Every finding on record at WellBridge of Rochester Hills

This citation pertains to intake: 3017844.Based on observation, interviews and record reviews the facility failed to complete a thorough investigation for an injury of unknown origin for one (R204) of three residents reviewed for an injury of unknown origin. R204 was diagnosed with a right leg . comminuted impacted proximal tibial shaft fractures, mild posterior displacement of the distal fracture fragment, minimal angulation. Comminuted proximal fibular shaft fractures (both lower right leg bones broken, the tibia and fibula fractured in multiple pieces and the broken bone pieces pushed into each other from the force of the injury) .Findings include:A review of a complaint submitted to the State Agency (SA) noted concerns regarding their loved one with dementia, who is immobile and required extensive assistance with care, to have sustained a broken right leg without a clear explanation as to how the injury occurred.A review of the medical record revealed R204 was initially admitted to the facility in 2024, with a readmission date of 5/19/26 and had diagnoses that included- dementia, parkinson's disease and absence of the left leg above the knee. A Minimum Data Set (MDS assessment) dated 3/15/26, noted Severely impaired cognitive skills for daily decision making and was dependent on staff assistance for all Activities of Daily Living (ADLs).On 5/26/26 at 12:23 PM, R204 was observed sitting up in an oversized portable reclining chair with their right leg elevated. The complainant was observed attempting to feed R204 lunch. The complainant helped to translate questions asked to R204 (whose primary language was noted to be Arabic). When asked, R204 could not remember how they obtained the injury to their right leg. The complainant then verbalized their frustration regarding the facility's explanation of R204 to have extensive medical comorbidities that made the resident prone to the multiple right leg fractures.A review of the progress notes revealed the following:A Nursing note dated 5/11/26 at 5:56 PM documented in part, . readmitted to (facility initials) from (hospital name) with a diagnosis of renal disease and hypoglycemia.A Skin issues note dated 5/11/26 at 4:05 PM, revealed a skin assessment that revealed no significant findings to the right leg or left amputated leg stump. An admission summary dated [DATE] at 7:30 AM, documented in part . resident is a/o x1 (alert and oriented times one- awake and alert but oriented to person); resident is incontinent of B/B (bowel/bladder). some language barrier; needing assistance 2PA (two person assistance); using a (mechanical lift) w (with)/transfer.A Change In Condition note dated 5/15/26 at 8:27 AM, documented in part . increased lethargy, decreased appetite, overall decline noted. recommendations: stat (immediate) cbc (complete blood count) and bmp (basic metabolic panel).On 5/16/26 at 11:02 AM, the Director of Nursing (DON) created a note and back dated it to 5/15/26 at 10:40 AM, that identified . No new skin issues identified.On 5/17/26 at 12:44 PM, a Change In Condition note documented in part . Observed a large bruise on guest right lower leg, MD (Medical Doctor) notified. CBC/BMP and 2view x-ray.On 5/17/26 at 1:54 PM, a Nursing note documented . Called 911 at 1817 (6:17 PM) to send EMS (Emergency Medical Services) at 1854 (6:54 PM). MD notified.On 5/17/26 at 1:55 PM, a Nursing note documented . his <sic> writer was informed by the Nurse assistant that resident had a large bruise on right lower leg and left stump, on assessment resident had a large bruise on her right lower leg and [NAME] <sic> bruises on left stump. Leg feel warm to touch and non pitting edema noted. report pain with movement. MD notified. CBC/BMP and 2 view X-ray order in per MD (Medical Doctor) orders. Right leg elevated in bed. Care ongoing.On 5/17/26 at 6:11 PM, a Nursing note documented . X-ray result came back and result shows guest has fractures, MD notified and order to send guest to hospital.A hospital Consultation-Internal Medicine consult dated 5/18/26 at 8:11 AM, documented in part . REASON FOR CONSULT - Fall. presents to the emergency department from (facility name) for concern of a fracture of her right leg. Patient was recently discharged from the hospital here on May 11. She was complaining of pain of her right lower leg and also noted some bruising so they did an x-ray and noted that there was a break, patient does not ambulate at baseline secondary to her history of a left above-the-knee amputation, there was no no <sic> reported falls. CT (computed tomography scan) Lower Extem (extremity) W/O (without) Contrast-Rt (right) (Reason for exam: fx (fracture) follow up from xray) Finalized: 05/18/2026 01:04. IMPRESSION: Comminuted impacted proximal tibial shaft fractures, mild posterior displacement of the distal fracture fragment, minimal angulation. Comminuted proximal fibular shaft fractures. DX (DEXA scan- dual-energy X-ray absorptiometry) Knee Complete Right (Reason for exam: pain, swelling) Finalized: 05/17/2026 20:59 (8:59 PM). IMPRESSION. There appear to be acute fractures of the proximal fibula/fibular neck and proximal tibial diaphysis as above. CT may be of benefit for better evaluation. DX Tibia/Fibula AP (anteroposterior)/Lateral Right (Reason for exam: pain, swelling) Finalized: 05/17/2026 20:59. IMPRESSION. There appear to be acute fractures of the proximal fibula/fibular neck and proximal tibial diaphysis as above. CT