Every finding on record at The Willows At East Lansing

This citation pertains to Intake 2808417.Based on observation, interview, and record review, the facility failed to complete wound care as ordered for one (R201) of one reviewed.Findings include:Review of the medical record revealed R201 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis and paraplegia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/10/26 revealed R201 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), had an indwelling urinary catheter, was frequently incontinent of bowel, and had moisture associated skin damage (MASD-inflammation and erosion of the skin caused by prolonged exposure to moisture, such as urine, stool, sweat, or wound secretions). Review of the Physician's Order dated 3/15/26 revealed an order to cleanse the right thigh wound with normal saline or wound cleanser, pat dry, apply skin prep to peri-wound, apply collagen dressing to wound bed, apply border dressing, and change daily. The wound treatment was scheduled to be completed daily between 2:00 PM and 10:00 PM. Review of the Wound Note dated 3/16/26 revealed right thigh wound is pink in color .measuring 1 centimeter (cm) by 3 cm. On 3/20/26 at 12:02 PM, R201 was observed in bed. Certified Nursing Assistant (CNA) C and CNA D were observed completing incontinence care for R201. R201 was incontinent of loose stool that had leaked out of the left side and the top of the brief onto the bedding, resulting in a complete linen change. A dressing was observed to the back of R201's thigh. The dressing was dated 3/16/26, indicating wound care had not been completed since 3/16/26. CNA D agreed the dressing was dated 3/16/26. Review of the Treatment Administration Record (TAR) revealed R201's wound care to the right thigh was documented as completed on 3/17/26 and 3/19/26 by Licensed Practical Nurse (LPN) E. The wound care was documented as refused on 3/18/26. Attempts to contact LPN E via telephone on 3/20/26 at 12:34 PM and 1:54 PM were unsuccessful. Nursing Home Administrator (NHA) A was asked to assist with contacting LPN E via telephone. On 3/20/26 at 2:28 PM, NHA A reported the facility was also unsuccessful with contacting LPN E via telephone. In an interview on 2/20/26 at 1:55 PM, Assistant Director of Nursing (ADON) F reported she was the facility's wound nurse. ADON F reported R201 had MASD to his right thigh that required daily wound care. A request was made to observe R201's wound and wound care with R201's permission. On 3/20/26 at 2:15 PM, ADON F reported R201 refused wound care upon request. In an interview on 3/20/26 at 2:36 PM, Director of Nursing (DON) B reported R201 had MASD, was being followed by the wound nurse, and had orders for daily wound care. DON B reported any wound care refusals would be documented in the Progress Notes or the TAR. DON B agreed that according to the TAR, R201's wound care was documented as completed on 3/17/26 and 3/19/26. DON B reported LPN E might have just clicked it off [as completed] or forgotten to document that R201 refused wound care on those days. DON B reported the facility was trying to contact LPN E to clarify. R201's medical record did not indicate that R201 refused wound care on 3/16/26 or 3/19/26.

This citation pertains to Intake 2808417.Based on observation, interview, and record review, the facility failed to ensure the accuracy of medical records for one (R201) of three reviewed. Findings include: Review of the medical record revealed R201 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis and paraplegia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/10/26 revealed R201 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), had an indwelling urinary catheter, was frequently incontinent of bowel, and had moisture associated skin damage (MASD-inflammation and erosion of the skin caused by prolonged exposure to moisture, such as urine, stool, sweat, or wound secretions). Review of the Physician's Order dated 3/15/26 revealed an order to cleanse the right thigh wound with normal saline or wound cleanser, pat dry, apply skin prep to peri-wound, apply collagen dressing to wound bed, apply border dressing, and change daily. The wound treatment was scheduled to be completed daily between 2:00 PM and 10:00 PM. Review of the Wound Note dated 3/16/26 revealed right thigh wound is pink in color .measuring 1 centimeter (cm) by 3 cm. On 3/20/26 at 12:02 PM, R201 was observed in bed. Certified Nursing Assistant (CNA) C and CNA D were observed completing incontinence care for R201. R201 was incontinent of loose stool that had leaked out of the left side and the top of the brief onto the bedding, resulting in a complete linen change. A dressing was observed to the back of R201's thigh. The dressing was dated 3/16/26, indicating wound care had not been completed since 3/16/26. CNA D agreed the dressing was dated 3/16/26. Review of the Treatment Administration Record (TAR) revealed R201's wound care to the right thigh was documented as completed on 3/17/26 and 3/19/26 by Licensed Practical Nurse (LPN) E. The wound care was documented as refused on 3/18/26. Attempts to contact LPN E via telephone on 3/20/26 at 12:34 PM and 1:54 PM were unsuccessful. Nursing Home Administrator (NHA) A was asked to assist with contacting LPN E via telephone. On 3/20/26 at 2:28 PM, NHA A reported the facility was also unsuccessful with contacting LPN E via telephone. In an interview on 2/20/26 at 1:55 PM, Assistant Director of Nursing (ADON) F reported she was the facility's wound nurse. ADON F reported R201 had MASD to his right thigh that required daily wound care. A request was made to observe R201's wound and wound care with R201's permission. On 3/20/26 at 2:15 PM, ADON F reported R201 refused wound care upon request. In an interview on 3/20/26 at 2:36 PM, Director of Nursing (DON) B reported R201 had MASD, was being followed by the wound nurse, and had orders for daily wound care. DON B reported any wound care refusals would be documented in the Progress Notes or the TAR. DON B agreed that according to the TAR, R201's wound care was documented as completed on 3/17/26 and 3/19/26. DON B reported LPN E might have just clicked it off [as completed] or forgotten to document that R201 refused wound care on those days. DON B reported the facility was trying to contact LPN E to clarify. R201's medical record did not indicate that R201 refused wound care on 3/16/26 or 3/19/26.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 64 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.Findings include:On 01/06/2026 at 11:15 A.M., An initial tour of the food service was conducted with Director of Food Service K. The following items were noted: The Globe stand mixer was observed soiled with accumulated and encrusted food residue. 2 of 2 South Bend oven interior and exterior surfaces were observed soiled with accumulated and encrusted food residue. The South Bend char broiler grill plate, backsplash, side panels, and front splash were observed heavily soiled with accumulated and encrusted food residue. Director of Food Service K stated: I will have staff clean the soiled equipment as soon as possible. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The [NAME] air handler intake filter and exit ports (7) were observed heavily soiled with accumulated and encrusted dust/dirt deposits. Director of Food Service K stated: I will place the concern into TELS. The 2022 FDA Model Food Code section 6-501.14 states: (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. (B) If vented to the outside, ventilation systems may not create a public health HAZARD or nuisance or unLAWful discharge. On 01/06/2026 at 1:35 P.M., A comprehensive tour of the food service was conducted with Director of Food Services K. The following items were noted: The Mechanical Dish Machine final rinse temperature gauge was observed to read 168-170 degrees Fahrenheit at the manifold, during the final rinse cycle. The final rinse temperature gauge should read a minimum of 180 degrees Fahrenheit, during the final rinse cycle. Thermometer tape was utilized to determine the accuracy of the final rinse temperature gauge. The thermometer tape turned black during the final rinse cycle, indicating the final rinse temperature at the dish surface was at least 160 degrees Fahrenheit. Director of Food Services K stated: I will enter the temperature gauge replacement into TELS. Note: There is a 20-degree Fahrenheit variance between the mechanical dish machine manifold and dishware surface. The 2022 FDA Model Food Code section 4-501.11 states: (A) UTENSILS shall be maintained in a state of repair or condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. (B) FOOD TEMPERATURE MEASURING DEVICES shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy. (C) Ambient air temperature, water pressure, and water TEMPERATURE MEASURING DEVICES shall be maintained in good repair and be accurate within the intended range of use. On 01/06/2026 at 1:45 P.M., An interview was conducted with Assistant (Interim) Director of Maintenance M regarding the [NAME] air handler filter replacement schedule. Assistant (Interim) Director of Maintenance M stated: We change the filters quarterly. On 01/07/2026 at 1:30 P.M., Record review of the Direct Supply TELS Work History Report for the last 12 months regarding air handler filter replacement, revealed the last filter replacement was completed on 12/8/2025. On 01/07/2026 at 1:45 P.M., Record review of the Policy/Procedure entitled: Grill dated (no date) revealed the following cleaning procedure: (1) Use a small amount of water (not cold) with the grill brick. (2) Scrub grill with grill brick scraping excess into drain. (3) Rinse surface clean. (4) Before next use, season the grill with a small amount of oil. On 01/07/2026 at 02:00 P.M., Record review of the Policy/Procedure entitled: Mixer dated (no date) revealed the following cleaning procedure: (1) Disassemble removable parts. (2) Wash all non-electrical parts in the three-compartment sink. (3) Wash non-removable parts of the mixer with a solution of pot & pan detergent. (4) Wash handle and underneath where paddle attaches. (5) Rinse with fresh water and wipe dry. (6) Using a different wiping cloth, apply sanitizing solution to the mixer. (7) Allow to air dry. (8) Reassemble.

Based on observation, interview, and record review, the facility failed to ensure Grievance/Concern forms were readily available to residents and families to file concerns anonymously and failed to follow facility Grievance policy, resulting the likelihood of unresolved concerns and frustration.During a confidential resident group meeting on 1/07/2026 at 1:31 PM, nine of nine residents reported the facility did not offer an option to complete a grievance confidentially and reported were not aware they had access or where to locate survey results. Residents reported if anyone had a concern they had to report to staff and they would complete form electronically. Residents reported they no longer have an option to complete a paper form. During an observation on 1/7/26 at about 2:30 PM, Tour of facility with no observed grievances available for resident/family use. During an interview on 1/07/2026 at 3:25 PM Registered Nurse (RN) C was quarried about facility grievance process. RN C reported residents and family verbally report concerns to staff who report to Director of Nursing (DON) B. RN C reported facility also had paper concern forms and observed looking for at [NAME] Nurse Station filing cabinets and took over 10 minutes attempting to locate. DON B arrived and located in file cabinet behind nurse station and reported was unsure if available without asking. During an interview and observation and record review on 1/07/2026 at 3:40 PM, Executive Director (ED) A reported the facility grievance process was for staff to complete forms electronically or paper copies were also available. ED A reported paper copies were available in same binder as survey results. ED A opened binder, labeled Survey Results located just outside ED A office, verified one copy of Resident Concern form in the binder, several pages in, inside page protector. ED A reported residents know grievance forms are available there and verified the outside of the binder was labeled survey results. (Resident [NAME] meeting attendees were not aware of survey results or concern form were available or located in the facility). ED A reported compliance poster posted in common area, observed about 6 foot high, with complaint number for corporation in a 3 inch by 2 inch square (very small print) and 1 inch QR code to Kentucky corporation.(not accessible or readily available to facility population who may have visual or physical limitation or have access to cell phone technology or knowledge for use of QR codes). ED A reported anyone has access to the poster and can call number or use QR code anonymously and verified corporation out of Kentucky shares information with her unless ED A and unable to say how facility tracks and trends corporation complaints. During an interview and observation on 1/07/2026 at 3:50 PM Social Work (SW) H and I reported Resident Concern forms should be available to residents and families at the Nurse Station without asking. SW H and I observed looking and Nurse station and reported were unable to locate. Review of the facility, Grievance-Resident Concern Policy, dated 12/16/24, reflected, Purpose: To provide a process for handling, tracking and resolving customer concerns to provide excellence in customer service.The facility will provide an open and customer friendly atmosphere for residents and their families and representatives to voice concerns and problems with the assurance that their concerns will be heard and acted upon.5. Enter the concern using the desktop icon labeled Resident Concern Form. All concerns should be entered electronically, however Environmental and Dining departments may use a paper Resident Concern form, submitted to their supervisor who will enter. We never ask a family member to complete the form.Resident rights for filling a grievance.Executive Director has been appointed as the Grievance Officer.Grievances or concerns can be filed verbally, in writing or anonymously. The resident or his/her representative has the right to receive a copy of the written grievance.

Based on interview and record review the facility failed to confirm that the Pre-admission Screening And Resident Review (PASARR Level I determination request was sent to the Community Mental Health Service Program (CMHSP) for a level II Omnibus Budget Reconciliation Act (OBRA) evaluation for 2 residents (#4 and 8) of 3 reviewed. Findings include: Review of the medical record reflected R4 was admitted to the facility on [DATE], with diagnoses that included chronic atrial fibrillation. Review of the medical record revealed R8 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes mellitus. During the record review, the PASARR Level I was located in the medical record for R4 and R8, however, no level II Omnibus Budget Reconciliation Act (OBRA) evaluation was able to be located. In an interview on 01/08/2026 at 9:10 AM, Social Services staff member H stated that R4 and R8 should have had a Level II OBRA evaluation completed, however, it was not completed for either resident.

