2/10/23 order. 2/13/23 (10:47 PM) - Heath Status Note (Authored by Nurse G): Resident observed in bed clammy, sweating profusely and tachycardic (increased pulse/heart rate) .BP (blood pressure) 146/87, P (pulse) 163.Spo2 (oxygen level) 89% .Writer called MD (Medical Doctor). Order received to put resident on 02 (oxygen) at 3L (liters) . It should be noted that review of R72's electronic record showed no order for O2 at 3L. There were no additional documents that indicated R72's O2 levels were monitored while on 3L 02. 2/13/23 (11:04 PM) SBAR (situation, background, assessment and recommendation) General Assessment: Situation: Name: R72 .what is the situation: Resident observed in bed tachycardia, clammy and labored breathing .Vitals (make sure the most current vitals are listed or you can add edit and update while completing the SBAR) : Blood Pressure -106/77 (date 2/7/23), Most Recent Pulse-61 bpm (date 2/7/23), Most recent Respiration- 20 breath/min (date 2/7/23), Most recent -Temperature 97.3 (date 2/7/23), O2 sats 91.0% (date 2/7/23) . Pain Level - 0 (date 2/12/23) .signs and symptoms .Hypoxia .Dyspnea .Weakness .confusion . *It should be noted that the vitals placed in the SBAR assessment were not current and dated as 2/7/23. There were no notes entered in R72's clinical record on 2/14/23. There were no vitals documented in R72's record for 2/14/23. The last electronic set of vitals noted in the resident's record was dated 2/7/23. Review of R72's MAR noted an order dated 4/18/22 that read Vitals BP/Pulse/Resp/Temp/02 Sats every evening shift. The response to the order was checked as completed however there was no indication as to the results of the vitals. The next note entered into R72's clinical record was dated 2/15/23 (11:27AM): .Resident has low BP 81/45 and tachycardic this morning .Resident encouraged to drink more fluids. Resident is cold and clammy with mottled Feet noted in bilateral extremities. (Authored by Nurse G) *It should be noted that this Note did not contain any information that indicated the resident's Physician was contacted. 2/15/23 (3:06 PM) Laboratory Results noted, in part: .White Blood Cell Count 15.6 (flagged as abnormal result (high) -usually meaning sign of infection) . 2/15/23 -Health Status Note: Order received from PA that was present in the facility at 4:30PM to send resident to ER (emergency room ) for Hypotension and Tachycardia. Writer called EMT (Emergency Medical Transport) and resident was transferred to (name redacted) Hospital at 4:50 PM for further evaluation . (Authored by Nurse G) On 5/10/23 at approximately 11:05 AM an interview and record review were conducted with Registered Nurse G. Nurse G was queried as to the facility's protocol for obtaining resident's vitals. Nurse G reported that vitals should be obtained every shift. When asked where the results of the vitals would be located, Nurse G reported that they can be entered into either the MAR, resident notes or in the Vitals tab in the electronic record. When asked why they entered R72's vitals dated 2/7/23 into the SBAR/Assessment note dated 2/13/23 and again in the Discharge to Hospital assessment dated [DATE], Nurse G was not certain as to why, but noted the last vitals recorded may have populated into the form. When reviewing the Health Status notes with Nurse G it appeared as if there were no notes, vitals, assessments completed on 2/14/23. Nurse 'G was queried as to whether they endorsed their concerns to the oncoming Nurse and/or the Director of Nursing (DON). Nurse G reported that they believe they did, but they did not work on 2/14/23 and was not sure what happened on that day. When asked when they determined the resident had a low BP of 81/45 on 2/15/23 at approximately 11:27 AM did they contact the physician. Nurse G stated that they believed they did but did not record the conversation. On 5/10/23 at approximately 12:15 PM an interview and record review were conducted with the DON. The DON was queried as to R72's change in condition and delay in monitoring the resident's vitals, monitoring SP02 levels and a delay in obtaining lab orders. The DON reported that vitals should be noted at least daily in the resident's electronic record. With respect to orders pertaining to lab work, lab services are generally in the building on Monday, Wednesday and Fridays and more if STAT labs are ordered. With respect to R72, the DON noted that there should not have been such a long delay regarding the lab order. As for a lack of documentation regarding R72's vitals, the DON noted that they should be taken and recorded in the resident's record. When asked about the potential order for O2 at 3L, the DON stated that an order should have been entered and O2 levels should have been monitored. . On 5/10/23 at approximately 10:23 AM, an e-mail was sent to (name redacted) hospital requesting R72's hospital records with a start date of 2/15/23. Hospital records were received on 5/12/23 and a review of (name redacted) Hospital records documented in part, the following: .presents toER on ,d+[DATE] . for abnormal blood work including high blood cell count and tachycardic at their facility. They were cold and clammy per reports .Pt (patient) now being managed for sepsis with antibiotics .Pt had gone into A-fib with RVR (rapid ventricular response) on admission .Assessment and Plan .patient has underlying dementia .stage IV pressure injury of the right heel .has been on IV antibiotic therapy .Sepsis likely from CAP (community acquired pneumonia) .Discharge Summary .Suspect Community Acquired Pneumonia . Pressure injury right heel .Present on arrival ,Wound care consult noted . *It should be noted that during the Survey review of R72's MAR/TAR had no documentation that R72 was being treated for a Stage IV pressure sore on the right heel. The facility policy titled Notification of Changes Guidelines (Revised 7.24.19) was reviewed and documented, in part: .Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representatives, and the resident's physician, to ensure best outcomes of care for the resident .

This citation pertains to Intake #MI 162 and MI 268 Based on observation, interview, and record review the facility failed to ensure one resident (R701) was cared for in a safe manor free from abuse, out of three residents reviewed for abuse, resulting in a spiral nondisplaced distal fracture of the left arm (a fracture caused by a pulling, twisting, or yanking motion of the arm). Findings include: A complaint and Facility Reported Incident were filed with the State Agency and alleged that R701 sustained an injury of unknown origin (fracture to the left arm) and alleged the resident was abused by employee/certified nursing assistant (CNA) W. A review of the facility's policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property (Effective date 11.28.2017) documented, in part: Purpose: .An .employee .of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident .Centers for Medicaid and Medicare Services (CMS) .DEFINITIONS OF ABUSE AND NEGLECT .a. Abuse: Abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish. It should be noted that CMS defines Willful as used in the definition of abuse as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. On 12/28/21 at approximately 8:55 AM, R701 was observed sitting in bed eating her breakfast. The resident had a blue colored splint/cast on the left arm. When asked what happened to her arm, R701 stated that someone who worked at the facility twisted her arm and it broke. R701 stated she was not in pain. When asked when it happened, the resident stated, a few weeks ago. When asked if she could identify the staff person, the resident stated a first name and described the staff person as a female and black. R701 noted that she had not seen her in sometime. When asked if she told someone after it happened, R701 said I don't know. A review of the resident's clinical record revealed R701 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) documented the resident had a BIMS score of 11/15 (moderately impaired cognition) and needs two person assist for transfers. Continued review of the clinical record revealed: A progress note dated 12/9/21: Resident c/o (complains of) left arm pain, (name redacted) NP (nurse practitioner) in room and ordered stat left arm wrist elbow Xray . 12/10/21 Health Status Note: .Stat Xray performed results showed an acute FX (fracture) to LT (left) forearm .PT (patient) sent out for a cast . An Orthopedic SOAP (Subjective, Objective, Assessment and Plan) note dated 12/10/21 documented, in part, Subjective: The patient .presents today with complaints of pain in the LEFT FOREARM. The onset was acute without injury that occurred a few nights ago when she states one of the aides in her residence .was rough handling her and twisted her LEFT ARM .Imaging .There is a spiral nondisplaced non-angulated distal ulnar shaft fracture .Plan .I place her in a short arm waterproof cast .she is having some pain .patient will avoid weightbearing left upper extremity .I will transition her to a brace and there is physical therapy available at her residence . A review of the Incident/Accident (IA) report documented, in part, .Incident Summary Resident has a fracture of unknown source .Investigation Summary Resident alleges that an aide had pulled on her left arm while she was in bed resulting in pain .After ongoing investigation, the facility feels R701 was improperly positioned while in bed, during an incontinent episode .the Resident continues to reside in the facility .although the facility Administration does not believe this was an intentional injury, due to the employee is within 90 days of employment, disgruntled attitude and interfering in an investigation (texting other staff member regarding the incident) the suspected violator <sic> has been terminated . Continued review of the I/A report included Interview Statements as follows: A typed/unsigned document dated read, in part: Wednesday 12/8 (Nurse U) notified me that R701 stated someone pulled on her arm during care . Continued review of the typed/unsigned document read: Thursday 12/9 (name redacted) activity aide notified me that R701 stated that someone pulled her arm, she replied the aide (name redacted) pulled it .When writer observed her arm two small yellow bruises were noted. One near inner wrist area and just below the antecubital area . The faciilty later reported that this typed/unsigned document was authored by the Administrator/Abuse Coordinator. 