may be of benefit for better evaluation. DX Ankle Complete Right (Reason for exam: pain, swelling) Finalized: 05/17/2026 20:59. IMPRESSION. There appear to be acute fractures of the proximal fibula/fibular neck and proximal tibial diaphysis as above. CT may be of benefit for better evaluation. IMPRESSION AND PLAN- Unwitnessed injury, R (right) proximal tibial and fibular fractures. does not ambulate at baseline, no reports of fall/trauma per daughter/(facility name). RLE (Right Lower Extremity) splinted in ED (Emergency Dept), pain control, RICE (Rest, Ice, Compression, and Elevation). ortho following, surgery vs. conservative management TBD (To Be Determined). earliest possible surgery 5/19 for IM (Intramedullary) nail.A review of a hospital Consultation-Orthopedic dated 5/18/26 at 7:18 AM, documented in part . REASON FOR CONSULT- right tibia fracture. presents with unwitnessed injury to right tibia right tibial shaft fracture. Plan: pain control. will discuss with granddaughter possible surgery vs (verses) conservative treatment. surgical risks due to her multiple medical conditions. medical optimization for surgery would be soonest tomorrow for possible IM nail. Otherwise may continue nonoperative care.Per the complainant on 5/26/26 at approximately 12:30 PM, they decided to hold off on surgery for now and will have to follow up with the Orthopedic physician to see if there is any improvement, if not, surgery may be required.A review of the medical record revealed no incidents or falls documented that involved the right leg from January 2026 to the date of the survey.On 5/26/26 at 10:55 AM, the Administrator was asked to provide all incident/accident and grievance reports from January 2026 to current.The Administrator provided an incident report dated 5/17/26 at 11:40 AM, of the incident of the identified large bruise on right lower left and left stump.No other incident, accident or grievance reports were provided.A review of a picture taken by the facility dated 5/17/25, revealed a dark purple/bluish bruise that covered the lateral aspect of the leg, from a little above the knee to the ankle of the right leg. Significant swelling was identified.A review of the facility's investigation submitted to the SA, documented in part . The guest was discovered to have bruising today on 5/17/2026 approximately around 12pm that was not present this morning at 6am. Guest was assessed for pain and presenting with pain. Further skin assessment were completed on rest of body with nothing else being noted. Investigation Summary/Actions Taken. Physician ordered a STAT X-Ray. Upon completion and results from the X-Ray at approximately 5:31PM, it showed a fx (fracture) in the left lower extremity of the tibia and fibula. The physician ordered immediate transfer to the emergency department. There were no falls, injuries, or incidents reported to the facility within the prior 24-48 hours. Chart review and staff interviews confirmed no observed trauma. Contributing Factors: Active malignancy as indicated by bilateral invasive breast cancer (diagnosed 3/13/2026), increasing risk of pathological fractures. Bone fragility of the resident as documented with osteoporosis and diffused bone demineralization. Behavioral patterns witness by staff as repetitive striking of right lower extremity against left stump or objects (e.g. remote, bed controls) and guardian made aware. Lastly, diagnostic findings from hospital imaging confirmed diffuse osteopenia, osteoporosis, and muscle atrophy. No deficient practice by the facility was identified.A review of the medical record revealed no documentation of the resident to have previously strike their lower extremity or stump.A review of the care plans revealed no identified behavior for the resident regarding striking their lower extremity or stump.Further review of the medical record revealed that R204 was given a shower on 5/15/26, the day of their documented change in condition, however the staff on 5/15/26 was not interviewed.At 1:29 PM, the complainant who was still present in the facility observed the aides changing R204's brief and took pictures of R204's left stump. The complainant provided a picture of R204's left stump that revealed two circular purple bruises still present on the stump as of 5/26/26.On 5/26/26 at 2:01 PM, the Administrator (who also serves as the facility's abuse coordinator), DON and Regional Director Consultant (RDC) A were interviewed. All three confirmed they completed the investigation together. When asked their thoughts after their investigation on how R204 sustained a broken right leg, neither responded. When asked how a resident who requires extensive assistance from staff for all care obtained an injury forceful enough to have fractured their right tibia and fibula, RDC A resported that R204 is known to hit their leg with the remote. When asked about the care plans and medical record, having no documentation of the resident to have incidents of hitting their leg with the remote or any other objects, neither responded. When asked why they did not interview the staff on 5/15/26- the day of the noted change in condition and the day R204 received a shower, the DON responded when they interviewed the staff on the 16th , all denied seeing anything on the resident they did not go further back. The Administrator, DON and RDC A was asked to provide any additional information or documentation for review regarding the incident, and nothing was provided before the end of the survey.