Based on interview and record review the facility failed to ensure a Preadmission/Annual Resident Review (PAS/ARR) was completed after the 30-day exemption period and failed to notify the State Agency Health Authority for 1 Residents (#7) of 3 residents reviewed for PAS/ARR from a total sample of 16.Findings include:According to the clinical record, Resident #7 (R7) was admitted on [DATE] with diagnosis that included acute and chronic respiratory failure, bipolar disorder, anxiety. Review of the Minimum Data Set (MDS) dated 12/09 revealed R7 scored 15 out of 15 on the Brief Interview for Mental Status. Review of R7's 3877 portion of PAS/ARR dated 12/4/25 revealed R7 had diagnosis that included bipolar disorder and was routinely prescribed an antidepressant or an antipsychotic medication within the last 14 days. Review of the 3878 portion of the PAS/ARR dated 12/05/25 revealed R7 was admitted to the facility with a 30-day exemption. There was no further PAS/ARR completed after R7 exceeded her 30 days at the facility. On 01/08/2026 at 9:17 AM, during an interview with facility Social Workers H and I it was acknowledged R7 was at the facility beyond the 30 day exemption period and had no follow up PAS/ARR. Social Worker H stated R7 was supposed to be discharged home before the 30 days but the discharge was delayed. When queried why a new 3877 wasn't completed and Community Mental Health notified, Social Worker H stated because R7 should be discharged soon.

Based on interview and record review, the facility failed to develop and implement care plans for 1 resident (R# 7) of 16 reviewed.Findings include: According to the electronic medical record (EMR), Resident #7 was admitted on [DATE] with diagnosis that included acute and chronic respiratory failure, bipolar disorder, anxiety. Review of the Minimum Data Set (MDS) dated 12/09 revealed R7 scored 15 out of 15 on the Brief Interview for Mental Status. Review of R7's physician orders revealed R7 was admitted on an anti-psychotic medication. Review of physician orders dated 12/08/25 revealed 4 separate physician orders to monitor and track R7's mood and behavior (1. depression, 2. insomnia, 3. behavior related to psychosis 4. anxiety). Review of R7's care plans did not reflect any care plans in place to address R7's mood, behavior, psycho-social wellbeing or use on psychotropic medication. 01/07/2026 1:08 PM during an interview with Social Workers H and I, R7's the electronic medical record was reviewed and neither Social Worker H or I were able to locate a care plan that addressed R7's mental health concerns. Social Worker H stated given R7's diagnosis, psychotropic medication use and targeted behavior tracking, mood, behavior, and psychosocial wellbeing care plans should have been developed and implemented.

Based on interview and record review the facility failed to routinely complete and invite residents and their representatives, if applicable, to participate in care planning for one resident (R51) of 1 reviewed for care conferences, resulting in the increased likelihood of decline in physical, mental, or psychosocial functioning.Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R51 was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses that Multiple Sclerosis. The MDS reflected R51 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact.During a confidential resident group meeting on 1/07/2026 at 1:31 PM, Confident group reported that they had not been invited to routine care conferences for several months.During an interview on 1/08/2026 at 1:45 PM, Social Worker (SW) H reported Care Conferences should occur quarterly including resident and/or responsible party and members of care team. SW H reported R51 last Care Conference was August of 2025 and should have had one November 2025. When queried why R51 did not have a quarterly care conference, SW H reported it must have gotten missed. SW H reported facility recognized that some residents had missed Care Conferences around November 2025 and thought they had a past non-compliance but was unsure when alleged compliance date was and verified R51's was currently late. During an interview on 1/08/2026 at 2:20 PM, Executive Director (ED) A and Director of Nursing (DON) B reported would expect Care Conferences to be completed at least quarterly. ED A reported facility had past non-compliance for care conferences with alleged compliance date of December 2025. ED A reported was unsure why R51 was currently out of compliance with last care conference from August 2025(currently about 2 months past due).During an interview on 1/08/2026 at 3:01 PM, ED A verified R51did not receive required care conference in November 2025 and should have. ED A reported the facility now knows that their action plan was not effective and plan to manually audit moving forward to make sure all residents are reviewed.

Based on interview, and record review, the facility failed to ensure the Advanced Directive was completed appropriately for one (Resident #4) out of one reviewed for advanced directives. Findings include: Review of the medical record reflected R4 was admitted to the facility on [DATE], with diagnoses that included chronic atrial fibrillation. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/14/25, reflected R4 scored 4 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the medical record revealed R4 had a medical power of attorney. Review of R4's Advanced Directive revealed a signature on the declarant signature line did not match the name of the appointment medical power of attorney. In an interview on 1/8/26 at 9:23 AM, Social Services H verified that the signature on the Advanced Directive was incorrect and should have been signed by the medical power of attorney.

Based on observation, interview and record review, the facility failed to develop and implement comprehensive Care Plans for one (Resident #5) of 15 reviewed for Care Plans, resulting in the potential for unmet care needs. Findings include: Resident #5 (R5) Review of the medical record reflected R5 was admitted to the facility on [DATE] with diagnosis which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and dysthymic disorder (persistent depressive disorder). The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/03/2024, reflected R5's Brief Interview for Mental Status (BIMS) was coded as a 12, indicating moderate cognitive impairment. On 10/15/24 at approximately 9:15 AM, R5 was observed in her room, going through her dresser drawers. R5 expressed frustration with not being able to locate a clothing item and stated that she gets very frustrated with the facility for keeping her here and with people removing her personal property. R5's roommate, who declined to be interviewed, only wanted to share that she had concerns for R5's wellbeing related to an increase in aggressive behaviors. Review of R5's Physician Order revealed an active order dated 6/26/24 for Escitalopram (Lexapro-an antidepressant) 10 mg (milligrams) once daily. Review of a Progress Note dated 8/08/2024 at 12:40 PM stated R5 was being followed by the Interdisciplinary Team for the use of the psychotropic medication. The same Progress Note stated Nursing will monitor resident q [every] shift for adverse effects r/t [related to] medication use and for behaviors. Plan of care is appropriate and up to date . Review of a Progress Note dated 9/08/2024 at 11:03 AM stated Resident [R5] woke up this morning in an extremely agitated state; staff ensured all needs were met and resident remained agitated. Resident tried leaving the building twice this morning and staff was able to redirect her . A Progress Note dated 9/13/2024 at 9:35 PM At about 1945 (7:45 PM) resident noted carrying one of her blanket, her and her dogs pictures, and a book walking out of her room stating that she has gotten all of her belongings she needed and she is going home. Redirection not effective. Her [family member] was in the building trying to redirect resident and not effective. She became very agitated with [family member]. Resident walked towards the front entrance wanting to leave .Multiple staff members approached resident to have her go to her room and not effective . Review of a Progress Note dated 10/10/2024 at 10:39 PM revealed Resident wanted to shut the door and her roommate wanted door open, because it causes her Claustrophobia. resident [R5] became agitated and pull [sic] a chair in front of the door and stared at her resident [sic]. This nurse asked resident if she could move to her chair. Resident stated that I pay enough money to sit where ever I want. Resident remained in chair for approximately 15 minutes, until activities staff help redirect resident and she returned to her recliner . Documentation of a Social Services follow-up could not be located in the electronic medical record (EMR). In an interview on 10/16/24 at 2:04 PM, Licensed Practical Nurse (LPN) K stated that she was working on the day R5 had a disagreement with her roommate regarding the room door. According to LPN K, R5 closed the door to their shared room, but the roommate requested it remain open due to her claustrophobia. R5 became angry, dragged her roommate's chair in front of the door, and stared at her. LPN K made several attempts to redirect R5, but none were successful and only seemed to aggravate R5 further. Eventually, another staff member was able to calm R5. LPN K also mentioned that prior to this incident, R5 had thrown her roommate's shoes in the trash out of anger and during a separate incident, had to have a roommate change back in September due to a conflict with her former roommate. LPN K noted that while R5 typically displays sundown behaviors (the term sundowning refers to a state of confusion that occurs in the late afternoon and lasts into the night. Sundowning can cause various behaviors, such as confusion, anxiety, aggression or ignoring directions. Sundowning also can lead to pacing or wandering), these behaviors had been increasing in frequency over the past few months and R5 was becoming more aggressive. She added that there are no interventions listed to guide staff on how to assist and/or redirect R5 with her aggression. LPN K stated that resident behaviors are documented under the Progress Note's in the EMR. LPN K stated that the Interdisciplinary Team will review the Progress Note's and discuss the behavior concerns in morning meeting. In an interview on 10/16/24 at 3:56 PM, Certified Nursing Assistant (CNA) L stated that she was familiar with R5. CNA L stated that R5 had sundowning behaviors that were more frequent and increasingly aggressive. CNA L stated that she has observed the aggressiveness and that R5 is difficult to redirect. CNA L verified that R5 had to be relocated to a different room last month due to an argument between R5 and her previous roommate. CNA L was unsure of any behavior interventions that were in place for R5. CNA L stated that behaviors are documented under the task section in the EMR. Review of a Physician Order revealed the following active order initiated on 9/18/24 which stated .target behavior-Depression (sadness, tearfulness, and withdrawn). At the end of each shift mark frequent-how often behavior occurred and intensity) . No Physician Order for monitoring any other behaviors and/or behavior related to the increased nighttime delirium were located in the EMR. Review of R5's Care Plan revealed no Care Plan for R5's behavior of increased confusion at night with the potential for aggression and no Care Plan for depression. In an interview on 10/17/24 at 9:45 AM, Social Worker (SW) E and SW F explained that when a resident exhibits behaviors, a Physician Order for behavior tracking is implemented, and a referral for psychiatric services is made if necessary. Social Work discusses these behaviors during interdisciplinary team meetings to develop a Care Plan with individualized interventions. Regarding the recent incident between R5 and her roommate on 10/10/24, SW E and SW F mentioned they were both informed about it only yesterday. SW E and SW F are currently following up on the matter, which includes creating a Care Plan for R5 that specifically addresses the behaviors and provides interventions to assist staff in managing them. Both SW E and SW K acknowledged that they should have been notified about the 10/10/24 incident immediately after it occurred to provide appropriate follow-up and develop a timely Care Plan for R5.

Based on observation, interview and record review the facility failed to update a care plan to include detailed person centered needs for one resident (#35) of 15 residents reviewed for care planning. Findings include: Review of the clinical record reflected Resident # 35 (R35) was admitted to the facility on [DATE], Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview Status Score of (7) severe indicating severe cognitive impairment. The MDS also reflected R35 had a history of falls. On 10/15/24 at 9:30 am, R35 was observed sitting in their room up in a wheel chair, R35 was observed to have a golf ball size abrasion to the top left side of the forehead. R35's family member D was present and reported R35 has had a few falls since admission and aside from the abrasion on the head, R35's left knee also sustained an abrasion. Family member D reported all of R35 falls were from the bed. One floor mat was observed in R35's room. On 10/15/24 at 02:50 pm, R35 was observed resting in bed, a floor mat was observed on left side of bed, family member D in room sitting in chair on left side , R35's bed was observed approximately knee height. Record review reflected R35 fell on [DATE] sustained an abrasion above the left eyebrow, left cheek and temple, left knee abrasion. An unwitnessed fall was documented to have occurred on 09/20/24 at approximately 11:30 pm, R35 sustained a right knee abrasion 1.5 centimeter by 1.5 centimeter. R35's third fall was documented as an unwitnessed fall that occurred on 10/08/2024, the incident and accident report revealed R35 rolled out of bed hit his head and was transferred to the emergency department for further evaluation. Review of R35's fall care plan dated 09/16/24 reflected R35 was at risk for falls and the intervention Fall mat to floor was added on 9/24/24. The care plan was not individualized and did not specify if the floor mat should be placed on the left side or the right side of R35's bed. On 10/16/24 11:42 am, during an interview with Director of Nursing (DON) B, R35's falls and interventions were reviewed. R35's care plan was reviewed with DON B acknowledged R35's fall care plan was not updated to R35's specific need of which side of the bed the floor mat was to be placed. On 10/16/24 at 12:01 pm, during an interview with Certified Nursing Assistant (CNA) H, she reported care was driven by the care plan, CNA H when queried how she knew where/what side of the bed to place a floor mat for a resident she said you have to look at the care plan. When CNA H was queried if the care plan read Fall mat to floor , CNA H stated she wouldn't know where to place the mat, and hoped it was mentioned in report or you would have to guess.