12/9/21: Interview/Statement: Person Interviewed: (CNA W) .I was taking care of R701 for the second day in a row. I have cared for her very often and I am familiar with her turning and positioning. That night she had loose stools which is sometimes normal for her .I last changed and repositioned her approximately 2145 (9:45 PM, no date was provided). She did not complain of pain or discomfort. When I left her room, she was resting quietly and ask me to give her a mint and her water .At no time that shift did I touch her arm or turn or reposition her. She turns herself when she is asked .She usually lies on her left side with her arm tucked under her body . 12/10/21: .Interview conducted today with R701 at her bedside .R701 initially refused to answer questions or speak with writer until writer assisted her back to bed. Writer inquired what happened to resident's arm: R701 replied I don't know, she broke it .R701 does not recall exactly what happened .R701 states I don't recall .Asked if CNA was positioning her in the bed, R701 replied I don't recall. Writer asked who was she? R701 stated (CNA W's first name), the black girl. She believed her to be a CNA who is new to the facility .states she has been her CNA many times, stated she is normally sweet and calls me (name redacted) honey or Miss (name redacted). R701 alleges she twisted her arm and then said, this will be our little secret .Writer inquired if she thought it was an accident and R701 agreed stating she (the CNA) did not want to get into trouble .R701 does not recall telling anyone about the incident until the next day when she told her son . Further review of this statement revealed it was signed by the Director of Nursing (DON). 12/10/21: Interview/Statement Record: Person interviewed (CNA T) .12/10/21. When was the last time you worked with R701? Tuesday 12/7 and Wednesday 12/8. Has R701 complained of pain? Wednesday 12/8 where? L Arm. Has R701 stated how she was hurt. R701 did not want to talk about it. Name starts with letter (letter redacted) on midnight shift .CNA T told the nurse. No bruises noted on arm on Wednesday. 12/10/21: Interview/Statement Record: Person interviewed: Nurse U .12/10/21 .Has R701 complained of pain? 12/8/21 after lunch. Where? Arm. Has R701 stated how she was hurt? 12/8 CNA T came and told nurse R701 was c/o arm pain, nurse assessed resident did not see any bruising, no redness, no swelling noted. R701 said the midnight CNA (first name redacted) pulled her arm and now it hurts. Nurse informed the Administrator on 12/8/21 . On 12/28/21 at approximately 1:40 PM an interview and record review were conducted with the Administrator/Abuse Coordinator and the DON. The Administrator reported that Nurse U had reported that on 12/8/21, CNA T told her the R701 complained of pain in the left arm. The resident was assessed, and we did not find any bruising or swelling, and she never told us her arm was twisted. On 12/9 during a zoom call with the R701's son, R701 stated that someone had pulled her arm and we noticed she had some bruising. X-rays were ordered and it was determined the resident had a fracture. We went back to see who was assigned to the resident and determined that it was CNA W. We did some education with her pertaining to proper bed mobility and transfers. The bruises appeared as if her arm was pulled. The DON indicated that CNA W was suspended, terminated, but rehired after a thorough investigation. The DON also reported that CNA V was in-serviced on timely reporting change in condition following an interview on 12/10/21 in which she stated the R701 complained of pain on the midnight shift 12/7/21. The Administrator and DON were asked to provide a copy of the facililty policy pertaining to abuse and further whether abuse is determined by intention only. The Administrator reported that they did not feel the resident was abused. On 12/28/21 at approximately 3:01 PM a phone call was made to CNA W and a voice message was left. No return call was made by the end of the Survey. On 12/28/21 at approximately 3:10 PM an interview was conducted with CNA V regarding the incident. CNA 'V recalled working the midnight shift on 12/7/21 and R701 was constantly putting on her call light so CNA W got her out of bed, and she was saying her arm hurt. She said my arm got twisted but never told me how or what happened. I should have told a nurse that evening, but she was put back to bed and I never heard anything again. On 12/28/21 at approximately 3:30 PM a phone interview was conducted with Nurse U regarding R701 Nurse U reported that she worked the day shift on 12/8/21 and was told by a CNA that the resident was complaining of pain in her arm. The Nurse recalls she had worked with her in the morning and R701 had not complained of pain or told her anything. Later in the afternoon the resident told CNA T that her arm got twisted by a CNA and they reported it to the Administrator. Nurse U further reported that the resident was assessed, no bruising or swelling was noted, and the resident was given a Tylenol for pain.

This citation pertains to intake #MI 7 Based on observation, interview, and record review, the facility failed to implement pressure ulcer prevention interventions, ensure complete, consistent, and accurate skin assessments and wound consultations, as well as ensure treatments were completed per physicians orders to prevent the development and or redevelopment of pressure ulcers for one resident (R801), of one resident reviewed for pressure ulcers, resulting in verbalized complaints and the development/re-development of a stage III pressure ulcer on their left foot (full-thickness tissue loss where subcutaneous fat, slough and eschar may be present, granulation tissue, and rolled edges are often present). Findings include: A review of a complaint reported to the State Agency included an allegation regarding the services and treatment for [REDACTED]. A review of R801's clinical record was conducted and revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. R801's Minimum Data Set assessment dated [DATE] indicated R801 had intact cognition, had no behaviors including rejection of care, was non-ambulatory, required extensive assistance of two staff for transferring and bed mobility, had bilateral lower extremity range of motion deficits, had a suprapubic catheter, and was incontinent of stool. A review of R801's most recent Braden Score (a score for predicting risk for pressure ulcer development) assessed on 11/12/20 indicated they were a high risk for developing pressure ulcers. On 1/20/21 at 10:25 AM, R801 was observed in bed lying on their back. It was observed R801 had a low air loss mattress on their bed to assist with offloading pressure. In the corner behind the door, an overhead trapeze set-up system was observed. At that time, an interview was conducted with R801. R801 said the trapeze had been in corner since it was ordered for them and they wished they could have it placed over their bed so they could use it to re-position themselves in bed. On 1/20/21 at 1:05 PM and 3:00 PM, R801 was observed in bed, still positioned on their back. On 1/21/21 at 9:20 AM, the Administrator was asked if the facility had a wound care nurse. The Administrator reported the facility did not currently have a wound care nurse, the assigned nurses performed the treatments and the wound care consultant rounded with Unit Manager 'J' every Wednesday. On 1/21/21 at 9:30 AM, upon entry to R801's room, the overhead trapeze set-up was observed in the corner of the room behind the door. R801 was observed in bed on their back. It was observed R801 had on soft heel pressure reducing boots, however R801 had slid down in bed and the balls of his feet were pressed against the bed's footboard. Both of R801's feet had dressings applied and were wrapped. At that time, an interview was conducted with R801. R801 was asked about the wounds on their feet and said, I got them because I slide down in bed and my feet press on the footboard. R801 continued to explain that if they had the overhead trapeze to use, they could pull themselves up in bed and get their feet off the footboard. On 1/21/21 at approximately 11:20 AM, R801 was observed in their bed on their back. At that time, R801 was asked if they had been assisted to reposition or be pulled up in bed. R801 indicated no one had assisted or offered him assistance for repositioning. R801 said, I thought I was supposed to call and ask for help, they don't offer. The overhead trapeze system remained in the corner of the room behind the door. On 1/21/21 at 2:10 PM, R801 was again observed in bed. At that time, it was observed the overhead trapeze system had been placed over the bed for R801's use. When queried about the trapeze, R801 said They moved it over here so I can use it. When asked about their ability to use the device, R801 demonstrated how they were able to pull themselves up towards the head of the bed preventing pressure to their feet from the footboard. On 1/21/21 at 2:20 PM, an interview with Certified Nursing Assistant (CNA) 'G' was conducted about and repositioning residents. CNA 'G' explained they knew which residents needed to be repositioned because it would show on the resident's Kardex (CNA care guide) and there was a place for them to sign off on the electronic (name of electronic medical record) to show they had repositioned residents. When asked if they (as the CNA) identified a resident that needed assistance with re-positioning, but it wasn't on their Kardex or in the electronic medical record for documentation could they add it; and CNA 'G' indicated they could report it to the nurse and the nurse could add it to the Kardex and electronic medical record. On 1/21/21 at 2:55 PM, the facility's Director of Nursing was asked about documentation for repositioning residents and they explained staff knew to reposition residents based on their Kardex and to show it had been done, it was documented on the CNA's charting. A review of R801's CNA documentation and task list was conducted and did not reveal a task for CNA's to sign off that they had been repositioning R801. Continued review of R801's record was conducted and a review of R801's weekly skin assessments was conducted and revealed the following: An assessment dated [DATE] indicated a sacral pressure ulcer and abrasions on the right and left foot. It was noted the next weekly skin assessment documented in R801's record was dated 1/5/21. The assessment on 1/5/21 did not identify any skin impairments and in response to the question 1. Does the resident have ANY skin issues observed? A box marked No was checked, and note at the bottom of the assessment read, No new skin issues reported. The weekly skin assessment dated [DATE] was also noted to have No marked for question 1. The weekly skin assessment dated [DATE] indicated R801 had ulcerated area(s) on their right heel, left heel, and sacrum. Continued review of R801's record included a review of R801's weekly wound care