Based on interview and record review, the facility failed to offer an updated COVID-19 immunization to two (Resident #7 and Resident #18) of five reviewed. Findings include: Resident #7 (R7) Review of the medical record revealed R7 was admitted to the facility on [DATE] with diagnoses that included diabetes, sleep apnea, and vascular dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/2/24 revealed R7 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R7 had a guardian. Review of R7's immunization history revealed R7 received their last COVID-19 immunization on 11/11/22. There was no record that R7 was offered the COVID-19 booster for 2023/2024. Resident #18 (R18) Review of the medical record revealed R18 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, heart failure, and dementia. The MDS with an ARD of 8/16/24 revealed R18 scored 2 out of 15 (severe cognitive impairment on the BIMS). R18 had a guardian. Review of R18's immunization history revealed R18 received their last COVID-19 immunization on 11/11/22. There was no record that R18 was offered the COVID-19 booster for 2023/2024. In an interview on 10/16/24 at 3:53 PM, Infection Preventionist (IP) C agreed R7 and R18's last COVID-19 immunization was given on 11/11/22. On 10/16/24 at 4:26 PM, IP C reported R7 and R18 both had a COVID infection in November of 2023 and therefore were not eligible for their COVID-19 immunization at that time. On 10/16/24 at 10:22 AM, IP C reported she spoke with the facility's physician who reported R7 and R18 would have been eligible to receive the COVID-19 immunization 90 days after testing positive for COVID. IP C reported the facility did not have documentation that R7 and R18 were offered the COVID-19 immunization in 2023/2024. People who already had COVID-19 and do not get vaccinated after their recovery are more likely to get COVID-19 again than those who get vaccinated after their recovery .If you recently had COVID-19, you still need to stay up to date with your vaccines, but you may consider delaying your vaccine dose by 3 months. (https://www.cdc.gov/covid/vaccines/getting-your-covid-19-vaccine.html#:~:text=When%20you%20can%20wait%20to,vaccine%20dose%20by%203%20months.)

Based on observation, interview and record review the facility failed to provide a meaningful, diverse and engaging activity program for one resident (#41) of one reviewed for activities. Findings include: Review of the clinical record reflected Resident # 41 (R41) was admitted to the facility on [DATE] with diagnosis that included neurocognitive disorder with Lewy body. Review of the Minimum Data Set (MDS) dated [DATE] reflected R41 scored 00 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of R41's activity assessment dated [DATE] reflected R41 enjoyed pet visits, being read to and easy listening music, and family visits. Review of R41's activity care plan dated 8/28/24 revealed R41 enjoyed pet therapy, (which the facility does not offer), catholic services, going outside, bingo, socials and happy hour, easy listening and bluegrass music. Review of the October Calendar revealed catholic services, bingo, bible study, reading groups and socials. Review of R41's activity participation record for October reflected R41 attended 2 sensory activities and one lunch time trivia. Septembers activity participation record reflected 4 activities (no dates) trivia, 1:1, and 2 group readings. The month of August reflected R41 had participated in 2 activities which were 2 episodes of watching television. On 10/15/24 at 10:06 AM, R41 was observed sitting in 100 hall activity/TV area, R41 was sitting, MTV playing on the television but R41 was not watching it. On 10/15/24 at 02:53 PM R41 was observed sitting in front of the television on the 100 hall activity/TV area, R41 was sitting, MTV playing on the television but R41 was not watching it. The volume on the television was low and not audible over the noise of the nearby fish tank motor and alarms sounding on hall. On 10/16/24 at 09:20 AM, R41 was brought into the 100 hall activity/TV area, R41 was instructed by unknown staff to sit on the couch, located in front of the television where MTV was playing a reality show. At 936 AM R41 was observed looking around the room, 2 other unidentified residents were present, sitting in reclining wheel chairs, one whom was asleep the other staring at the ceiling. At 9:47 am an unidentified Certified Nursing Assistant took R41 back to her room without explanation. On 10/16/24 at 11:22 AM R41 was observed in the 100 hall activity/ TV area sitting in a wheelchair in front of the television, head down looking at the floor. MTV playing on the television. The same 2 peers from the 9:20 am observation were present and also not watching MTV. R41 was again observed on 10/16/24 at 12:05 PM and again at 3:01 PM, sitting in front of the television with MTV on. On 10/17/24 at 9:28 am R41 was observed in the 100 hall activity/ TV area sitting in a wheelchair in front of the television, R41's head was down looking at the floor. MTV playing on the television. On 10/17/24 at 9:30 am during an interview with Nursing Home Administrator (NHA) A and Clinical Support Life Enrichment J R41's activity assessment and activity care plan was reviewed. NHA A reported the facility no longer offers pet therapy with the exclusion of some hospice residents receiving pet therapy (R41 is not a hospice resident). NHA A reported the facility has books, and music programs, socials etc . but did not offer any explanation as to why R41 was not invited or encouraged to attend, as there is no documentation that R41 had refused any invitations to group activities.

Based on observation, interview and record review the facility failed to ensure one out of one resident (Residents #5) received the necessary behavioral health care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being, resulting in the potential for unmet emotional and/or mental well-being care needs. Resident #5 (R5) Review of the medical record reflected R5 was admitted to the facility on [DATE] with diagnosis which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and dysthymic disorder (persistent depressive disorder). The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/03/2024, reflected R5's Brief Interview for Mental Status (BIMS) was coded as a 12, indicating moderate cognitive impairment. On 10/15/24 at approximately 9:15 AM, R5 was observed in her room, going through her dresser drawers. R5 expressed frustration with not being able to locate a clothing item and stated that she gets very frustrated with the facility for keeping her here and with people removing her personal property. R5's roommate, who declined to be interviewed, only wanted to share that she had concerns for R5's wellbeing related to an increase in aggressive behaviors. Review of R5's Physician Order revealed an active order dated 6/26/24 for Escitalopram (Lexapro-an antidepressant) 10 mg (milligrams) once daily. Review of a Progress Note dated 8/08/2024 at 12:40 PM stated R5 was being followed by the Interdisciplinary Team for the use of the psychotropic medication. The same Progress Note stated Nursing will monitor resident q [every] shift for adverse effects r/t [related to] medication use and for behaviors. Plan of care is appropriate and up to date . Review of a Progress Note dated 9/08/2024 at 11:03 AM stated Resident [R5] woke up this morning in an extremely agitated state; staff ensured all needs were met and resident remained agitated. Resident tried leaving the building twice this morning and staff was able to redirect her . A Progress Note dated 9/13/2024 at 9:35 PM At about 1945 (7:45 PM) resident noted carrying one of her blanket, her and her dogs pictures, and a book walking out of her room stating that she has gotten all of her belongings she needed and she is going home. Redirection not effective. Her [family member] was in the building trying to redirect resident and not effective. She became very agitated with [family member]. Resident walked towards the front entrance wanting to leave .Multiple staff members approached resident to have her go to her room and not effective . Review of a Progress Note dated 10/10/2024 at 10:39 PM revealed Resident wanted to shut the door and her roommate wanted door open, because it causes her Claustrophobia. resident [R5] became agitated and pull [sic] a chair in front of the door and stared at her resident [sic]. This nurse asked resident if she could move to her chair. Resident stated that I pay enough money to sit where ever I want. Resident remained in chair for approximately 15 minutes, until activities staff help redirect resident and she returned to her recliner . Documentation of a Social Services follow-up could not be located in the electronic medical record (EMR). In an interview on 10/16/24 at 2:04 PM, Licensed Practical Nurse (LPN) K stated that she was working on the day R5 had a disagreement with her roommate regarding the room door. According to LPN K, R5 closed the door to their shared room, but the roommate requested it remain open due to her claustrophobia. R5 became angry, dragged her roommate's chair in front of the door, and stared at her. LPN K made several attempts to redirect R5, but none were successful and only seemed to aggravate R5 further. Eventually, another staff member was able to calm R5. LPN K also mentioned that prior to this incident, R5 had thrown her roommate's shoes in the trash out of anger and during a separate incident, had to have a roommate change back in September due to a conflict with her former roommate. LPN K noted that while R5 typically displays sundown behaviors (the term sundowning refers to a state of confusion that occurs in the late afternoon and lasts into the night. Sundowning can cause various behaviors, such as confusion, anxiety, aggression or ignoring directions. Sundowning also can lead to pacing or wandering), these behaviors had been increasing in frequency over the past few months and R5 was becoming more aggressive. She added that there are no interventions listed to guide staff on how to assist and/or redirect R5 with her aggression. LPN K stated that resident behaviors are documented under the Progress Note's in the EMR. LPN K stated that the Interdisciplinary Team will review the Progress Note's and discuss the behavior concerns in morning meeting. In an interview on 10/16/24 at 3:56 PM, Certified Nursing Assistant (CNA) L stated that she was familiar with R5. CNA L stated that R5 had sundowning behaviors that were more frequent and increasingly aggressive. CNA L stated that she has observed the aggressiveness and that R5 is difficult to redirect. CNA L verified that R5 had to be relocated to a different room last month due to an argument between R5 and her previous roommate. CNA L was unsure of any behavior interventions that were in place for R5. CNA L stated that behaviors are documented under the task section in the EMR. Review of a Physician Order revealed the following active order initiated on 9/18/24 which stated .target behavior-Depression (sadness, tearfulness, and withdrawn). At the end of each shift mark frequent-how often behavior occurred and intensity) . No Physician Order for monitoring any other behaviors and/or behavior related to the increased nighttime delirium were located in the EMR. No Progress Notes or Social Work Assessments could be located in the EMR regarding the recent incident with the roommate or the increase in nighttime agitation. In an interview on 10/17/24 at 9:45 AM, Social Worker (SW) E and SW F explained that when a resident exhibits behaviors, a Physician Order for behavior tracking is implemented, and a referral for psychiatric services is made if necessary. Social Work discusses these behaviors during Interdisciplinary Team meetings to develop a Care Plan with individualized interventions. Regarding the recent incident between R5 and her roommate on 10/10/24, SW E and SW F mentioned they were both informed about it only yesterday. SW E and SW F are currently following up on the matter, which included conducting psychosocial well-being visits with R5 and the roommate. Both SW E and SW K acknowledged that they should have been notified about the 10/10/24 incident immediately after it occurred to provide appropriate follow-up.