consultations performed by Nurse Practitioner 'I' and revealed the following in regard to R801's left foot pressure ulcer: A consult dated 11/4/20 indicated a .Left Foot Stage 3-Proximal .Measurement: Length 6.0 (no unit of measurement) Width: 4.5 Depth: (blank) ., and a Resolved . (circled on the wound care form) Left Foot Stage 3-Distal . A consult dated 11/11/20 that did not address any pressure ulcers on R801's left foot. A consult dated 11/18/20 that indicated a Left Dorsal Foot Stage 3 .Measurement: Length 1.0 (no unit of measurement) Width: 1.0 Depth: (blank) . A consult dated 11/25/20 that indicated a .Left Dorsal Foot Stage 3 .Measurement: Length: 1.5 (no unit of measurement) Width: 1.2 Depth: 0.2 . A consult dated 12/2/20 that indicated a .Left Dorsal Foot Stage 3 .Measurement: Length: 2.0 (no unit of measurement) Width: 1.2 Depth: 0.5 . A consult dated 12/9/20 that indicated the Left Dorsal Foot Stage 3 had been Resolved as circled on the consultation form. Consults dated 12/16/20, 12/23/20, 12/30/20, 1/6/21, and 1/13/21 were reviewed and did not indicate the presence of a pressure ulcer on R801's left foot. A request was made for NP 'I's weekly wound care documentation for their visit on 1/20/21 was requested on 1/21/21 at 1:52 PM, however; it was not provided by the end of the survey. A document titled, WOUND ASSESSMENT DETAILS REPORT dated 1/20/21 contained in R801's record was reviewed and read, .Wound .Left Plantar-scattered .Wound Information .Type: Pressure .Clinical Stage: Stage 3 .Size (cm) 5.50 x 1.50 x 1.40 . On 1/21/21 at 4:10 PM, a phone call was placed to NP 'I'. NP 'I' returned the call at 5:00 PM, and an interview was conducted. NP 'I' was asked about R801's Left foot pressure ulcer having once been healed and they indicated the pressure ulcer had healed but did not recall the date. They were asked about the current status of R801's left foot and having a stage 3 pressure ulcer and they said, It either re-opened or it's a new ulcer. A review of R801's treatment orders and Treatment Administration Records (TAR) was conducted and revealed the following: An order dated 12/11/20 to cleanse all open areas on the left foot and apply a wound care treatment of [REDACTED]. A new order dated 12/23/20 to cleanse all open areas on the left foot, apply a treatment of [REDACTED]. A new order dated 1/4/21 to cleanse all open areas on the left foot, apply a treatment of [REDACTED].no [MEDICATION NAME] available . The treatment for 1/17/21 was left blank on the TAR, and the treatment on 1/18/21 not documented as being completed with an accompanying nursing note that read, .[MEDICATION NAME] not available, a new bandage was applied . On 1/21/21 at 4:30 PM, an interview with Unit Manager 'J' was conducted regarding the facility's availability of [MEDICATION NAME] wound care treatment. Unit Manager 'J' indicated that before taking the Unit Manager position, they had been the facility's wound care nurse, and [MEDICATION NAME] was a house stocked product, stored downstairs. Unit Manager 'J' indicated the staff member probably just didn't go look for it. On 1/21/21 at approximately 4:15 PM, a follow-up interview was conducted with the Director of Nursing and Administrator regarding concerns around R801's pressure ulcer. During the interview, they were asked why R801's trapeze had not been set up for use until 1/21/21 and it was explained that maintenance went to the room on 1/21/21 and adjusted it properly or added another part to it so it would fit over the bed properly. When asked why it hadn't been done prior to 1/21/21, they indicated Maintenance could explain, however; upon request, no one from the Maintenance Department reached out prior to the exit of the survey. They were then asked about missing treatments and indicated the treatments should be done per physician's orders [REDACTED]. A review of the facility provided policy titled, Skin Management Guideline Effective 11/28/17 was conducted and read, I. Prevention of Pressure Ulcers .Interventions for prevention, removing and reducing predicting factors and treatment for [REDACTED].Adaptive equipment and seating to support and encourage correct anatomical alignment .B. Monitoring of Skin Integrity .Weekly skin observation on the bath/shower day will be performed by a Licensed Nurse .II. treatment of [REDACTED]. Update the Care Plan for Skin Integrity and nursing assistant care cards with skin concern .turning intervals and interventions as appropriate .11. When a pressure ulcer is present, daily wound monitoring .

This citation pertains to Intake(s): MI 3493. Based on observation, interview, and record review, the facility failed to ensure physical abuse did not occur for five (R#s 818, 821, 822, 823, and 825) of 20 residents reviewed for abuse, resulting in a severely cognitively impaired resident (R#818) being physically abused by a staff member who forcibly removed their wedding ring from their finger causing injury and forcibly pushed them into a chair twice during the same shift causing psychosocial harm using the reasonable person concept; and R#823 punching R#821 in the face causing the resident to feel unsafe and express fear of going to sleep, attempting to hit R#822 causing them to fall, and hitting R#825 multiple times in the back. Findings include: R#818 A complaint was submitted to the State Agency that alleged, in part, the following: .There is a 4 minute struggle on and off with a medical assistant at the facility. The medical assistant was observed pushing on (R#818) and taking her ring off of her finger. This incident occurred on ,[DATE] and was observed on video. (R#818) sustained a injury to her finger which was scabbing over .The medical assistant has been arrested as of ,[DATE] . An unannounced onsite investigation was conducted from [DATE] through [DATE]. R#818 was admitted on [DATE] (the day of the above physical abuse) with [DIAGNOSES REDACTED]. A 5 Day Minimum Data Set (MDS) assessment dated [DATE] documented R#818 was unable to complete a Brief Interview for Mental Status (BIMS) assessment. A staff assessment documented R#818 had moderately impaired cognition for decision making and required cues and supervision. The MDS documented R#818 had verbal, other, rejection of care, and wandering behaviors. On [DATE] at 11:15 AM, video footage from the date in question ([DATE]) was observed with the facility's Administrator and revealed the following: At 6:59 PM on [DATE], R#818 was observed seated in the hallway near the 2nd floor nurses station with a rolling table placed in front of them. From 7:07 PM until 7:10 PM, R#818 stood up from the chair, walked with the rolling table to the nurses station and began picking up random papers placed at the nurses station. There was no staff present at that time. At 7:10 PM, Certified Nursing Assistant (CNA) Q entered the area where R#818 was located and followed the resident with a chair to try to get them to sit down. Between that time and approximately 8:00 PM, R#818 was observed repeatedly standing up from the chair, including climbing on the steps that led to the upper part of the 2nd floor unit. During this time, various staff members, including CNA Q were observed to be present and not present in the 2nd floor nurses station area. In the video at 8:04 PM, R#818 was observed to stand up and walk behind the nurses station desk. CNA Q entered the same area at that time and was observed holding on to R#818's right arm and pulling on the resident's right hand. R#818 was observed to place her hand up to her mouth as if to indicate shock or surprise. CNA Q continued to direct R#818 over to a chair located near the nurse's station while holding the resident's arm and directed them into the chair. When zoomed in on the resident's hand a ring was observed to be located on their right hand ring finger. CNA Q then left the unit. R#818 immediately stood back up and walked behind the desk a second time. CNA Q was observed to approach R#818 behind the nurses station desk at approximately 8:07 PM, grabbed the resident's hand and pulled on their arm. There appeared to be a physical struggle between CNA Q and R#818 and CNA Q was observed to forcibly pull on R#818's right hand and slide something into their pocket. During this time, R#818 a facial grimace is observed at one point which indicated R#818 may have been in pain. CNA Q then led R#818 back to the chair and forcibly pushed the resident backward into the chair. R#818 appeared confused and exhausted. When zoomed into R#818's hand, their ring was no longer present on their finger. At 8:10 PM, CNA Q was observed playing basketball with balled up papers over R#818's head, throwing the paper from behind R#818, over their head and across the nurses station desk. Further review of the video footage was conducted and R#818 was observed to repeatedly stand from the chair and attempt to walk around the area and wandered out of the camera view. At 8:29 PM, R#818 was observed being brought back to the 2nd floor nurses station area in a geriatric chair (large padded chairs with wheeled bases that are designed to assist individuals with limited mobility) in a reclined position by CNA Q. CNA Q shoved the chair from the foot rest backwards onto the unit causing the chair to roll backwards away from CNA Q. R#818 was observed to climb out of the geriatric chair. At 9:00 PM, CNA Q was observed to grab R#818 under their arms and around their body and forcibly place them back into the geriatric chair. A staff member (identified by the Administrator as Nurse R) was observed to be in direct vicinity and within view of R#818 and CNA Q and was not observed to provide assistance or intervene. After review of the video footage, the Administrator was interviewed about the forcible manner in which CNA Q was observed to handle R#818. The Administrator stated, It was a little rough. On [DATE] at 2:30 PM, a police report provided by the local police department was reviewed. The police report documented R#818 was a victim of strong arm robbery and elder abuse by (CNA Q) who was arrested on [DATE]. The police report was made by R#818's family member and alleged R#818 was transferred to a local hospital after a fall at the facility. At the hospital, the family member noticed R#818's wedding ring finger was all bloodied and her ring was not on her finger anymore. (R#818's family member's name redacted) found this to be peculiar because the staff at (hospital name redacted) were unable to get her wedding ring off, without causing her too much pain, so they let her continue to wear it. The police report further documented, in part, the following: .I then went to the facility to review the cameras. We were able to narrow down the time frame of when the ring went missing, ultimately observing the elderly abuse and strong arm robbery on video surveillance .Observed on video on [DATE] at 20:04 hrs (8:04 PM), it appears that (CNA Q) attempts to remove (R#818's) ring from her finger but is unable to. (R#818) covers her mouth with her left hand in shock. At 20:07:34 hrs (8:07 PM and 34 seconds) the ring is still visible on (R#818's) finger. At 20:07:45 hrs (CNA Q) grabs (R#818's) hand and arm and pulls her hand down to the side. There is a brief struggle and a moment when (R#818) looks as though she is in pain. At 20:07:53 it appears as though (CNA Q) drops something into his right shirt scrub pocket with his left hand. (CNA Q) then forcibly moves (R#818) to her chair where is forcibly makes her sit down. When (R#818) lays back in her chair appearing exhausted at 20:08:09 hrs, it is obvious that (R#818's) ring is no longer on her ringer <sic> . On [DATE] at 7:45 AM, Nurse U was interviewed. Nurse U reported they worked on the night R#818 fell and was transferred to the hospital. Nurse U reported they received a phone call from R#818's family member prior to R#818 returning to the facility and the family member reported the resident's ring was missing. Nurse U further explained that R#818's family member told her that R#818's ring was previously difficult to remove during the hospital stay prior to their admission into the facility which was why the resident wore it to the facility. When queried about any assessment of R#818's fingers, Nurse U reported R#818 had old scabs but they were on their right hand (the hand R#818 wore the wedding ring on). On [DATE] at 10:12 AM, Nurse U provided additional information. Nurse U reported they read the hospital records when R#818 returned to the facility and they documented the missing ring and injury to R#818's finger. There was no documentation in R#818's clinical record regarding any new or old injury, including scabs, to their right ring finger. Hospital records received by the facility upon readmission on [DATE] documented R#818's family was concerned about the resident's wedding ring being missing and it was documented R#818's right ring finger was swollen. A Report of Resident Grievance/Compliments dated [DATE] and completed by Nurse U documented, Res. was sent to the (hospital name redacted) post fall. (Family members names redacted) met her at the ER where they noticed she did not have her wedding ring on. (Family member) called the facility to report it missing . R#821, R#822, R#823, and R#825 A report was made by the facility to the State Agency on [DATE] that CNA Z reported to the Director of Nursing (DON) that R#823 allegedly hit R#821 in the face. It was also reported that R#823 tried to hit R#822 which caused them to fall from the bed to the floor. On [DATE] at 9:45 AM, R#821 was observed lying in bed. R#821 was interviewed regarding the alleged incident with R#823 that occurred on the evening of [DATE]. R#821 stated, I was sound asleep when a man came in. He put his hand on my arm and on my leg and then he hit me in the face! I was screaming the whole time. I was terrified! He's so much bigger than me and I couldn't get him away. R#821 reported screaming for approximately two to three minutes before staff came in and removed the resident. When queried about how R#821 felt after the incident, R#821 stated, I am not feeling safe. I don't think he is here anymore, but I don't feel safe. I don't sleep at night. Anyone can come in here and terrorize me when I'm sleeping! On [DATE] at 9:55 AM and 1:25 PM, interviews were attempted with R#822. On both occasions, R#822 was observed lying in bed sleeping and did not respond when their name was called. On [DATE] at 3:45 PM, CNA Z was interviewed via the telephone. When queried about what occurred with R#823 on the evening of [DATE], CNA Z reported they were not assigned to R#823, but recalled around 7:00 PM they saw R#823 exit R#821's room and closed the door. CNA Z reported they heard loud screaming from R#821's room and when they went to check on R#821, they reported R#823 hit her in the face. CNA Z further reported she then went to tell the DON who was in their office on the upper level of the 2nd floor unit and when she returned, R#823 was in R#821's room again. CNA Z reported she then redirected R#823 out of R#821's room and the DON and the other CNA (CNA M) tried to monitor him until the police came to pick him up. On [DATE] at 3:24 PM, the DON was interviewed. When queried about what occurred with R#823 on the evening of [DATE], the DON reported she was working the floor with one other nurse from a contracted agency and two CNAs (CNA Z and CNA M) the DON reported around 7:45 PM, CNA Z came to get her and explained R#821 said R#823 punched her in the face. The DON further explained she went down to see what happened and R#823 was not with the CNAs. When the DON was talking to R#821 about what happened she heard another resident yelling. The DON reported it was R#822 who was observed on the floor in their room on their right side with playing cards around him. According to the DON, R#822 reported R#823 came into their room, tried to hit them and they leaned and fell to the ground. The DON further explained that she was trying to divert R#823's attention by having him assist with the garbage but R#823 shoved the DON against the wall and punched her in the ribs multiple times. At that time, the DON reported the police were called to stay with the resident until EMS arrived to transfer R#823 to the hospital. The DON stated, We did not have enough staff to do 1:1 with him so we called the police to stay with him. The DON reported that before the police arrived to the facility, there was an altercation between R#823 and his roommate R#825 which resulted in R#823 punching R#825 in the back. When queried about whether or not the CNAs and the other nurse working on that shift reacted appropriately to R#823's behaviors, the DON reported she could not find the other nurse due to the nurse going on a break without informing the DON that they left the unit. The DON reported that it appeared the CNAs were nervous about getting hit by R#825 and should have contained the resident and kept him in sight. The DON stated, We did the best we could. R#823's clinical record was reviewed and revealed R#823 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented R#823 had moderately impaired cognition. A review of R#823's progress notes revealed a note written on [DATE] at that documented, Aide (CNA Z) informed Director of Nursing (name redacted) at approximately 7:58 PM that witnessed resident (R#823) come out of resident (R#821) room shutting the door. Heard (R#821) screaming get out of here. Aide (CNA Z) asked (R#821) what happen. (R#821) stated that the man touched me. Director of Nursing (name redacted) went into (R#821) room in which (R#821) stated that the man just came into my room and punched me in the face, noted red mark to the right side of face, (R#821) also stated that the man hit her twice in the right thigh and grabbed her leg, (R#821) also stated that she kicked at him and he left. When speaking with (R#821) heard two men yelling, notice (R#823) coming out of the room at the end of the hall on the right side. Resident (R#822) was yelling out he was laying on the floor, on the left side of bed, bedside table had playing cards on them, resident stated he was sitting on the side of the bed toward the window playing cards when a man entered room and almost hit him he leaned to the left and slid out of bed onto the floor onto right hip . A second progress note written on [DATE] documented, pt being sent to ER due to combative behaviors and fighting with residents. pt punched DON 3 times in ribs. pt is wandering and punched roommate in the back twice. A Late Entry progress note for [DATE] documented, Resident was placed on ,[DATE] till police arrived and sent out by EMS with petition to hospital for aggrieve <sic> behavior. However, in an interview with the DON (as documented above) there was not enough staff to provided 1:1 supervision for R#823 prior to police arrival. R#821's clinical record was reviewed and revealed R#821 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented R#821 had moderately impaired cognition. R#821's progress notes were reviewed and revealed a note written on [DATE] at 1:45 PM as a late entry for the event that occurred on [DATE]. The progress note documented, Late Entry .Resident informed staff that a man entered her room and hit her in the face and thigh, along with grabbing lower leg. No noted issues to the skin at this time (a progress note written in R#823's clinical record documented R#821 had a red mark on her face). Resident doesn't fear staying here just doesn't want the man to enter her room again, closed the resident room door and informed that the man would not enter again tonight . There were no additional progress notes documenting R#821's emotional health following the incident of physical abuse by R#823. R#822's clinical record was reviewed and revealed R#822 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented R#822 had modified independence for decision making, unclear speech, and required extensive physical assistance for bed mobility and transfers. R#822's progress notes revealed a note written on [DATE] at 7:50 PM that documented, pt had a fall that was seen by CNA. pt was laying on left side. pt complains of pain in left hip. pt stated he was playing cards and slid out of bed. However, this documentation is not consistent with the DON's interview or the documentation in R#823's clinical record that noted R#822 fell out of bed after R#823 entered the room at tried to hit him. R#825's clinical record was reviewed and revealed R#825 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS assessment dated [DATE] documented R#825 had severely impaired cognition and verbal and other behaviors. R#825's progress notes were reviewed and revealed a late entry note written for [DATE] that documented, Late Entry: .Resident and roommate were having a disagreement in their room when the resident in bed B (R#823) had walked out of the room and down the hall, the resident in A bed (R#825) came out of the room continuing to yell at resident in B bed. Resident from B bed turned around and before staff could redirect, resident from bed B began hitting resident from A bed in the back several times . A review of a facility provided document titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property with an effective date of [DATE] was reviewed and it documented, .Abuse Policy .It is the policy of the Facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse .Additionally, resident will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection .

This citation pertains to MI 416: Based on interview and record review, the facility failed to consistently and accurately assess the resident's skin to promptly identify changes in skin condition, implement treatment orders recommended by the facility's wound Nurse Practitioner (NP), and ensure interventions were implemented in a timely manner to prevent the development and worsening of pressure ulcers for one (R#815) of four residents reviewed for pressure ulcers, resulting in the worsening of a coccyx wound to an infected, draining malodorous stage IV (full thickness skin and tissue loss) pressure ulcer which required sharp debridement to the muscle and antibiotic use at the hospital, the development of a facility-acquired unstageable (obscured full-thickness skin and tissue loss) pressure ulcer to R#815's right heel, and pain. Findings include: Review of a complaint received by the State Agency alleged the resident was brought into the hospital emergency room by emergency medical services (EMS), in part, related to increased drainage and a foul odor from a sacral decubitus ulcer. Review of the clinical record for R#815 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE], it was documented the resident scored 9 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident was moderately cognitively impaired. Per this assessment it was documented R#815 was at risk for pressure ulcer/injury development and had one Stage 2 (partial-thickness skin loss with exposed dermis) pressure ulcer documented as present on admission. Also, per this assessment it was documented R#815 required the extensive assistance of two plus persons for bed mobility and transfer. Continued review of R#815's medical record revealed the following: Per the skin section of the resident's Nursing Evaluation (Admit/Readmit, Qtly (Quarterly), Annual, Sig (Significant) Change) - V 4 dated 3/19/20 R#815 was noted to have the following skin integrity concerns to the coccyx: has purple area to coccyx and has open area between buttock. No other sites of skin abnormality were identified on the body diagram section of the assessment. Review of R#815's admission Comprehensive Nutrition Assessment (Admission/Sig Change/ Annual) - V 3 dated 3/25/20 documented a response indicating No to the following question: 1d. Presence of skin alteration/s. Also, per section titled Assessment it was documented, No pressure ulcers noted at this time. Per a Skin Observation - V 1 form dated 3/28/20 it was documented the resident had a small lesion between buttocks at the site of the coccyx. Review of skin observation tools for R#815 for April 2020 revealed the resident had an assessment completed on 4/1/20 and 4/20/20. No other Skin Observation - V 1 tools were observed in the resident's clinical record for the month of April 2020. Per a Skin Observation -V 1 form dated 4/1/20 it was documented R#815 had a Lesion between buttocks at the site of the coccyx. Review of a WOUND ASSESSMENT DETAILS REPORT for R#815 dated 4/1/20 identified the resident had a present-on-admission pressure ulceration to the coccyx, which had been staged as a stage 1 (intact skin with localized area of non-blanchable redness). Per the Tissue Types section it was documented, [MEDICATION NAME] (Pale Pink or Red) =100%. Measurements per the 4/1/20 assessment were as follows (measured in centimeters, cm): 1.50 x 0.50 x unknown (L x W x D) (Length x Width x Depth). The form documented an outcome of probable improvement to the site. Review of a WOUND ASSESSMENT DETAILS REPORT for R#815 dated 4/22/20 also documented the resident's coccyx wound as a Stage 1, which measured the following (cm): 10.00 x 0.4 x Unknown (L x W x D). Per a Wound Care H & P (History and Physical)/Consult form by Nurse Practitioner (NP) 'A' for R#815 dated 4/29/20 it was documented R#815 had three wounds, including a right gluteal UTD (unable to determine), a right heel DTI (deep tissue injury) and a right great toe DTI. Documentation for the right gluteal UTD documented the wound measured 9.5 (unit not written) in length times 4.5 width. Depth was not documented on the assessment. The form documented the site as 100% eschar (dead tissue), dusky in color, had attached edges, and denuded surrounding skin. Nothing had been selected on the form to indicate the presence or absence of drainage or odor to the wound. Per the form R#815's right gluteal UTD was to be cleansed with normal saline, a (Brand name ointment) was to be applied to the wound, a (Brand Name barrier cream) was to be applied to the peri-wound, and the area was to be covered with (both border and non-border gauze had been circled) QD (daily) and PRN (as needed.) Review of R#815's Treatment Administration Record (TAR) for April 2020 documented R#815 received treatment to the coccyx on 4/1/20-4/5/20. No additional treatment other than a barrier cream was documented as administered to the coccyx area for the remainder of the month. Review of Wound Care Progress Notes dated 5/6/20 by NP 'A' documented, in part, the following that had been handwritten on the form: NEEDS AIR LOSS MATTRESS. Per the assessment, the wound identified as right gluteal UTD had the word gluteal crossed out, which had been replaced with the word parasacral. The wound was documented to measure 7.5 length by 5.5 width, depth not documented. The assessment documented 80% soft eschar, the presence of minimal light serosanguineous drainage, color was documented as pink/red, edges were attached, and surrounding skin was intact. It was documented the denuded area had improved. Treatment documented to cleanse the area with (Brand Name Antiseptic), use of (Brand Name Ointment), and (Brand Name barrier cream) to periwound. Frequency of the treatment was not specified on the form. Review of a physician's orders [REDACTED]. Per a progress note dated 5/12/20 at 6:25 AM it was documented, .CNA (Certified Nursing Assistant) notified writer that the residents buttocks were looking worse, cleaned and covered with a bordered dressing, on dr. log today to get a new treatment order. The next two Skin Observation - V 1 tools following the resident's assessment on 4/20/20 were noted to be dated 5/12/20 and 5/13/20. The following findings had been documented: -5/12/20 documented R#815 had an open pressure ulcer to the left buttock and pressure ulcer starting to the right buttock. -5/13/20 documented R#815 had a lesion on buttocks to the coccyx. Review of Wound Care Progress Notes dated 5/13/20 by NP 'A' documented, in part, the following that had been handwritten on the form: STILL NEEDS AIR LOSS MATTRESS. Evaluation of R#815's Right Parasacral UTD wound documented the wound as chronic, measuring 8.5 length by 5.0 width, documented with 100% soft eschar. It was documented the wound had moderate serosanguineous drainage as well as odor present. The wound edges were documented as unattached, and surrounding skin was documented as intact. Per this assessment, the wound was to be cleansed with a (Brand Name Antiseptic), (Brand Name Ointment) was to be applied, and it was documented to add 500 mg (milligram) crushed (Antibiotic) to the (Brand Name Ointment). It was also documented to change the dressing to twice per day. Review of a physician's orders [REDACTED]. It was noted this order was for daily, and not twice daily treatment as recommended by the Nurse Practitioner. Review of R#815's TAR for May 2020 revealed no treatment other than barrier cream was administered to the resident until 5/14/20 for the month. Review of a physician's orders [REDACTED]. Review of a Physician/PA (Physician Assistant)/NP-Progress Note (Narrative) dated 5/18/20 at 1:51 PM documented, in part, .Seen in f/u (follow up) of debility/sacral wound .Sacrum/buttock wound unstageable with necrotic tissue and odor .14) wound to buttock unstageable/infected-wound care with (Brand Name Antiseptic) solution and (Brand Name Antibiotic). Needs mechanical debridement vs. Hospice care . Review of a progress note dated 5/18/20 at 6:59PM documented, .Resident sent out to hospital for wound debridement (removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process) and infection of wound . Review of an EMERGENCY DEPARTMENT VISIT NOTE dated 5/18/20 for R#815 revealed, in part, (R#815 name) is a (age and sex redacted) presenting to the ED for concern of wound infection. Per EMS staff, noticed sacral ulcer was looking worse and had a foul smell this evening and thus sent him for evaluation. Patient complains of some mild, sharp, achy pain in that region . Continued review of the emergency department notes documented, in part, Patient has a wound infection [MEDICAL CONDITION]. Will admit for IV (intravenous) abx (antibiotics) and wound care .Clinical Impression: 1. Wound Infection 2. Pressure injury of skin of sacral region, unspecified injury stage . Continued review of hospital paperwork revealed consult documentation dated 5/19/20 which revealed, .The patient resides at (nursing home name redacted) and was sent to ED due to concerns for a sacral wound worsening and had a new foul smell. The patient admits to pain around the region of the sacral ulcer A superficial wound swab was sent from the ED. Due to concern for infected decub, the patient was started on IV [MEDICATION NAME] and IV [MEDICATION NAME] -tazobactam and admitted .ID (infectious disease) has been consulted for an infected decubitus ulcer . Review of an infectious disease note dated 5/22/20 documented, in part, Assessment and Plan by Problem: *Sacral decubitus ulcer, Stage IV .Stage IV sacral decubitus ulcer - Pt is bed bound due [MEDICAL CONDITION], dementia - Sent to ED (emergency department) on 5/18 from nursing home for worsening ulcer + (positive) leukocytosis - Superficial wound swab 5/18 .-s/p (status [REDACTED]. Review of hospital discharge summary paperwork for a date of stay of 5/18/20 through 5/27/20 for R#815 documented, in part, Patient was sent in to the ER (emergency room ) for foul smelling, infected, worsening sacral wound .For the last 2 months he has been in rehab. Now he was sent from the rehab because of increasing drainage and foul odor from the sacral decubitus ulcer, worsening ulcer. He is alert and oriented x1 to <sic> and is unable to provide any further history .During his hospital stay he received IV (intravenous) antibiotics, wound care consult. Sharp debridement was done of the wound. Wound culture grew multiple floor <sic> including Pseudomonas. Id (infectious disease) recommended antibiotics IV when he was in the hospital, and then changed to (antibiotic name) and (antibiotic name) to complete a course through June 1st . Right Heel: Per the skin section of the resident's Nursing Evaluation (Admit/Readmit, Qtly, Annual, Sig Change) -V 4 dated 3/19/20 R#815 was noted to have the following skin integrity concerns to the coccyx: has purple area to coccyx and has open area between buttock. No other sites of skin abnormality were identified on the body diagram section of the assessment. Review of a Skin Observation -V 1 form dated 4/1/20 did not document the presence of a heel wound for R#815. The next Skin Observation -V 1 form was not observed in the resident's clinical record until 4/20/20, which documented R#815 had an ulceration of the sacrum and an ulceration of the right heel. Per the assessment it was documented, Resident already seeing wound rounds for sacrum. New treatment and referral to wound rounds for right heel. The assessment also indicated yes to the question, New Wound, Wound Team Evaluation Needed. Review of a health status progress note dated 4/20/20 at 10:37 AM for R#815 documented, .Resident has a new spot on his right heel . Per a Physician/PA (Physician's Assistant)/NP (Nurse Practitioner) note dated 4/20/20 at 12:09 PM it was documented, .R (right) heel with unstageable ulcer noted today per nursing . Review of a physician order [REDACTED]. Review of a WOUND ASSESSMENT DETAILS REPORT dated 4/29/20 for R#815's right heel wound identified the area as an unstageable facility-acquired pressure ulceration, documented as identified on 4/22/20. Per the Tissue Types section it was documented, Blood filled blister=100%. Measurements per the 4/29/20 assessment were as follows: 5.00 (cm, centimeter) x 4.50 (cm) x 0.00 (cm) (L x W x D) (Length x Width x Depth). Per a plan of care dated 5/27/20 for R#815 it was documented, (R#815 name) has actual impairment to skin integrity r/t (related to) coccyx area, right heel, left lateral ankle, right gluteal, LLE (left lower extremity. Interventions per the plan of care included, in part, the following: -3/19/20: Evaluate and treat per physician's orders [REDACTED]. -3/19/20: Evaluate resident for S/SX (signs/symptoms) of possible infections. On 8/26/20 at 12:15 PM the facility's Director of Nursing (DON), who was not the DON at the time of the resident's wound development, was queried in regard to frequency of skin assessments at the facility, and explained they would be done weekly by the nurses. When queried in regard to wound staging, the DON explained nurses would describe the wound and the physician would classify. Per the DON, if further clarification was needed, the wound doctor would be consulted. On 8/26/20 at approximately 12:40 PM the facility's DON explained she had identified a concern with wounds at the facility and explained a new process for wound management was being implemented, however indicated the new process was impacted by staffing. Per the DON, staff had not been getting resident up, and were now doing so. Review of a facility policy titled, Skin Management Guideline dated 11/28/17 revealed, in part, Purpose: To ensure residents that are admitted to the facility are evaluated to determine appropriate measures to be taken by the interdisciplinary care team to determine appropriate measures and individualized interventions to prevent, reduce and treat skin breakdown. It is the practice of this facility to properly identify and evaluate residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers; to implement preventative measures; and to provide appropriate treatment modalities for wounds according to industry standards of care.