Based on observation, interview, and record review, the facility failed to justify the increase in an antipsychotic medication for one (Resident #18) of five reviewed. Findings include: Review of the medical record revealed Resident #18 (R18) was admitted to the facility on [DATE] with diagnoses that included anxiety, major depressive disorder, and vascular dementia with psychotic disturbance. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/16/24 revealed R18 scored 2 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had no behaviors, hallucinations, or delusions during the look back period. On 10/16/24 at 7:33 AM, R18 was observed asleep in bed. On 10/16/24 at 9:17 AM, R18 was observed sitting in the dining room, drinking tea. Review of the Physician's Order dated 12/19/23 revealed an order for Risperidone 0.25 milligrams (milligrams) once a day for hallucinations/delusions. The medication was scheduled to be administered between 6:00 AM and 10:00 AM. Prior to this, R18 was prescribed Risperidone 0.25 mg twice a day. Review of the CAR Review Psychotropic Medication progress note dated 12/26/23 revealed Resident has had a successful GDR [gradual dose reduction] to risperidone [antipsychotic medication] on 6/30/23 and 12/19/23. Review of the Progress Note dated 1/30/24 revealed Resident presents with the following dx's [diagnoses] of Psychotic disorder with hallucinations due to known physiological condition, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and Major Depressive Disorder. She is currently taking Sertraline [Zoloft/antidepressant medication] 100mg once daily along with Risperidone .25mg once daily. She was last seen by [psychiatry services] on 1/17/2024 stating Plan: continue Zoloft 100mg PO daily. Plan: Continue Risperdal 0.25mg PO q. HS [every day at bedtime] at this time as she had a recent GDR. Evaluate in the next quarter for further GDR. The Risperidone continued to be administered between 6:00 AM and 10:00 AM, despite the note indicating the plan was to administer Risperidone at bedtime. Review of the medical record revealed R18 was transferred to the hospital on 3/21/24 for concerns not related to behaviors or psychiatric well-being. Review of the hospital records revealed the hospital was giving R18 Risperidone 0.25 milligrams twice a day based on an order they had in their system that was dated 8/25/23. The hospital records did not reveal why they did not implement R18's current order of Risperidone once per day. R18 was readmitted to the facility on [DATE] with diagnoses that included urinary tract infection and sepsis. Review of the Physician's Order dated 4/4/24 revealed an order for Risperidone 0.25 mg twice a day for behavioral disorders associated with dementia. Review of the Progress Note dated 8/7/24 revealed She is currently taking Sertraline 200mg once daily along with Risperidone .25mg once daily. Plan: Continue Risperdal [Risperidone] 0.25mg and Sertraline 200mg. Evaluate in the next quarter for further GDR. The note indicated R18 was receiving Risperidone once per day, but she was received the medication twice per day. Review of Behavior Analysis Report dated 10/1/23 to 10/16/24 revealed the following behaviors documented: 12/22/23- Rejection of care; Tried to get resident out of bed 4 times, multiple people also tried to get her out, but she refused all activity for the day. 2/5/24- False beliefs/misperceptions; There were no details documented; redirection was successful 3/10/24- Other behavior; Resident woke up confused thinking it was 1pm rather than 1am. days and nights mixed up. 8/21/24- Other behavior; attempted to change resident but was interrupted. I informed the hairdresser that she will need to be changed before her appointment. The hairdresser stated that she was overdue for a appointment and had the available slot at 9:45 AM and will be quick with her, then wheeled her away. Review of the Progress Note dated 9/18/24 revealed This resident's daughter approached this nurse at this time with concern due to the resident's increased hallucinations. Resident is currently seeing dogs in my room. Resident's daughter concerned with infection due to ureter stents being removed yesterday (09/17/24) . A message was passed on to the rounding providers for evaluation and potential treatment. No new orders at this time. The note did not indicate that the hallucination was distressful to R18. In an interview on 10/16/24 at 9:22 AM, Social Worker (SW) E and SW F reported the behavior tracking was documented in progress notes. When asked why risperidone was increased during and after R18's hospitalization , SW E and SW F were not able to provide a rationale. SW E and SW F were asked to provide any documentation they find. Documentation was not received prior to survey exit. In an interview on 10/17/24 at 9:16 AM with Director of Nursing (DON) B and Clinical Support (CS) I reported R18's Risperidone dose was changed while at the hospital from 3/21/24 to 4/3/24. Documentation was requested to show the rationale for the increase in Risperidone. Documentation was not received prior to survey exit.

Based on interview and record review, the facility failed to provide written notice of bed hold policy for two (Resident #19 and Resident #37) of two reviewed. Findings include: Resident #19 (R19) Review of the medical record revealed R19 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, anxiety, and diabetes. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/9/24 revealed R19 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R19 was their own responsible party/decision maker. Review of R19's history revealed they were transferred to the hospital on 7/4/24 and returned on 7/5/24, transferred to the hospital on 9/29/24 and returned on 9/30/24, and most recently transferred to the hospital on 10/10/24. R19 had not yet returned to the facility. Review of the medical record revealed no indication that R19 received a written notice of the bed hold policy upon transfer to the hospital. In an interview on 10/16/24 at 9:22 AM, Social Worker (SW) E reported they were present when R19 transferred to the hospital on 10/10/24. SW E reported the only paperwork they provided was the petition to psychiatric services. In an interview on 10/16/24 at 10:58 AM, Registered Nurse (RN) G reported they were assigned to care for R19 on 10/10/24. RN G reported the only paperwork that was provided to R19 was the Continuity of Care Document (CCD), face sheet, and code status. RN G was not aware of a written bed hold policy notice. RN G reported if any additional paperwork was completed, Assistant Director of Nursing (ADON) C would have done that. In an interview on 10/16/24 at 11:13 AM, ADON C reported the only paperwork provided to R19 upon transfer to the hospital was the CCD, face sheet, and the petition to psychiatric services. Clinical Support (CS) I was also present during the interview. CS I and ADON C were unable to provide a written notice of bed hold policy. An email received from Nursing Home Administrator (NHA) A on 10/16/24 at 11:26 AM, revealed Residents are provided the bed hold policy upon admission. In an interview on 10/17/24 at 09:16 AM, Director of Nursing (DON) B and CS I reported they were unable to find documentation that R19 was provided with a written notice of bed hold policy for each of the three hospital transfers. 49103 Resident 37 (R37) Review of the medical record revealed R37 was last admitted [DATE]. R37 had been readmitted after a hospitalization beginning on 6/11/24 with a diagnosis of Urosepsis (a life-threating complication of urinary tract infection). R37 had previously been readmitted [DATE] after a hospitalization for a diagnosis of Sepsis. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/10/24 revealed R37 scored 09 out of 15 (indicating moderate cognitive impariment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R37 was their own responsible party/decision maker. Record review revealed no indication that R37 received a written notice of the bed hold policy upon either transfer to the hospital. On 10/16/24 a request to the Nursing Home Administrator (NHA) A for the written notice of bed hold policy was made. A notice for a hospitalization in May was submitted, but none for June. 10/17/24 at 10:40 AM the Clinical Support Nurse T and Director of Nursing (DON) B were interviewed concerning the lack of paperwork (bed hold policy notification) for the hospitalization s in June. Clinical Support I explained that around that time (June 2024) some process changes had been going on and administration was trying to sort through and find out what happened. On 10/17/24 no further documents were submitted prior to the survey exit.

Based on interview and record review, the facility failed to provide written notice of transfer for two (Resident #19 and Resident #37) of two reviewed. Findings include: Resident #19 (R19) Review of the medical record revealed R19 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, anxiety, and diabetes. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/9/24 revealed R19 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R19 was their own responsible party/decision maker. Review of R19's history revealed they were transferred to the hospital on 7/4/24 and returned on 7/5/24, transferred to the hospital on 9/29/24 and returned on 9/30/24, and most recently transferred to the hospital on 10/10/24. R19 had not yet returned to the facility. Review of the medical record revealed no indication that R19 received a written notice of transfer upon transfer to the hospital. In an interview on 10/16/24 at 9:22 AM, Social Worker (SW) E reported they were present when R19 transferred to the hospital on 10/10/24. SW E reported the only paperwork they provided was the petition to psychiatric services. In an interview on 10/16/24 at 10:58 AM, Registered Nurse (RN) G reported they were assigned to care for R19 on 10/10/24. RN G reported the only paperwork that was provided to R19 was the Continuity of Care Document (CCD), face sheet, and code status. RN G was not aware of a written transfer notice. RN G reported if any additional paperwork was completed, Assistant Director of Nursing (ADON) C would have done that. In an interview on 10/16/24 at 11:13 AM, ADON C reported the only paperwork provided to R19 upon transfer to the hospital was the CCD, face sheet, and the petition to psychiatric services. Clinical Support (CS) I was also present during the interview. CS I and ADON C were unable to provide a written notice of transfer. An email received from Nursing Home Administrator (NHA) A on 10/16/24 at 11:26 AM, revealed The transfer notice can be found in [electronic medical record system] under observations and/or via progress notes. Written transfer notices were not found under observations or progress notes. In an interview on 10/17/24 at 09:16 AM, Director of Nursing (DON) B and CS I reported they were unable to find documentation that R19 was provided with a written notice of transfer for each of the three hospital transfers. 49103 Resident 37 (R37) Review of the medical record revealed R37 was last admitted [DATE]. R37 had been readmitted after a hospitalization beginning on 6/11/24 with a diagnosis of Urosepsis (a life-threating complication of urinary tract infection). R37 had previously been readmitted [DATE] after a hospitalization with a diagnosis of Sepsis. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/10/24 revealed R37 scored 09 out of 15 (indicating moderate cognitive impariment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R37 was their own responsible party/decision maker. Record review further revealed no indication that R37 received a written notice of transfer upon transfer to the hospital. On 10/16/24 a request to the Nursing Home Administrator (NHA) A for the written notice of transfer was made. A notice for a hospitalization in May was submitted, but none for June. 10/17/24 at 10:40 AM the Clinical Support Nurse T and Director of Nursing (DON) B were interviewed concerning the lack of paperwork (transfer notice) for the hospitalization s in June. Clinical Support I explained that around that time (June 2024) some process changes had been going on and administration was trying to sort through and find out what happened. On 10/17/24 no further documents were submitted prior to the survey exit.

This citation pertains to MI 00145328 Based on observation, interview, and record review the facility failed to thoroughly assess or provide treatment for a hot liquid burn for one Resident (#1) out of one reviewed resulting in the potential of medical complications from a hot liquid burn. Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted [DATE] with diagnoses that included cerebral infarction (stroke), fracture of nasal bones, history of falls, urinary tract infection, acute respiratory failure, heart failure, hypertensive heart disease, hypothyroidism (low thyroid hormone), hyperlipidemia (high fat content in blood), diplopia (double vision), dysarthria (slurred speech), anarthria (inability to articulate speech), dysphagia (difficulty swallowing), osteoarthritis, gastro-esophageal reflux, and chronic pain. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/17/2024, revealed a Brief Interview for Mental Status (BIMS) of 11 (moderated cognitive impairment) out of 15. During observation and interview on 07/05/2024 at 10:04 a.m. R1 was observed lying down in bed. Bed was observed to be in the lowest position. R1 explained that she had been at the facility since June of 2024. R1 was asked if she had ever spilled hot liquids on herself while at the facility. She had explained that she had but could not recount the date of the incident. Review of R1 medical record revealed a progress note dated 06/18/2024, at 06:30 p.m., which revealed, During dinner, res (Resident) was mixing 2 mild temperature beverages together and spilled them in her lap. She immediately removed her pants and cool compresses were applied. No blistering noted and redness is improving. Res (Resident) requested Tylenol for mild discomfort. Will continue to monitor. spoke with . PA (Physician Assistant). He recommended monitoring are until resolved. R1's medical record also revealed progress note dated 06/19/2024 at 04:40 a.m. Denies any discomfort to the mild redness on anterior thighs area from spilling warm beverage on lap. R1's medical record also revealed progress note dated 06/19/2024 at 02:50 a.m.no blistering noted and redness improving. Review of R1 medical record revealed a progress note dated 06/27/2024 at 02:32 p.m. revealed, Wound note: bilateral thighs, resident has open area on R thigh measuring approximately 0.5cm (centimeters) x (by) 7.5cm. area is read, no drainage, or odor present. States it does not hurt or itch. L thigh open area measuring approximately 0.5cm x 0.5cm area is red, no drainage, or odor present, states area does not hurt or itch. Will continue to monitor. In an interview on 07/05/2024 at 10:30 a.m. Director of Nursing (DON) B explained that R1 had spilled mild liquids on herself that had been provided on her meal tray. She further explained that mild liquids would have been coffee. When asked if R1 had developed blisters after the spill, DON B explained that she was not aware of any blisters. DON B was asked to review progress note dated 06/27/24 at 02:32 p.m. and explain what the open areas on R1's thighs were attributed to. DON B explained that those open areas were related to R1 scratching herself. DON B could not provide an incident report for the open areas. DON B explained that a skin assessment was to be completed every shift for at least 72 hours after the coffee was spilled on R1. DON B could not provide or demonstrate that skin assessments were completed as required. DON B' also explained that an order should have been put into place to monitor the burned area and a treatment should have been provided to the open areas. DON B could not provide documentation of an order for monitoring or documentation of any treatment that had been provided following the burn or for R1's open areas. In an interview on 07/05/24 at 12:46 p.m. Certified Nursing Aide (CNA) E explained that she provides care to R1 on a regular basis. She explained that she had been told that R1 had spilled coffee on herself during a meal. CNA E explained that she had provided care the day after the 'burn. On that day CNA E explained that she had observed blisters and redness on R1's right thigh and had reported her observation to the one of the nursing managers and had also report her observation to the Nursing Home Administrator. During observation and interview on 07/05/2024 at 01:15 p.m. R1 was observed sitting up in chair. R1 was asked if she had developed any blisters after spilling coffee on herself. She stated, yes I did, and a man even took pictures of it. She was asked if any treatments had been applied to the blisters and she explained that no treatments were done on that area. R1 then proceed to get into bed and remove her pants. A red area with approximately 12 cm (centimeters) in length and 1cm in width was observed. Several scabbed areas were observed along the area. Review of R1's June physician orders, medication record, and treatment record did not demonstrate that any treatment or medication had been ordered or applied to the area of R1's burns. R1's medical record did not demonstrate any pictures of the R1's burned areas.

This citation pertains to MI 00145328 Based observation, interview, and record review the facility failed to prevent accidents (falls) by not following the plan of care, for one Resident (#1) out of five Residents reviewed resulting in injury related to a fall. Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted [DATE] with diagnoses that included cerebral infarction (stroke), fracture of nasal bones, history of falls, urinary tract infection, acute respiratory failure, heart failure, hypertensive heart disease, hypothyroidism (low thyroid hormone), hyperlipidemia (high fat content in blood), diplopia (double vision), dysarthria (slurred speech), anarthria (inability to articulate speech), dysphagia (difficulty swallowing), osteoarthritis, gastro-esophageal reflux, and chronic pain. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/17/2024, revealed a Brief Interview for Mental Status (BIMS) of 11 (moderated cognitive impairment) out of 15. During observation and interview on 07/05/2024 at 10:04 a.m. R1 was observed lying down in bed. Bed was observed to be in the lowest position. R1 explained that she had been at the facility since June of 2024. She explained that she had several falls while at the facility. She explained that her last fall had occurred while she was in the bathroom taking a shower. R1 explained that a certified nursing aide, that was helping her with her shower, had left her alone in the shower. R1 explained that she was reaching for a washcloth and fell off the shower chair. R1 explained that she was taken to the hospital after the fall, at which time she received several sutures to her forehead. R1 explained that she was not to be left alone while she was in the shower because the facility knew she had a history of falling. Review of the facility Event Report dated 07/01/2024, timed at 03:49 p.m., revealed, Resident with fall on 07/01/2024 while in the shower, the resident had requested privacy. Resident states was reaching for a wash cloth that was on the hand rail and slid of the shower chair. Resident was sent to ER (emergency room ) for further evaluation and treatment. Review R1's progress notes dated 07/01/2024 at 10:10 p.m. revealed . returned from . hospital, received 6 stitches to the laceration on her forehead . In an interview on 07/05/2024 at 10:30 a.m. Director of Nursing (DON) B explained that she was aware of the R1's fall that occurred on 07/01/2024. She explained that R1 had been left alone in the shower, because she had asked for privacy, and feel off the shower bench while reaching for a washcloth. DON B was asked if she had interviewed R1 and she explained that she had not, but the nurse had interviewed R1 after the fall. She explained that Certified Nursing Aide (CNA) D had been interviewed and provided a statement. DON B explained that CNA D had reported that R1 had requested privacy and CNA D was honoring her request. In a telephone interview on 07/05/2024 at 11:10 a.m. Registered Nurse (RN) I had been taking care of R1 on 07/01/2024. RN I explained that Certified Nursing Aide (CNA) D had been assisting R1 with a shower. She explained that CNA D had left her alone because R1 had requested privacy. When R1 was left unattended she fell of the shower bench. RN I was asked if she interviewed R1 and she explained that she had not. RN I explained that the events were told to her by CNA D. During observation and interview on 07/05/2024 at 01:15 p.m. R1 was observed sitting up in her wheelchair. R1 was asked additional details regarding her fall on 07/01/2024. She was asked if she had requested privacy during her shower. R1 explained that she had not asked for privacy during her shower and that the facility understood she was not to be left alone, as she has a history of falling. In a telephone interview on 07/05/2024 at 01:27 p.m. Certified Nursing Aide (CNA) D explained that she was the person taking care of R1 on 07/01/2024. CNA D explained that she was assisting R1 with a shower and R1 had fallen off the shower bench. She explained that she had left R1 alone because she had assumed that she would like some privacy. CNA D was asked if R1 had requested privacy and she responded that R1 had not asked for privacy. CNA D explained that she was aware that R1 was a fall risk and explained that if a resident is a fall risk they should not be left alone. CNA D could not explain why she had assumed that R1 wanted privacy during the shower. CNA D explained that she had received a teachable moment, from the facility after R1's fall, which she was re-educated that resident that are a fall risk are not to be left alone while providing shower care. Review of the facility Teachable Moment document dated 07/03/2024 revealed On 07/02/2024 you were providing a shower for a resident with a history falls when you left the shower room. Resident had requested privacy however due to her impulsivity and history of falls, the resident should have remained near and within vision while providing as much privacy as possible. Going forward resident with a history of falls are not be left unattended in the shower. The Teachable Movement document dated 07/03/2024 demonstrated Certified Nursing Aide's (CNA) D signature.

Based on observation and interview the facility failed to ensure a call light was accessible for 1 out of 13 residents (Resident #11 ) reviewed, resulting in the potential for resident needs to be unmet. Findings include: Resident #11 Review of an Admission Record revealed Resident #11 (R11) admitted to the facility on [DATE] with pertinent diagnoses which included acute kidney failure, Type 2 diabetes mellitus with diabetic chronic kidney disease, Restless legs syndrome, Overactive bladder, and weakness. The Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/31/23 reflected R11 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R11 required extensive assistance of two or more people for transferring and toileting. On 09/18/23 at 09:21 AM, R11 was observed in bed with her eyes closed. R11 greeted me and reported that she was doing okay but was looking for her call light because she needed to go to the bathroom. R11's call light cord was observed twisted around the upper rails of the bed and laying on the floor near the head of the bed. When asked if R11 was able to pull on the call light cord to access the end of the light with the push button, R11 attempted but was unable to obtain her call light. In on observation on 09/18/23 at 3:38 PM, R11 was in bed resting her eyes. R11's call light cord was twisted around the upper rail of the bed and the end with the push button mechanism was on the floor. On 09/18/23 at 3:46 PM, a staff member entered R11's room to distribute medication. After staff exited, the call light appeared to be in the same location as the previous observation In an observation and interview on 09/18/23 at 4:12 PM, R11 attempted to pull the call light so she could again access the push button mechanism at the end. R11 reported that she preferred to have her call light clipped to her blanket but when she attempted to attach the light to her blanket she reported that she was unable to pinch the clip and clip the cord to her blanket. On 09/20/23 at 9:21 AM and 10:53 AM, R11's call light was again hanging out of reach from the resident. In an interview on 09/20/23 at 11:36 AM, Director of Nursing B reported that the expectation for call lights would be ensuring that they are answered in a timely matter and in reach. If noticed that the call light is out of reach or hanging onto the floor, the call light should be returned to the resident.