This citation pertains to Intake #MI00 4 Based on observation, interview and record review, the facility failed to ensure nursing staff reconcile medications with the physician's of 2 ( #'s 701 and 704) of 4 sampled residents reviewed for medications, resulting in administration of multiple medication doses, sedation, lethargic, shortness of breath, and hospitalization . Findings include: R#701 On 7/2/19 at approximately 8:30 AM, a call was made to the complainant. It was alleged R#701's medications had not been transcribed correctly on admission to the facility and R#701 had received too much medication and been over sedated. Review of R#701's clinical record revealed R#701 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to a Nursing Evaluation form dated 6/6/19, R#701 was alert and orientated to Person and Time. Review of R#701's hospital transfer record revealed a medication list that included [MEDICATION NAME] (an antianxiety medication) 0.5mg (milligram) take 1 tablet by mouth every 4 hours as needed for anxiety. Review of R#701's physician's orders [REDACTED]. Review of R#701's Medication Administration Record [REDACTED]. On 6/8/19, R#701 had received [MEDICATION NAME] four times, with two doses held due to sleeping. On 6/9/19, R#701 had received [MEDICATION NAME] two times, before the medication was discontinued. For a total amount of 12 doses of the medication. Review of R#701's progress notes revealed a nursing note dated 6/9/19 that read in part, . being sent to (name redacted) hospital . lethargic and SOB . R#704 On 7/2/19 at 10:18 AM, R#704 was observed sitting in a wheelchair in front of the second floor nurses station. R#704 appeared slightly agitated and was pulling at her clothing. R#704 was talking, but was not able to contribute to a conversation. Review of R#704's clinical record revealed R#704 had been admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment dated [DATE], R#704's cognition was Severely impaired. The MDS also indicated R#704 required the extensive assistance of staff for all activities of daily living (ADLs). Review of R#704's hospital transfer records revealed a medication list that included [MEDICATION NAME] (an antidepressant medication) (brand name) tablet 150 mg Oral TWICE DAILY. Review of R#704's physician orders [REDACTED]. Review of R#704's MAR for (MONTH) revealed R#704 had received [MEDICATION NAME] HCl ER two times a day from 5/8/19-5/19/19 for a total of 12 days receiving 25 doses before the medication was discontinued on 5/20/19. Review of a facility provided Incident and Accident (I & A) report dated 5/20/19 revealed A RESIDENT > MEDICATION ERROR event. Under Describe the error it read, Resident admitted on [DATE] <sic>. Medication from hospital read ([MEDICATION NAME]) 150 mg twice daily. Ordered entered as ([MEDICATION NAME] ER) 150 mg twice daily. Under Possible causative factor there was a mark for Medication order read incorrectly. On 7/2/19 at 11:42 AM, LPN 'B' was interviewed and asked about entering orders for residents. LPN 'B' stated, The nurse puts the orders into the computer, then calls the doctor and goes over all the orders with him. If the doctor doesn't want one (medication), you put in a discontinue order and write a progress note. On 7/2/19 at 3:25 PM, an interview with the Director of Nursing (DON) was conducted. The DON was queried about the medication orders entered for R#701 and R#704. The DON stated, (R#701) was admitted a day after being admitted to Hospice. She had some orders that were supposed to be PRN (as needed) that were put in as scheduled. We held all the medications as soon as the family brought it to our attention that she was sedated, then she was sent to the hospital. (R#704) the ([MEDICATION NAME]) was a transcription error. The DON was asked what should be done if the nurse wasn't sure about the dose of a medication. The DON stated, They should reconcile with with doctor. The DON was asked if a nurse puts in a code to see progress note, should there be a progress note. The DON stated, There should be a progress note. We are going to make sure the nurses will get training and education to prevent this type of errors. Review of a facility policy titled, Medication Orders revised (MONTH) (YEAR) read in part, .B. any dose or order that appears inappropriate considering the resident's age, condition, allergies [REDACTED]. C. The prescriber is contacted by nursing to verify an order (e.g., when the resident has allergies [REDACTED].

This citation refers to Intake #MI 845 Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place to prevent the reoccurrence of falls for a resident with a known history of poor safety awareness and falls for one (R#2) out of four resident's reviewed for falls resulting in a left [MEDICAL CONDITION], overnight hospital stay, surgery, decline in mobility and pain. Findings include: The facility reported to the State Agency the R#2 had sustained an injury of unknown origin (fracture to left hip) and a subsequent investigation report indicating the resident had a fall resulting in a left [MEDICAL CONDITION]. On 1/28/19 at approximately 9:20 AM R#2 was observed lying in bed, flat on his back with foam braces on both legs. Floor mats were on each side of the bed. The Resident was alert, but unable to answer questions asked. On 2/4/19 at approximately 3:00 PM R#2 was observed in the hallway with a CNA. The CNA reported that R#2 just had his stitches removed following his hip surgery. The Resident again was asked about his injury and was not able to provide further information. A review of R#2's clinical record documented that resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#2's Minimum Data Set ((MDS) dated [DATE] indicated that the resident had a BIMS score of 99 (severely cognitively impaired) and required extensive one person assist for activities of daily living. Further review of the MDS documented that that the R#2 had sustained two prior falls. A review of R#2's Fall Care Plan documented, in part, the following: Focus (date initiated 6/7/17) The resident has had an actual fall 11/16/18 resident attempts self transfer. 12/25/18 res. fell in his room sent to the ER for eval and tx (treatment) as indicated .Interventions: (6/7/17) Anticipate and meet the resident need. (6/7/17) ensure the resident's call light is within reach and encourage resident to use it .(6/9/2017) remind resident to ambulate with assistance and walker (8/13/18) Assess resident Q2 hours and PRN for toileting needs .(1/14/19)Floor mats next to bed on both sides when in bed . A review of the Resident's ADL (activities of daily living) documented, in part, the following: Interventions .Resident requires ext. (extensive) physical assistance x1 (date initiated 4/18/17 - resolved date 1/10/19) Interventions: Resident requires extensive assist X2 (date initiated 1/11/2019). A Fall Risk Evaluation (effective date 11/22/2018) documented that R#2 had a score of 40 (score of 16 or greater equals High Risk for Falls). A Late Entry progress note created 1/11/2019 with an effective date of 1/8/19 and authored by Nurse H documented, in part, the following: CNA came and got writer stating that Resident was complaining of leg pain. Writer and Unit Manager went to resident's room and was unable to verbalize what happened and complained of pain to touch. I contacted Physician and stat x-rays were ordered of Left hip and pelvis . An Radiology Report (dated 1/8/2018) documented, Acute left femoral neck fracture. A review of R#2's I & A (Incident/accident) reports and investigation pertaining to falls was reviewed and documented, in part, the following: Event Date: 10/7/18 1:15 AM .Describe objectively what was observed: Resident was observed sitting on the floor facing the sink with his legs outstretched .missed chair .was the resident who fell attended by an employee? No .Activity at time of event Attempting to get out of chair unattended . No further investigation documents were provided by the Facility. No new interventions following the 10/7/18 incident were noted in R#2's Fall Care Plan. Event Date: 11/16/18 14:25 PM .Describe objectively what was observed: Resident was sitting on the floor on left side of bed. Wheelchair behind resident. Resident's pants down to his ankles .Description of event: fall to floor (unwitnessed) .Activity at time of event .Going to the bathroom unassisted .Preventative measures .call light kept in reach .non-skid shoes/slippers .Investigation/Action Plan .gait instability .wheelchair not locked .A new Plan of Care/Intervention has been completed to prevent further events and these new changes communicated to staff .NOTE: Plan of care and interventions should be documented in the medical record and care plan for this resident . No further investigation documents were provided. No new interventions following the 11/16/18 incident were noted in R#2's Fall Care Plan. Event Date: 12/25/2018 19:45 PM CNA (certified nursing assistant) came to get writer and Resident was on the floor next to his bed in the room .Description of event: fall to floor: unwitnessed .Activity at time of event .Attempting to get into bed unattended .minor injury (description to left forehead) resident complained of pain in this area .A new Plan of Care/Intervention has been completed to prevent further events and these new changes communicated to staff .NOTE: Plan of care and interventions should be documented in the medical record and care plan for this resident . No further investigation documents were provided. Fall interventions after the 12/25/18 incident documented in R#2's Fall Care Plan as follows W/C (wheelchair) brakes locked when sitting in w/c and ask visitors to inform staff when leaving. Event Date: 1/7/2019 