This citation is related to intake MI 875. Based on observation, interview and record review the facility failed to implement interventions for 1 of 3 cognitively impaired residents (Resident #3) and provide adequate supervision to prevent an avoidable accident resulting in immediate jeopardy due to the facility's failure to implement elopement risk interventions, prevent elopement and provide supervision of a cognitively impaired resident who sustained a fall with major injury outside of the building on facility grounds for R3. On 7/4/18 at approximately 11:19:05 AM, unbeknownst to staff, R3 eloped from the facility, and was found by another resident's family member/visitor E, on the pavement in the back of the facility property. R3 sustained a fall with clavicle fracture, hematoma to the left side of the head, bruising, hospitalization , and contributing to R3's decline and subsequent death. Findings Include: According to the Electronic Medical Records (EMR) R3 was born on 8/21/14 ([AGE] years old). R3 was most recently admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS: resident assessment tool) reflected R3 had a Brief Interview of Mental Status (BIMS) score of 3 out of 15 (0-7 equals severely cognitively impaired); required total assistance of 1 person for eating; extensive assistance of 2 persons for bed mobility, transfers and hygiene; frequently incontinent of bowel and bladder; extensive assistance of 1 person for dressing, toilet use and bathing; supervision of 1 person assist with locomotion on unit, and was independent with locomotion off unit with no assistance. R3's care plans dated 2/27/18 reflected R3 had the following problems: Resident has potential for impaired vision related to (r/t) : [AGE] year old male admitted for m hospital with [DIAGNOSES REDACTED]. Resident has potential for experiencing symptoms of fatigue, weakness, and confusion related to [MEDICAL CONDITION]. Resident requires staff assistance to complete Activity of Daily Living (ADL) tasks completely and safely. Family provides a companion to sit with resident every day for extra companionship. Resident is at risk for falling related to (r/t) [AGE] year-old male admitted for m hospital with [DIAGNOSES REDACTED]. Resident demonstrates short term memory loss. The facility's Event Report reflected on 7/4/18 at 11:07 AM R3 fell outside on facility grounds. Prior to fall his wheelchair went off the curb and was witnessed. R3 denied pain. The fall resulting in a hematoma and skin tear injuries. Neurological checks were performed for R3, R3 was given first aide and sent to a local hospital's emergency room (ER). R3 was checked on the report as having cognitive or memory impairment that effects safety and judgement, required assistance to transfer and had a recent change in his medications. Progress Notes dated 7/4/18 at 11:28 AM on the Event Report reflected: Resident had a fall outside from his wheelchair (w/c). Resident had went out on the front porch since being a nice day out. When resident was moving along the sidewalk in his wheelchair his wheel went off the curb and resident tipped over landing on his left side. Another resident family was outside sitting on the front porch and had seen the resident the whole time and then reported to staff that he had fallen out of his wheelchair and what occurred. 9 cm (centimeter) x 1 cm hematoma noted to the left side of his head and skin tear 10cm noted to the left elbow. Skin tear cleaned and steri-strips applied. Doctor (Dr. E) on site and assessed and order received to send to the ER for evaluation. Resident denied any pain when assessing limbs. Denied head pain. Resident was alert. Family notified. Resident sent to (name of hospital) ER for eval. Care Plan updated. Progress Note dated 7/6/18 at 2:54 PM reflected: IDT Review: resident sustained [REDACTED]. Per hospital records he also has a UTI. Resident had fall right in front of Red Cedar window, family sitting on porch witnesses the entire event. Red Cedar nurse responded immediately. Dr. E in building and assessed resident as well. Resident sent to ER per her orders for evaluation. Dr E also spoke with daughter as well. Resident was alert and appropriate throughout the fall and afterward. Will re-asses plan of care when upon resident return. R3's Admission Observation and Data Collection dated 2/7/18 reflected: Risk for Elopement-Mobility Is resident ambulatory or mobile with/without device (cane, walker, w/c etc), was checked No. Risk for Elopement-Cognitive Impairment Resident is not alert and oriented x 3, was checked Yes. Wandering device needed Apply wandering device if resident is independently mobile and not alert and oriented, was marked No device required. R3's Admission Observation and Data Collection dated 4/5/18 reflected: Risk for Elopement-Mobility Is resident ambulatory or mobile with/without device (cane, walker, w/c etc), was checked Yes. Risk for Elopement-Cognitive Impairment Resident is not alert and oriented x 3, was checked Yes. Wandering device needed Apply wandering device if resident is independently mobile and not alert and oriented, was marked No device required. Yet, based on the given section, R3 should have had a wander guard device placed. The facility's Observation Detail List Report for R3 Quarterly Observation and Data Collection dated 5/1/18 reflected the following Safety section: R3 was checked for the following items: Has cognitive impairment that effects safety/judgement, has difficulty understanding the following directions, has a history of falls, requires assistance to transfer, incontinent of bower and/or bladder. The facility's Guidelines: Elopement Risk Assessment and Prevention Policies and Procedures Clinical dated 9/28/16 reflected: PURPOSE: The campus strives to promote resident safety and protect the fights and dignity for the residents. A process to assess all residents for risk for elopement implement prevention strategies for those identified as an elopement risk, institute measures for resident identification at the time of admission ,and conduct a missing resident procedure. These policies assist to define the mechanisms and procedures for monitoring and managing residents at risk for elopement help to minimize the risk of a resident leaving a safe area without authorization and/or appropriate supervision. DEFINITIONS: Elopements occur when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. Wandering: refers to a cognitively-impaired resident's ability to move about inside the facility aimlessly and without an appreciation of personal safety needs and who may enter into a dangerous situation, PR[NAME]EDURE: 1. Each resident will be assessed for elopement risk upon admission, quarterly, and with change in condition. 3. A plan of care will be developed and implemented for each resident identified as having the potential to leave the facility unauthorized, requiring supervision for off ground privileges or wandering to an unsafe area. 14. Should a resident be found to have exited the doorway, in an unsafe area or missing the Elopement/Missing Resident Guidelines and Checklist should be initiated and appropriate steps followed. On 8/2/18 at 10:13 AM Certified Nursing Assistant (CNA G) was asked if he recalled R3. CNA G stated, He was extensive care. Alert and Oriented (A&O) depending on the day. Incontinent, used the urinal throughout the day, wheeled around and chatted daily. He never went very far up until the event that happened. If he got too far he would normally ask for help. He was unsteady of his feet and needed Extensive Assistance (EA), and he had bad shoulders. CNA G denied R3 was able to self transfer. He would always yell or ask for help. His daughter drilled that in his head, she was an advocate for him. He did not remember my name, but called me Big Guy. CNA G was asked to recall incident dated 7/4/18. CNA G revealed, I was giving a person a shower, stepped out to grab something supplies? and R3 was in the hall. He was waiting for help in the midst of giving a shower. I could not leave the person in the shower alone. I told R3, I was coming back 10-15 minutes. Later and staff had told me what happened. CNA G revealed R3's call light was not on when he requested assistance, or when made aware of incident, and that R3 knew how to use his call light. He had a touch call light. He had said, I need your help when you have a second. He seemed really calm about it. CNA G revealed Registered Nurse (RN H) worked with him that day, and we were both doing something. Staff had asked him, if he had seen the knot on his head. Staff said did you see or know what happened. Also, that he and RN H both ran out the Red Cedar door exit to help, but there was a big group of people there already. Lastly, CNA G stated, Whenever he would go outside, I would have to open the door for him. He could not open the door himself. All staff knew he could not open the door. He was not to be outside alone. CNA G also revealed, All doors are alarmed and are at the end of the door. You have to put in the code to open the doors and they are really loud. Maintenance always test the doors. On 8/2/18 at 10:36 AM Licensed Practical Nurse (LPN J) was interviewed and asked to describe R3. LPN J revealed, He was previously a resident on (name of unit). He was friendly cheerful. He would move around in his wheelchair. LPN J was then asked to recall the incident dated 7/4/18. I was coming out of a resident's room and was alerted by a family member, that a resident had fell out of a wheelchair. I looked out the window and saw that his w/c had slipped off the edge of the sidewalk and he was laying on his left side. I stayed with the resident. shortly after Physical Therapist (PT L) assisted me as well. The Director Of Nursing (DON B) came in and helped as well. He was A&O and denied pain. He had a skin tear on his left elbow and a hematoma on the left side of his skull. LPN J denied moving R3, but revealed neuro (neurological) checks were done to make sure he was awake, alert and oriented. DON B called Emergency Medical Services (EMS). He was not moved until EMS came. LPN J revealed she was not aware if R3 could open the door by himself and that R3 went out the front entrance door. When asked if the Red Cedar/Health Center door was alarmed. LPN J replied, It only alarms if a resident has a wander guard on. At the time he was not an elopement risk. LPN J denied seeing R3 exit the building At this time at 10:54 AM PT L was interviewed and asked to describe R3. PT L revealed, R3 would come down to PT and we would give him 1 to 2-pound hand weights and he would lift the weights up and own. He was like a [MEDICATION NAME], he would go around the building and interact with everyone. PT L was asked if R3 seemed A&O. PT L replied, There were some days you could question it. He would have a slur at times. PT L was asked to recall R3's incident dated 7/4/18 and revealed, I was inside the building down Grand River and someone came in, a visitor and stated a resident had fallen. I went outside. LPN J was there with him. I came out by her and assessed him. I told her to go get DON B: and the doctor. The doctor and DON B came outside assessed him and the doctor said to call 911. LPN J had assessed him before that. I had assessed him and asked him questions and he could respond. He denied pain. There was blood on the ground. He had a nice sized contusion on his left temple. He was face down on and he was on his left side. PT L denied alarms were going off at the time. He went out the Health Center door on the far end. Out the door on the right-hand side. It looked like he fell off the sidewalk. PT L was asked if wander-guards were used at the facility. PT L replied, Yes, it's a collaboration with PT, nursing, and the doctor. I don't think he had one. I could be wrong. If you try to exit a door, and one of them are by you, the alarm will go off . On 8/2/18 at 11:06 AM DON B was interviewed and asked to describe R3. DON B revealed, I always had pleasant conversations with him. He would self-propel himself in his w/c stop and talk to people. DON B was asked how was R3's vision and replied, I believe he wore glasses. DON B revealed she had never seen R3 open and close a door, and she normally saw R3 by the therapy room or in his hall. When asked to recall the incident dated 7/4/18 DON B revealed, I was walking down toward the um entrance there, and the staff had alerted me he was outside. I was walking that way and I could see him out the corner of my eye, and LPN J or PT L came to tell me he had fallen. Which I had already seen. I assessed him, went and got the doctor, and she assessed him. I asked if he was hurt, and he said he was not hurt. He was talking to us the whole time. DON B revealed after the fall R3 was on his back, he had a goose egg, skin tear on his elbow and his w/c was on the sidewalk. Also, that she had never known R3 to go outside. DON B was asked if the facility informed family members and visitor about not letting residents out of the building. DON B replied, Yes and that it was a husband of a past resident who let R3 out of the building. DON B was asked if R3 was assessed for a wander-guard, and revealed she was not sure. DON B revealed the facility doors alarmed if residents had on wander guards and after a certain time at night. When asked how the facility determined what residents received wander guards DON B replied, If they are exit seeking, trying to go out the door, very confused, or saying they want to leave. We would assess them. If they say they are trying to get out the door or pack their bags and leave. We look over all that stuff in the CAR (Clinically At Risk). We sit down with social work and go over who we felt was at risk with the FAR (Facility Activity Report). We run a report. On 8/2/18 at 11:51 AM R3's daughter (M) was called and interviewed by phone. Daughter M revealed the facility had informed her that her father R3 had been in a serious incident, that no-one witnessed the incident, an ambulance was called, and he was transferred by an ambulance to a hospital because he was seriously injured. I talked to the nurse on duty that day RN H. She said she did not know how he got to the back of the facility, and no one witnessed it. His injuries were serious enough that he was admitted to (name of local hospital's) Neurological Intensive Care Unit. The accident happened 7/4/18 and he passed 7/24/18. I talked to the doctor later. I expressed concern to the DON (DON B) about the medical care my father was given. The doctor told me she ordered him to not be moved and called for the ambulance. They claimed it appeared, he rolled his w/c over the curb and fell out the w/c. He had a fractured collar bone, bruises across his back, neck and face was bruised. We were so shocked. He had a laceration on the side of his face. His ribs were bruised, and he had free floating bone in his elbow. The trauma doctor thought he fractured his arm but later that they were unsure. He was admitted from the ER to the neuro ICU. This was not a minor fall. One of the reasons we had been asking the (name of facility) to have him medically checked the prior week on Thursday or Friday. He was on [MEDICATION NAME] daily and having confusion. My dad was bright as a button. The aide there shared he was having confusion. I had requested a urinalysis be done and his electrolytes checked. His Vital Signs (VS) were normal. I got a call on that Monday night that his Sodium (NA) was 121 (Normal 135-145). They said they were going to elect to hold his [MEDICATION NAME] on Monday and Tuesday and would give Wednesday. The hospital ICU thought his NA was critically low. Our issue is that they should have taking medical action and they did not. That was an issue. The greater issue is that we thought his injuries were too significant to have fallen out of the w/c. Nobody we talked to could tell anything different. They told us he had went outside himself. We hired a companion from 11 to 7 and 5 to 11 to help him, because we knew the staffing was low. They did not have adequate manpower. The aide we hired privately from 11-7 told me, she told the nurse R3 was extremely confused. When the doctor called me on 7/4/18, she said she had never been told about his confusion. Our help told them for 4 days. He should have been checked medically. On 8/2/18 at 1:43 PM care plans and the Quarterly MDS for R3 was provided by DON B. DON B was asked if R3's incident was reported to the state agency and the DON B stated, No. On 8/2/18 at 1:49 PM Maintenance Director (MD I) set up video footage of the incident dated 7/4/18 to be viewed. R3 was observed to self-propel himself to the Red Cedar/Health Center exit door at 11:16 AM and stayed in front of the door until a male visitor open (2) sets of doors for R3 to exit at 11:19 AM. At 11:22 AM a female visitor (F) of a female resident at the facility, entered the building and appeared to alert LPN J of a situation (possibly R3's fall). LPN J was then observed to exit the building at 11:23 AM and to the right of the building. PT L, DON B, Dr. E and others exit the building to assist allegedly R3 from 11:24 AM until 11:44 AM which appears to be the end of the event. The video surveillance reflected DON B had a device in her hand that prevented her from opening the door. During the video DON B was observed to have handed the device to another staff, which appeared to be a wander guard device. On 8/2/18 at 2:39 PM Administrator (ADM A) was asked if he was notified of the incident dated 7/4/18. ADM A revealed he had received a phone call about the incident. ADM A was asked if he reported the incident to the state agency and ADM A replied, No. When asked why ADM A revealed, We knew how it happened, it was not suspicious in nature. I called the Regional Supervisor and reviewed it. The determination was made it did not meet criteria to be reportable. On 8/2/18 at 3:29 PM Visitor F (who was present outside the day of the fall) was interviewed by phone and asked to recall the incident dated 7/4/18. Visitor F revealed, We were sitting outside in the chairs. He (R3) came out, was in his w/c. He came next to us and said something, but I could not understand what he said. He wheeled past us. I then heard this bang and saw that he had fallen. When I got up, it looked like he tipped to his side on the ground. His w/c tipped over and he was still positioned in the wheelchair, like he was sitting in the chair. As soon as I saw him, I ran and got someone. When the staff came out. I was out there. There was another gentleman who had come out before R3 who had maybe walked to the pond. The other gentleman was not in view at the time. My mom was rattled, so I took her back in side. When asked if any facility staff were outside before R3 fell , Visitor F stated, No, not that I am aware of. No staff had been out there when we had been out there. We had been out there a good 20 minutes before R3 came out. Visitor F denied that she had actually saw R3 fall, but had heard the bang from the fall. Visitor F was visiting her mother, and was not designated to supervise any facility residents. On 8/2/18 at 3:36 PM DON B revealed, When he came in he was a Hoyer, but then he got change to a (2) Person Assist. When asked if R3 had always been independently mobile DON B stated, I would have to check. DON B was asked if she recalled R3's daughter complaints of her father R3 having confusion. DON B revealed, We had talked. She had spoke with the nurses. They had put it in the physician book. The Nurse Practitioner (NP N) saw him on 7/2/18. The daughter told me she spoke with the nurses about seeing some confusion in him. NP N saw him on the 2nd (7/2/18). They did an ammonia level and had held some meds or something and had labs redrawn. When I spoke with her (R3's daughter M), I told her the doctor had seen him. (Actually, R2 was not seen by the doctor at this time). DON B was asked where was the documentation related to the discussions shared, and revealed some were in the doctor's book. DON B also revealed, that she told daughter M she would have doctor E talked to her on 7/4/18. Daughter M said that would be fine, staff asked daughter if she would like them to call the doctor as well, the daughter said no, and chest X-rays were done. Progress Note dated 6/4/18 and dictated 6/4/18 at 15:55:23 by Nurse Practitioner (NP N) reflected R3's daughter felt R3 was more fatigued and confused than his baseline, as the CHIEF COMPLAINT. NP N documented, .He was pleasantly confused, which is his baseline , under the HISTORY OF PRESENT ILLNESS section. Also, NP N ordered a CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) blood test. The CBC lab dated 6/5/18 reflected a sodium level of 132. The lab report sheet reflected a reference range of 136-145. Progress Note dated 7/2/18 and dictated 7/2/18 at 22:14:45 by NP N for R3 reflected: CHIEF COMPLAINT: I was asked to see R3 because he has had significant decline over the past two day. He is confused. He is lethargic. He is coughing and wheezing. This is definitely a change from his baseline. HISTORY OF PRESENT ILLNESS: 2. Confusion. The nurse aide and his daughter both had noted that he was much more confused than usual. He was talking but not making much sense. This was definitely a change from baseline. I did order STAT CBC , CMP and chest x-ray. I have not received the chest x-ray back yet, but I did get the labs. Although his white count was normal, his sodium, was 121. 3. [MEDICAL CONDITION]. This is a new finding. His last sodium was 141. It was 121 today and I think that is probably what is responsible for his confusion. He does have [MEDICATION NAME] 20 mg twice a day and that was just increased in early June. I suspect that is the culprit. I am going to hold his [MEDICATION NAME] for 24 hours and then restart it at a somewhat lower dose. ASSESSMENT AND PLAN: 2. Confusion. He is definitely decreased from baseline. 3. [MEDICAL CONDITION] with sodium of 121. I suspect that this is causing the confusion. Hold [MEDICATION NAME] for 24 hours and then restart one daily, except three days a week give two because of his [MEDICAL CONDITION]. Recheck basic profile and BNP (Brain Natriuretic Peptide) on Wednesday. The Progress Note documented on 7/4/18 and dictated on 7/4/18 at 19:48:55 by Dr E reflected that R3 fell on the curbside and suffered a laceration of the left arm, temple with left temple hematoma. The DON B (Director of Health Services) had called her and stated she (DON B) had talked to R3's daughter about R3 going to the ER, daughter was upset and thought R3 was not getting good medical care and the physician was not following. They were concerned for the last several days that the patient was more confused and was not doing well, that nobody took care of it. Dr E called the daughter who revealed she had been having concerns since last Thursday (6/28/18) or Friday (6/29/18), R3 was fatigued and she (daughter) requested R3 be seen. Dr. E further wrote, .I did tell her that this is the first time I am hearing from the director of health services that she wanted to talk to me and I had never gotten any notification. Apparently the nurses had put a note in our communication work and the patient was seen by NP N. He had a low sodium of 121 on (MONTH) 2nd. His [MEDICATION NAME] (diuretic) was put on hold for a day and then it was supposed to have a recheck with a BMP on Wednesday (7/4/18). The patient apparently did not have the blood drawn this morning and had a fall. I did call the daughter and apologized to her that I did not get any notification from the nursing staff about her concerns and that this is the first time I am hearing this. Definitely as the patient is [AGE] years old and any small insult can affect him . Page 2 of the Dr. E Progress Note dated 7/4/18 under the PLAN section reflected: .I talked to the patient's daughter and apologized for any miscommunication and I did call and conveyed my concerns to the director of health services with not being informed that the family was so keen and that the patient was not doing well, and if the patient was not doing well and there was more and more confusion and [MEDICAL CONDITION], then maybe he should have been sent to the hospital An observation on 8/2/18 at 7:30 AM and 5:00 PM, revealed no signage on doors or in the facility alerting visitors to not let residents out of the building unattended. In an interview on 8/2/18 at 11:40 AM, Director of Nursing (DON) B reported elopement risk assessments were completed on admission and quarterly. In an interview on 8/2/18 at 4:24 PM, Registered Nurse (RN) C reported she usually worked second shift on the hallway which Resident #3 resided. RN C reported by the time she got onto the unit for her shift, Resident #3 was usually out and about in the facility by himself, wheeling around talking to people. RN C stated when Resident #3 was off the hallway, she didn't know who he interacted with. When asked about his cognitive status, RN C stated well he was 103 (years old) .alert to person and place. He knew he was in a nursing home, but it might be a stretch to say (name of facility). When asked about elopement assessments on the Admission Observation and Data Collection, RN C reported the assessment consisted of 2 questions and was not very thorough. RN C stated everyone here knew (Resident #3) and not one employee would have let him out that door. RN C reported there was a recent education regarding keeping an eye on who is at doors and the elopement books. When asked how the doors were monitored, RN C stated just people (staff) walking around. When asked what visitors/family members were told, RN C stated I don't know .not brought up in inservice. In a telephone interview on 8/3/18 at 7:32 AM, Licensed Practical Nurse (LPN) D reported the 2 questions regarding cognitive status and mobility status were the only two questions involved in the elopement assessment upon admission. When asked when a wanderguard would be applied to a resident, LPN D stated if exit seeking behaviors, which she described as a resident voicing wanting to leave the facility, going to the doors, sitting at the doors, and trying to open the doors. LPN D stated it's up to the nurse I guess. LPN D recalled Resident #3 as a resident who was wheelchair bound, but was active in going around to see people. He would come out and wander the hall and talk to staff .he definitely went around hallways talking to people. He would go to doors and windows and look out. He had bouts of confusion. LPN D reported Resident #3 was not able to independently open doors, as he could not lift his arms without staff assistance. When asked who monitored Resident #3 when he was off his hallway, LPN D stated everyone knew who he was. When asked if Resident #3 ever sat outside, LPN D stated not unless family was with him. They took him out often .I wouldn't let him out by himself. When asked why not, LPN D stated I don't think he could get back in. The doors are heavy and I don't know if he would know to push the handicap button .I would think someone should be with him. Also he couldn't see very well. I wouldn't have had him go out by himself. When asked what prevented visitors from letting residents out of the building, LPN D stated I think it was obvious who was a visitor and who was a resident. I think visitors just knew. I guess I can't answer that question. In an interview with LPN P on 8/7/18 at 2:46 PM, when asked if a wanderguard would be placed on a resident who was alert and oriented times one to two and independently mobile in a wheelchair, LPN P stated I don't know why we wouldn't put a wanderguard on. Nursing Home Administrator (NHA) A was presented with Immediate Jeopardy Notification on 8/7/18 at 8:30 AM due to the facility's failure to implement elopement risk interventions, prevent elopement and provide adequate supervision resulting in fall with major injury for R3.; when on 7/4/18 at approximately 11:19:05 AM, unbeknownst to staff, R3 eloped from the facility, and was found by another resident's family member/visitor E, on the pavement in the back of the facility property. R3 sustained a fall with clavicle fracture, hematoma to the left side of the head, bruising, hospitalization , and contributing to R3's decline and subsequent death. A corrective action plan was requested from the facility to remove the immediate jeopardy. Immediate Jeopardy was removed on 8/7/18 when it was verified that the facility implemented interventions which included the following interventions were put into place: 1. R3 was discharged from the facility 7/9/2018. At the time of the incident on 7/4/2018 investigation was started. 2. All residents in the facility have been re-assessed for elopement on 8/7/18. Residents were re-assessed by reviewing their Admission and/or Quarterly assessment and then completing the Elopement Risk Review. A progress note will be added to explain determination if assessment is inidicating something/ difference of need for wander device. New admissions will be assessed for elopement upon admission, starting 8/7/18. Residents found to be at risk will have a wanderguard in place effective 8/7/18. 3. On 8/7/18, staff have been re-educated on Elopement Policy. Licensed nurses have been re-educated on looking at the Admission Observation and Data Collection Exit Seeking questions and then completing the Elopement Risk Review. A progress note will be added to explain determination if assessment is inidicating something/ difference of need for wander device. DON and/or designee(s) will provide the education completed 8/7/18. Signs have been placed at the main entrances to inform visitors not to allow residents outside of the campus without checking with licensed nurse beforehand. 4. Audits will be completed 3 times a week on residents found to be at risk for elopement, audits will be done for 8 weeks. NHA will ensure compliance. Although the Immediate Jeopardy was removed on 8/7/18, the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the State Agency.

This citation pertains to MI 979. Based on interview and record review the facility failed to provide supervision and interventions to prevent falls for 2 (Resident #3 and #4) of a total of 5 sampled residents reviewed for falls, resulting in all 2 residents falling multiple times, and suffering fractures. Findings include: Review of the Facility's Falls Management Program Guidelines policy last revised 2/15 revealed, 1. The fall risk assessment is included as part of the Admission and Monthly Nursing Assessments and Review and Circumstance forms .b. Care plan interventions should be implemented that address the resident's risk factor .3. Should the resident experience a fall .complete the Fall Circumstance and Reassessment Form. The form includes an investigation of the reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT (Interdisciplinary Team) .4. An Accident and Incident Report should be completed at the time of the incident .7. The resident Icare plan/profile (Care Plan) should be updated to reflect any new or change in interventions. Resident #3 Review of the Admission Record and most recent Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was a [AGE] year old female resident readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the complete medical chart revealed Resident #3 had fallen on 2/10/15, 2/12/15, 3/11/15, 4/13/15 and 4/26/15. Review of the Resident Transfer Form dated 3/11/15 revealed Resident #3 was to be transferred to the hospital for the reason of a fracture of the left hip. Further review of the form revealed, Resident went to grab walker realized she was too far from walker foot became stuck in wheel. Resident fell backwards. Review of the Fall Circumstance, Assessment and Intervention Report completed by nurse M and dated 3/11/15 revealed that on 3/11/15 at 5:20 a.m., Resident #3 was found by CRCA (nursing assistant) on floor, Nurse assisted to bed and revealed no injury. Under the notification section it is written that on 3/11/15 at 5:32 a.m. MD (Medical Doctor) was notified, in the Who section, the name of Resident #3's doctor's name is written in, but it is not in the same hand witting as the rest of the form, it appears that this name was written in by another person, not the original person completing the form. Further review of the form reveals, Root Cause: needed to toilet . Review of the Accident/Incident Report, completed by the same nurse M, and dated 3/11/15 at 5:20 a.m., revealed, Resident (#3) found on floor by CRCA after roommate rang call bell. (Resident #3) says she fell .denies hitting head, but did bump (left) thigh on ground and stated some tenderness. Further review of the same form, in the location of injury section there is an X drawn on the left hip of the figure and it states, pain. Further review of this form reveals that 3/11/15 at 5:35 the on call physician was notified, however in the Physician Statement/Orders section it states no new orders, and to observe for pain . Neither Nurse M that completed the forms, the Nursing Assistant that first found the resident, nor the individual that that wrote in the doctor's name on the Fall Circumstance, Assessment and Intervention Report work at the facility, and were not available for questions. Further review of these two forms and the nurses notes failed to reveal that a full head to toe assessment was completed before getting the resident back to bed. Review of Licensed Practical Nurse (LPN) Os Nurses Note dated 3/11/15 at 2:30 p.m., revealed, Assessed (Resident #3) at 7:00 a.m. (secondary) to fall. (Resident #3) guarding (left) hip stating, 'It sure does hurt .' Physician notified of possible injury and a 2 view X-ray of (left) hip STAT .Xray results showed hip (fracture) . Review of the Fall Circumstance, Assessment and Intervention dated 2/10/15, revealed Resident #3 had fallen on 2/10/15 at 1:30 a.m., Resident was soiled, tried to get to the bathroom. Under the Care Plan Section it states that a new intervention of toileting every 2 hours to be implemented, however review of Resident #3's care plan failed to reveal this intervention. Review of the Fall Circumstance, Assessment and Intervention dated 2/12/15, revealed Resident #3 had fallen on 2/12/15 at 8:50 p.m., walking without walker to bathroom, under the Care Plan section, it states that an updated intervention of toilet every 2 hours to be implemented, however review of Resident #'s care plan failed to reveal this intervention. Review of the Physical Therapy Progress and Discharge Summary dated 2/26/15 revealed Resident #3 used a 4-wheeled walker for ambulation and required, physical assistance for safe transfer and ambulation. Review of Resident #3's careplan from 1/5/2015 thru 3/11/15 failed to reveal any interventions related to the resident using a 4-wheel walker, or toileting the resident every two hours were implemented. During an interview on 7/22/15 at 2:19 p.m., Director of Nursing (DON) B stated, They (staff) did not document (toileting Resident #3) every 2 hours like they were supposed to. DON B further stated that she agreed that the toileting every two hour interventions were not on the care plan. Review of Resident #3's medical record failed to reveal that a Monthly Nursing Assessment for February 2015, which is required per the Facility's Falls Management Program Guidelines policy, was completed. During an interview on 7/27/15 Medical Records nurse, LPN L stated, I was unable to find a February Monthly Nursing Assessment for (Resident #3). Resident #4 Review of the Admission Record and most recent Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 was a [AGE] year old male resident readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #4 had clear speech, was understood, understands and was moderately impaired cognitively. Review of the complete medical chart revealed Resident #4 had the following falls: Falls: 8/6/14 (twice), 8/7/14, 8/9/14, 8/20/14, 8/23/14, 8/28/14, 9/6/14, 9/10/14, 9/17/14, 11/5/14, 11/14/14, 11/17/14, 11/23/14, 12/24/15, 3/24/15, and 3/31/15. Review of the Fall Circumstance, Assessment and Intervention form dated 9/17/14 revealed Resident #4 fell and suffered a right femoral neck (hip) fracture. Further review of the form revealed, Resident states, 'I was trying to sit in my wheelchair and it rolled back and I fell ' .Resident has right hip fracture. Sent to hospital. Review of the Readmission History and Physical dated 9/24/15 revealed Resident #4, was admitted to (name of hospital) on 9/17/14 after a fall from the wheelchair .(Resident #4) has been noncompliant with his instructions of moving about and doing things. He is at high risk for falls with all of his multiple issues, but he usually does not follow instructions. Part of it probably could be because of his underlying dementia .had hemiarthroplasty (hip replacement) done on 9/18/14 . Review of the Monthly Nursing Assessment and Data Collection form dated 9/6/14 revealed Resident #4 required extensive assistance with transfers and toileting. Further review of the form revealed Resident #4 require the use of a wheelchair, was a risk for falls, and that an individualized care plan was initiated. Review of Resident #4's multiple Accident/Incident reports revealed multiple times the resident was attempting to transfer, toilet or ambulate without using his call light, and that the immediate action to prevent further falls was to reeducate the resident on use of the call light. Review of Resident #4's careplan that was in effect during the 9/17/14 fall revealed there were no interventions in place for Resident #4's [DIAGNOSES REDACTED]. In an interview on 7/23/15 at 9:15 a.m., Resident #4 stated that the staff in the facility are not the right help, Some of the girls are not strong enough to help him in and out of bed. Resident #4 was not able to provide this surveyor details surrounding his 9/17/14 fall, and actually stated he thought it happened at home. Resident #4 stated, They need more people, it takes quite a long time to get people to help me in and out of bed. In an interview on 7/27/15 at 1:26 p.m., DON B confirmed that to her knowledge neither of these falls with fractures were reported to the state agency. ( )