21:00 PM .Describe objectively what was observed .The resident was interviewed by the Administrator and writer on 1/11/19 s/p (status [REDACTED]. When the resident was asked if he knew what happened: resident replied, I fell and broke my leg. When asked how did he fall; resident replied I got up to take a piss and I just fell down hard. Resident denied anyone pushing him out of bed. When asked how he got up from the floor, resident replied he got up by himself initially then stated his roommate helped him up. When asked how he got back into bed; resident replied that he crawled in the bed and pulled himself up .Description of event: Fall to floor: Unwitnessed Continued review of the documentation pertaining to the incident that occurred on 1/7/19 documented, in part, the following: Interview Statement Record: Person Interviewed (name redacted) R#43. Date of Interview 1/9/19, Resident stated that he heard a loud noise around 9:00 PM, definitely after dinner coming from the room next door and said he heard You broke my leg. Resident said that the resident (initials redacted) R#2 said I broke my leg. Resident states he told staff (name redacted) about it. Said that R#2 went to the Hospital the next day .writer informed R#43 that CNA S did not work on 1/7/19. Interview Statement Record: Person Interviewed (name redacted) CNA J . Date of Interview 1/9/19 , Employee states that he was assigned to R#2 on 1/7/19 for afternoons around 5:30 PM and for midnights. Employee states that the assignment was changed r/t (do to) no other male caregivers. Employee states that he received the resident in bed and wanting to change his linens and wash the resident up .Employee states the resident c/o (complained of) his leg is broken, employee states he was moving both legs independently. Employee states resident did not express any pain or have an signs of pain during care .Employee states he did not observe any swelling, redness or discoloration to L (left) hip .Resident did not display any pain while sitting on edge of bed . Interview Statement Record: Person Interviewed (name redacted) CNA I. Date of Interview 1/9/18, Employee assigned to resident regularly. On 1/8/19 employee passed trays to unit and sat down next to resident on (R) side. Resident said don't sit on my leg, it's broken. Employee noticed a lump on LLE (left lower extremity) .Employee notified oncoming nurse around 11:00 AM .employee states resident does get up unassisted at times to the bathroom and was observed ambulating in the hallway . On 2/4/19 at approximately 4:00 PM an interview and record review was conducted with both the DON (Director of Nursing) and the Administrator. Both the DON and the Administrator reported that they had been employed for approximately one week and were not completely familiar with R#2 and the FRI reported to the State Agency pertaining to the incident involving R#2 sustaining a fracture to the left hip. When reviewing R#2's records, the DON and Administrator were queried as to the facility's policy pertaining to those with a high fall risk assessment and history of falls. The DON reported that if a resident is to sustain a fall an intervention(s) should be put in place to prevent further falls. When reviewing R#2's care plan , the DON and Administrator were queried as to the interventions put into place following R#2's falls on 10/7/18, 11/6/18 and 12/25/18, the DON reported that there did not appear to be new and/or effective interventions added into the care plan. When queried as to the investigation pertaining to R#2 as to the cause of the injury, the DON and Administrator where not able to determine the cause as they were not employed at the time. When asked as to the investigation statement made by CNA J that indicated R#2 reported to CNA J that his leg was broken on 1/7/19 and CNA J determined there was no redness or discoloration, the DON reported that a CNA should not assess a resident. On 2/4/19 at approximately 4:30 PM a phone interview was conducted with CNA J. CNA J was queried as to the incident that led to R#2's [MEDICAL CONDITION]. CNA J reported that he was assigned to work with R#2 because he was a male. CNA J reported that he did not often work with R#2, but new he had a history of [REDACTED]. When queried as to R#2's statement that he had broken his leg and what was done following the statement, CNA J stated, it didn't look like his leg was broken, he didn't say he fell , I didn't think anything was wrong. When queried as to whether R#2 would have been able to return himself back to bed, CNA J was not able to provide an answer. On 2/4/19 at approximately 4:00 PM a review of the Facility Policy titled, Fall Prevention Safety Guideline (Effective date 11.28.17) documented, in part, the following: Purpose: To consistently identify and evaluate residents at risk for falls and those who have fallen to treat or refer for treatment appropriately and develop an organization-wide ownership for fall prevention to .prevent or reduce injuries related to falls .The intent of this guideline is to ensure this facility provides an environment that is free from hazards .Fall Management: Develop and implement interventions. Ongoing evaluation of effectiveness of interventions, Education for Interdisciplinary Team of interventions .Guideline .Residents who evaluated as being at risk for falls will be identified and individualized fall precautions will be developed for each resident .to prevent or reduce injuries related to falls .Fall related to toileting needs .bed is locked and in lowest position .toilet schedule .from bed .Contour/Perimeter Mattress .Mat beside bed .use of bedside commode .Multiple Falls . trend falls for the resident, reason for fall, location of fall, consider room change to move resident closure to nurses station review the direct caregivers and ask them for intervention during high risk .Falls Prevention .Root Cause Analysis .

This citation pertains to MI 011: Based on observation, interview, and record review the facility failed to provide the resident with hands-on ambulation assistance per the resident's assessed needs for one(#702) of three residents reviewed for falls, resulting in the resident experiencing a fracture requiring surgical intervention, and a decrease in her functional mobility and a significant decrease in the resident's ability to ambulate with assistance. Findings include: On 1/10/17 at 10:59am, Resident #702 was observed to be seated in a wheelchair in the first floor therapy room. Resident #702 engaged in conversation and did not express any concerns at this time. On 1/10/17 at 9:00am, Resident #702's clinical record was reviewed and revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident scored 3/15, which indicated that the resident was severely cognitively impaired. Per this MDS assessment Resident #702 was noted to be not steady and only able to stabilize with staff assistance for walking, turning around, moving on and off of the toilet, and for surface to surface transfers. Resident #702 was identified as needing the physical assistance of one person for transfers and ambulation per this assessment. On 1/10/17 at 9:30am, a facility reported incident investigation summary dated 12/14/16 pertaining to Resident #702 was reviewed and revealed the following: (Resident #702) was sitting in the living room in a stationary high back chair, she had just finished participating in activities. Once the activity had completed (Resident #702) got up from her chair and was beginning to ambulate to the table to prepare for dinner. There as (was) another resident sitting in the living room, her back was to (Resident #702)as (Resident #702) was ambulating past her, the resident backed up and (Resident #702)hit her foot on the wheel of the chair causing (Resident #702) to lose her balance and fall On 1/10/17 at 9:51am, an interview statement taken from CNA 'B' was reviewed and revealed, in part, the following: (CNA 'B') said to (Resident #702) Come on (Resident #702) it's time for dinner. (Resident #702) started walking towards (CNA 'B'), when the resident in the wheelchair moved back and (Resident #702) hit her foot on the back of the wheelchair, causing her to lose her balance and fall On 1/10/17 at 10:08am and 1/10/17 at approximately 1:00pm, further review of the resident's clinical record was conducted. Per an other note dated 12/13/16 at 6:00pm, it was noted that on 12/13/16 at 4:45pm, post the resident tripping, an assessment of Resident #702 was as follows: Assessed resident she was laying on her back moaning in pain. Pt (patient) pointed to left hip and left elbow. Gave pt pillow and did not move pt. Laceration to left elbow and left leg rotated outward . Per this note the physician was then contacted, 911 was contacted, and the resident was transferred to the hospital. Further review of Resident #702's hospital radiology report(s), hospital documentation, fall risk observation assessments, and falls careplan was conducted at this time and revealed, in part, the following: Per the resident's history and physical report from the hospital dated 12/14/16 at 2:12pm, History of Present Illness the following was documented: (age) year old female with a history of dementia who presents to the ED (emergency department) with a c/o (complaint of) mechanical fall and subsequent (lt) hip pain. History is assisted by EMS (emergency medical services)/nursing staff and family. Patient was walking in her room and tripped falling onto her left hip. There was no LOC (loss of consciousness) or head injury. She c/o of immediate pain to her left hip and unable to bear weight. She was transported to the ED for further evaluation. X rays of hip revealed a comminuted intertrochanteric/subtrochanteric # of left femur. Pt admitted for definitive management Per the Final Report from the a hospital X-Ray of the Left Hip with Pelvis dated 12/15/16 at 6:27 pm, Findings: There is a comminuted intertrochanteric /subtrochanteric fracture of the left femur with valgus deformity at the fracture site . Further review of hospital documentation revealed the resident had undergone an ORIF (open reduction internal fixation) surgery of the left femur. Per a fall risk observation assessment dated [DATE], Resident #702 had a fall risk score of 17, which indicated that the resident was at high risk to fall. Per the Gait Analysis portion of the assessment, Resident #702 was identified as requiring hands-on assistance to move from place to place. Per review of the resident's fall care plan initiated 1/21/13, the following intervention was initiated 4/14/16: Limited assistance x1 staff with amb (ambulation). On 1/10/17 at 10:00am, Activities Staff 'A' was queried in regards to what she had observed regarding Resident #702's fall. Staff 'A' replied that the residents had been getting ready for dinner. Staff 'A' responded that she had seen CNA 'B' go over towards Resident #702 and tell the resident Come on (resident name.) Per Staff 'A', the resident then got up, and Staff 'A' thought she saw the resident trip on her own foot, grab the bedside table, and fall. When queried as to the level of assistance required by Resident #702, Activities Staff 'A' responded, We walk with her. When queried if CNA 'B' was observed to walk with the resident at that time, Staff 'A' responded, He was not walking with her that second he was going towards her. On 1/10/17 at 10:30am, CNA 'B' was queried in regards to Resident #702's fall. CNA 'B' responded that he had been getting residents set for dinner, and had been setting people at their dining room tables. CNA 'B' said, I was 20 feet from her .she started walking towards me. CNA 'B' stated that another resident had run into Resident #702, and Resident #702 went down on the ground. CNA 'B' said that he could not have been more than two feet away from the resident. When queried about any inservicing that CNA 'B' had received in regards to Resident #702's fall, CNA 'B' responded, She was a limited assist .I should have had my hand on her .I figured I was close enough she walks by herself, or she did. On 1/10/17 at 2:39pm, the Director of Nursing (DON) was queried in regards to the needs of a resident who required limited assistance. The DON responded that if a resident was limited assist, then staff should be standing by within close proximity. When queried in regards to limited assistance for Resident #702, the DON responded that the CNA should have been next to her. On 1/10/17 at 5:00pm, Occupational Therapist (OT) 'E' was queried in regards to Resident #702. OT 'E' responded that she had been working with Resident #702 prior and post the resident's fall. OT 'E' responded that prior to her fall, Resident #702 was able to walk by herself with OT 'E' holding onto her hand. Upon return to the facility post the resident's fall, OT 'E' replied that the resident is not walking without therapy yet. On 1/10/17 at 5:15pm, a Physical Therapy PT Evaluation and Plan of Treatment dated 12/21/16 for Resident #702 was reviewed and revealed the following: Current Referral Reason for Referral: Patient being seen status [REDACTED]. Patient exhibits new onset of decrease in strength, decrease in functional mobility, decrease in transfers, decrease in range of motion (ROM), reduced ability to safely ambulate, reduced functional activity tolerance, increased need for assistance from others, reduced ADL (activities of daily living) participation, and pain indicating the need for PT (physcial therapy) to increase independence with gait, facilitate (I) with all functional mobity, promote safety awareness, increase coordination, improve dynamic balance, increase LE (left extremity) ROM and strength, minimize falls and increase functional activity tolerance. On 1/10/17 at 5:20pm, review of the facility policy titled Falls and Fall Risk, Managing dated 2001 was reviewed and revealed, in part, the following: In conjunction with the Attending Physician, staff will identify and implement relevant interventions ( )

REFER TO INTAKE NUMBER MI 279 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE A TWO (2) PERSON TRANSFER FOR 1 (#500) OF 6 SAMPLED RESIDENTS RESULTING IN A FALL AND FRACTURE OF THE RIGHT LEG. FINDINGS INCLUDE: RESIDENT # 500, [AGE] years OLD WAS INITIALLY admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. THE MDS (MINIMUM DATA SET) ASSESSMENTS DATED 2/16/10, 8/11/10 AND 11/8/10, INDICATED RESIDENT #500 HAD SHORT AND LONG TERM MEMORY PROBLEMS, SEVERE COGNITIVE IMPAIRMENT AND REQUIRED EXTENSIVE ASSISTANCE OF TWO (2) FOR BED MOBILITY, TOILETING/BATHING AND TRANSFERS. THE RAP'S (RESIDENT ASSESSMENT PROTOCOL) DATED 2/16/10 INDICATED THE RESIDENT WAS AT RISK OF FALLS RELATED TO MEDICATIONS, COGNITIVE IMPAIRMENT, IMMOBILITY, DECREASED STRENGTH AND BALANCE, CONTRACTURES AND HISTORY OF FALLS. A REVIEW OF RESIDENT # 500'S CLINICAL RECORD REVEALED RESTORATIVE NURSING EVALUATIONS DATED 12/17/09 TO 11/4/10 THAT DOCUMENTED RESIDENT # 500 REQUIRED TOTAL ASSISTANCE OF TWO (2) PERSONS FOR ADL (ACTIVITES DAILY LIVING) CARE. RESIDENT #500'S 'RESIDENT CARE REQUIREMENT SHEET' (ORIGINALLY DATED 12/4/09 AND UPDATED 1/20/10 AND 5/12/10) CONTAINED IN THE ADL BINDER AT THE NURSES STATION, DOCUMENTED SHE WAS DEPENDENT AND REQUIRED TOTAL ASSISTANCE OF TWO (2) FOR ADL'S, INCLUDING BATHING,TRANSFERS AND TOILET USE. CARE PLANS FOR FALLS DATED 2/3/10 AND SELF CARE DEFICIT DATED 2/16/10 DOCUMENTED RESIDENT #500 REQUIRED TOTAL ASSISTANCE OF TWO (2) PERSONS FOR BED MOBILITY, BATHING AND TRANSFERS. FALL ASSESSMENTS DATED 8/11/10 AND 11/4/10 WHICH DOCUMENTED SHE WAS AT HIGH RISK FOR FALLS. A FACILITY INCIDENT REPORT DATED 12/3/10 AT 7:30 PM DOCUMENTED THAT CNA (CERTIFIED NURSING ASSISTANT) # 22 STATED SHE LOWERED RESIDENT #500 TO THE FLOOR WHEN THE RESIDENT WAS UNABLE TO BEAR HER WEIGHT DURING A TRANSFER IN HER ROOM FROM HER WHEELCHAIR TO A SHOWER CHAIR. ON 12/6/10 CNA #22 WROTE AND SIGNED A STATEMENT WHICH READ, ON 12/3/10 AT 7:30 PM SHE WAS TRANSFERRING RESIDENT #500 TO A SHOWER CHAIR AND "GRABBED HER ON HER PANTS AND WRAPPED MY ARMS AROUND HER AND STRAIGHTENED HER LEGS AND COUNTED TO THREE AS WE BOTH STOOD. I NOTICED SHE WAS LOOSING HER BALANCE SO I SET HER ON TO THE FLOOR GENTLY B/C (BECAUSE) THE CHAIR WAS NO LONGER IN REACHING DISTANCE". IN AN INTERVIEW PER PHONE ON 1/7/10 AT 9:30 AM CNA #22 STATED SHE HAD RETURNED RESIDENT #500 TO HER ROOM TO SHOWER HER. CNA #22 STATED SHE SET UP THE SHOWER CHAIR AND WHEELCHAIR ON AN ANGLE, LOCKED THE WHEELCHAIR AND STOOD RESIDENT # 500 UP FOR 3-5 SECONDS WHEN HER (RESIDENT #500) LEGS GAVE OUT AND THE CNA LOWERED RESIDENT # 500 TO THE FLOOR IN A SITTING POSITION BETWEEN THE TWO CHAIRS. CNA # 22 STATED RESIDENT # 500 STATED" HER KNEE WAS HURTING". WHEN QUERIED BY THE SURVEYOR CNA #22 STATED SHE HAD READ RESIDENT # 500'S ADL SHEET ( RESIDENT CARE REQUIREMENT SHEET) AT THE START OF THE SHIFT, BUT CONFUSED HER WITH ANOTHER RESIDENT. CNA #22 STATED "I HAD INSERVICE TRAINING ON RESIDENT TRANSFERS AND WAS TAUGHT ALL RESIDENTS WERE TWO (2) PERSON TRANSFERS, I THOUGHT SHE (RESIDENT #500) WAS ABLE TO DO IT". CNA #22 STATED SHE COULD HAVE LOOKED AT THE ADL SHEET AT THE NURSES STATION OR ASKED ANOTHER CNA OR THE NURSE IF SHE WAS NOT SURE OF THE RESIDENTS TRANSFER STATUS. WHEN QUERIED BY THE SURVEYOR WHETHER SHE DID ANY OF THOSE THINGS SHE STATED "NO, I DID NOT". ON 1/3/11 AT 1:25 PM RN (REGISTERED NURSE) # 7 STATED SHE HAD CARED FOR RESIDENT #500 APPROXIMATELY 3-4 DAYS A WEEK SINCE HER ADMISSION. SHE STATED CNA #22 CALLED TO HER ON 12/3/10 ABOUT 7:30 PM AND STATED ''COME AND LOOK AT RESIDENT #500". RN #7 STATED SHE ENTERED RESIDENT #500'S ROOM AND OBSERVED HER SITTING ON THE FLOOR NEAR THE BATHROOM BETWEEN THE SHOWER CHAIR AND HER WHEELCHAIR. RN #7 STATED SHE ASSESSED RESIDENT #500 WHO DID NOT INITIALLY COMPLAIN OF PAIN, BUT THEN COMPLAINED OF RIGHT KNEE PAIN. RN #7 STATED SHE ASKED CNA #22 WHAT HAPPENED AND THE CNA STATED RESIDENT #500 WAS UNABLE TO SUPPORT HER WEIGHT AND SHE HAD LOWERED HER TO THE FLOOR. RN #7 STATED ALL OF OUR RESIDENTS ARE 2 PERSON TRANSFERS AND CNA #22 TRANSFERRED RESIDENT #500 ALONE. RN #7 STATED WHEN SHE ASKED CNA #22 WHY SHE HAD TRANSFERRED RESIDENT #500 ALONE, CNA #22 STATED "I DON'T KNOW, I DIDN'T THINK". ON 1/3/11 AT 2:40 PM THE DON (DIRECTOR OF NURSING) STATED RESIDENT #500 WAS A 2 PERSON TRANSFER AND CNA #22 TRANSFERRED HER ALONE. THE DON STATED WHEN SHE ASKED CNA #22 WHY SHE HAD TRANSFERRED THE RESIDENT WITHOUT ASSISTANCE CNA #22 STATED SHE THOUGHT SHE COULD DO IT BY HERSELF. THE DON STATED THE CNA WAS NEW AND HAD USED POOR JUDGEMENT, AND SHOULD HAVE CHECKED THE ADL FLOW SHEET IF UNSURE OF THE RESIDENTS TRANSFER. THE DON STATED,THAT ON "12/8/08 FACILITY QA (QUALITY ASSURANCE) RECOMMENCED 2 PERSON TRANSFERS ON ALL RESIDENTS WHO REQUIRE ASSISTANCE. THEY ( QA) TRACKED IT FOR 1 YEAR, THEN DECIDED TO CONTINUE IT. IT IS NOT WRITTEN IN OUR POLICY BUT IS THE PROCEDURE WE FOLLOW AND THE CNA'S ARE AWARE OF IT". ON 1/3/11 AT 11:00 AM AND 1:30 PM AND ON 1/5/11 AT 6:45 AM OBSERVATIONS WERE MADE OF RESIDENT #500 IN HER ROOM. RESIDENT #500 WAS DRESSED APPROPRIATELY, CLEAN AND DRY AND WELL GROOMED, RIGHT LEG IMMOBILIZER AND TAB ALARM WERE OBSERVED TO BE IN PLACE. RESIDENT # 500 WAS UNABLE TO CONDUCT AN INTERVIEW REGARDING THE INCIDENT ON 12/3/10. X-RAY RESULTS DATED 12/3/10 AT 8:04 PM DOCUMENTED RECENT DISPLACED OBLIQUE FRACTURE OF THE DISTAL SHAFT OF THE FEMUR (FRACTURE OF RIGHT THIGH BONE). HOSPITAL EMERGENCY RECORDS DATED 12/4/10 DOCUMENTED RESIDENT #500 WAS treated for [REDACTED]. ( )