This citation pertains to MI 979. Based on interview and record review, the facility failed to develop and update a comprehensive plan of care for 2 residents (#3 and #4) from a total sample of 5 residents reviewed for care plans, resulting in both residents falling and sustaining fractures. Findings include: Review of the Facility's Falls Management Program Guidelines policy last revised 2/15 revealed, 1. The fall risk assessment is included as part of the Admission and Monthly Nursing Assessments and Review and Circumstance forms .b. Care plan interventions should be implemented that address the resident's risk factor .3. Should the resident experience a fall .complete the Fall Circumstance and Reassessment Form. The form includes an investigation of the reassessment to identify possible contributing factors, interventions to reduce risk of repeat episode and a review by the IDT (Interdisciplinary Team) .4. An Accident and Incident Report should be completed at the time of the incident .7. The resident Icare plan/profile (Care Plan) should be updated to reflect any new or change in interventions. Resident #3 Review of the Admission Record and most recent Minimum Data Set ((MDS) dated [DATE] revealed Resident #3 was a [AGE] year old female resident readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the complete medical chart revealed Resident #3 had fallen on 2/10/15, 2/12/15, 3/11/15, 4/13/15 and 4/26/15. Review of the Resident Transfer Form dated 3/11/15 revealed Resident #3 was to be transferred to the hospital for the reason of a [MEDICAL CONDITION] hip. Further review of the form revealed, Resident went to grab walker realized she was too far from walker foot became stuck in wheel. Resident fell backwards. Review of the Fall Circumstance, Assessment and Intervention Report completed by nurse M and dated 3/11/15 revealed that on 3/11/15 at 5:20 a.m., Resident #3 was found by CRCA (nursing assistant) on floor, Nurse assisted to bed and revealed no injury. Under the notification section it is written that on 3/11/15 at 5:32 a.m. MD (Medical Doctor) was notified, in the Who section, the name of Resident #3's doctor's name is written in, but it is not in the same hand witting as the rest of the form, it appears that this name was written in by another person, not the original person completing the form. Further review of the form reveals, Root Cause: needed to toilet . Review of the Accident/Incident Report, completed by the same nurse M, and dated 3/11/15 at 5:20 a.m., revealed, Resident (#3) found on floor by CRCA after roommate rang call bell. (Resident #3) says she fell .denies hitting head, but did bump (left) thigh on ground and stated some tenderness. Further review of the same form, in the location of injury section there is an X drawn on the left hip of the figure and it states, pain. Further review of this form reveals that 3/11/15 at 5:35 the on call physician was notified, however in the Physician Statement/Orders section it states no new orders, and to observe for pain . Neither Nurse M that completed the forms, the Nursing Assistant that first found the resident, nor the individual that that wrote in the doctor's name on the Fall Circumstance, Assessment and Intervention Report work at the facility, and were not available for questions. Further review of these two forms and the nurses notes failed to reveal that a full head to toe assessment was completed before getting the resident back to bed. Review of Licensed Practical Nurse (LPN) Os Nurses Note dated 3/11/15 at 2:30 p.m., revealed, Assessed (Resident #3) at 7:00 a.m. (secondary) to fall. (Resident #3) guarding (left) hip stating, 'It sure does hurt .' Physician notified of possible injury and a 2 view X-ray of (left) hip STAT .Xray results showed hip (fracture) . Review of the Fall Circumstance, Assessment and Intervention dated 2/10/15, revealed Resident #3 had fallen on 2/10/15 at 1:30 a.m., Resident was soiled, tried to get to the bathroom. Under the Care Plan Section it states that a new intervention of toileting every 2 hours to be implemented, however review of Resident #3's care plan failed to reveal this intervention. Review of the Fall Circumstance, Assessment and Intervention dated 2/12/15, revealed Resident #3 had fallen on 2/12/15 at 8:50 p.m., walking without walker to bathroom, under the Care Plan section, it states that an updated intervention of toilet every 2 hours to be implemented, however review of Resident #'s care plan failed to reveal this intervention. Review of the Physical Therapy Progress and Discharge Summary dated 2/26/15 revealed Resident #3 used a 4-wheeled walker for ambulation and required, physical assistance for safe transfer and ambulation. Review of Resident #3's careplan from 1/5/2015 thru 3/11/15 failed to reveal any interventions related to the resident using a 4-wheel walker, or toileting the resident every two hours were implemented. During an interview on 7/22/15 at 2:19 p.m., Director of Nursing (DON) B stated, They (staff) did not document (toileting Resident #3) every 2 hours like they were supposed to. DON B further stated that she agreed that the toileting every two hour interventions were not on the care plan. Review of Resident #3's medical record failed to reveal that a Monthly Nursing Assessment for February 2015, which is required per the Facility's Falls Management Program Guidelines policy, was completed. During an interview on 7/27/15 Medical Records nurse, LPN L stated, I was unable to find a February Monthly Nursing Assessment for (Resident #3). Resident #4 Review of the Admission Record and most recent Minimum Data Set ((MDS) dated [DATE] revealed Resident #4 was a [AGE] year old male resident readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #4 had clear speech, was understood, understands and was moderately impaired cognitively. Review of the complete medical chart revealed Resident #4 had the following falls: Falls: 8/6/14 (twice), 8/7/14, 8/9/14, 8/20/14, 8/23/14, 8/28/14, 9/6/14, 9/10/14, 9/17/14, 11/5/14, 11/14/14, 11/17/14, 11/23/14, 12/24/15, 3/24/15, and 3/31/15. Review of the Fall Circumstance, Assessment and Intervention form dated 9/17/14 revealed Resident #4 fell and suffered a right femoral neck (hip) fracture. Further review of the form revealed, Resident states, 'I was trying to sit in my wheelchair and it rolled back and I fell ' .Resident has right [MEDICAL CONDITION]. Sent to hospital. Review of the Readmission History and Physical dated 9/24/15 revealed Resident #4, was admitted to (name of hospital) on 9/17/14 after a fall from the wheelchair .(Resident #4) has been noncompliant with his instructions of moving about and doing things. He is at high risk for falls with all of his multiple issues, but he usually does not follow instructions. Part of it probably could be because of his underlying dementia .had hemiarthroplasty (hip replacement) done on 9/18/14 . Review of the Monthly Nursing Assessment and Data Collection form dated 9/6/14 revealed Resident #4 required extensive assistance with transfers and toileting. Further review of the form revealed Resident #4 require the use of a wheelchair, was a risk for falls, and that an individualized care plan was initiated. Review of Resident #4's multiple Accident/Incident reports revealed multiple times the resident was attempting to transfer, toilet or ambulate without using his call light, and that the immediate action to prevent further falls was to reeducate the resident on use of the call light. Review of Resident #4's careplan that was in effect during the 9/17/14 fall revealed there were no interventions in place for Resident #4's [DIAGNOSES REDACTED]. In an interview on 7/23/15 at 9:15 a.m., Resident #4 stated that the staff in the facility are not the right help, Some of the girls are not strong enough to help him in and out of bed. Resident #4 was not able to provide this surveyor details surrounding his 9/17/14 fall, and actually stated he thought it happened at home. Resident #4 stated, They need more people, it takes quite a long time to get people to help me in and out of bed. ( )

This citation pertains to MI 283. Based on observation, interview, and record review, the facility failed to implement interventions to prevent the worsening of pressure ulcer for 1 (Resident #2) and failed to properly track a pressure ulcer for 1 (Resident #2) of a total sample of 4 residents, reviewed for pressure ulcers, resulting in Resident #2 not receiving proper care and her Stage II pressure ulcer (a wound which as partial thickness loss of skin presenting as a shallow open ulcer...may also present as an intact or open/ruptured blister) worsening to a Stage IV pressure ulcer (a wound which has full thickness tissue loss with exposed bone, tendon or muscle), which required surgical intervention, and resulting in the potential for Resident #4 receiving inadequate and/or inappropriate care. Findings include: Resident #2 Review of the Record of admitted d 7/14/14, revealed Resident #2 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Wound Clinic Progress Note dated 9/10/14 revealed Resident #2 was being treated for [REDACTED]. Review of the Nursing Admission Assessment & Data Collection form dated 7/11/14, revealed Resident #2 had a "Blister" on her right heel. According to the National Pressure Ulcer Advisory Panel (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/), a stage II pressure ulcer may present as an intact or open blister. Review of the complete medical record from 7/11/14 thru 8/1/14 to include physician orders, nursing notes, physician progress notes [REDACTED].#2's right heel pressure ulcer. Review of the admission orders [REDACTED]. Review of the History and Physical dated 7/13/14, revealed, "Skin: On her initial skin assessment, she did have some blisters on arrival on the right foot, with blister inside of right heel and abrasion of the right foot. Under the "Plan" section of the History and Physical, there are no interventions listed for Resident #2's right heel blisters. Review of the Progress Note dated 7/30/14 revealed, "Extremities: Some chronic [MEDICAL CONDITION]. Lower extremities with recent surgeries. Otherwise unremarkable". Review of the Progress Note dated 8/1/14, only two days after the previous progress note, revealed, Right heel with black ? necrotic tissue...wound clinic consult for right heel, may need debridement. Review of Resident #2's physician orders, since her admission on 7/11/14, revealed that it was not until 8/1/14, 21 days after Resident #2's right heel pressure ulcer was first assessed, that any type of medical interventions were added to Resident #2's plan of care. The physician order [REDACTED]. Further review of Resident #2's medical chart revealed it was not until 8/8/14, 28 days after the right heel pressure sore was first assessed, that a "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" from was initiated for Resident #2's pressure sore. Review of the wound clinic progress notes revealed the following: Resident #2 was treated by the wound clinic on 8/7/14 for a "Diabetic pressure ulcer of right heel...Unstageable". Resident #2 was treated on 8/27/14 for a "Pressure ulcer of heel, right, unstageable...Patient will be scheduled for a surgery to do a debridement of the Right heel wound". Resident #2 was treated on 9/10/14 for a "Pressure ulcer of heel, right stage IV." Resident #4 Review of the Resident Master Face Sheet Form dated 8/25/14 revealed Resident #4 was a [AGE] year old female that was admitted to the facility on [DATE], and no longer resided in the facility. The form revealed Resident #4 was admitted with [DIAGNOSES REDACTED]. Review of the Nursing Admission Assessment and Data Collection dated 8/26/14, revealed Resident #4 was admitted to the facility with a pressure ulcer on the sacrum. Review of the physician progress notes [REDACTED]. Review of the complete medical chart failed to reveal a "Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" from was initiated for Resident #4's pressure sores. Further review of the complete medical chart failed to reveal any documentation that the facility was tracking, measuring or frequently assessing Resident #4's pressure ulcers. During an interview on 9/29/14 at 1:40 p.m., DON "B" stated, "no there are no purple sheets ("Pressure/Stasis/Arterial/Diabetic Ulcer Assessment" forms) for Resident #4. ( )