This citation pertains to intake #3015838. Based on interview and record review, the facility failed to assess and implement interventions/diagnostics in a timely manner for one resident (R202) of three residents reviewed for changes in condition. Findings include:On 5/26/27 a concern submitted to the State Agency was reviewed which alleged R202 experienced a delay in assessment and interventions when they sustained a dislocated hip. On 5/26/27 at approximately 9:29 a.m., during a discussion with family member F (FM F), FM F indicated they had a concern regarding a delay in identifying a change in condition for R202 which resulted in a dislocation of their right hip. FM F reported that the change in condition started on 3/18/26 when they noticed R202 was experiencing increased pain in afternoon during a visit. On 3/20/26 another visit, a member from the therapy department reported that R202's right foot and hip looked turned out and R202 was experiencing more increased pain and on 3/21/26. A different family member informed a Nurse that something was wrong with R202's hip and an X-ray should have been done earlier. FM F indicated they had reported their concerns regarding the delay identifying the change to facility staff. On 5/26/27 the medical record for R202 was reviewed and revealed the following: R202 was initially admitted on [DATE] and was discharged on 3/23/26 with diagnoses including Aftercare following joint replacement surgery and Fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing. A review of R202's MDS (minimum data set) with an ARD (assessment reference date) of 3/16/26 revealed R202 required assistance from facility staff with most of their activities of daily living. R202's BIMS score (brief interview of mental status) was six indicating severely impaired cognition. 3/16/2026-Physican progress note- Note Text: HPI (history of presenting illness) Reason for Visit: Medical management, Pt (patient) is a [R202 demographics] presenting to facility for SAR (sub-acute rehab) s/p (status/post) hospitalization for fall, right femur fx (fracture). Here for PT/OT (physical therapy/occupational therapy) needs: Patient seen and examined .Tolerating PT/OT. Per nursing cloudy, foul odor urine noted. Also, restlessness at bedtime per nursing. Denies dysuria, flank pain. Collect UA (urine analysis) and CS (culture/sensitivity) to r/o (rule out) UTI (urinary tract infection). Assessment/Plan 5. Abnormal urine odor +UA and CS . 3/16/2026-Physican's order-Urinalysis to R/O suspected UTI. one time only for suspected UTI for 1 Day 3/17/2026-Therpay daily skilled services-Precautions: WBAT (weight bearing as tolerated) Rt (right) LE (lower extremity), cognition Contraindications Contraindications = No contraindications present. Pre-Tx (treatment) Is skilled therapy needed to address pain? = Nursing to address .: pt (patient) completed BUE (bilateral upper extremity) strengthening exercises with use of 1# weight in order to improve overhead grooming, assistance with sit to stands, and reaching. pt completed chest press, overhead press, bicpes curls, triceps ext (estensions), :progress report completed, goals reviewed with pt. pt alert and participated without encouragement this date. pt completed standing balance activity while crossing midline and forwards reach in order to improve standing tolerance during ADLs (activities of daily living) .functional mobility completed with use of 2ww (two-wheeled walked), mod pa (partial assist), and . for safety to improve I with functional transfers. toilet transfer completed min (minimal) pa from wc (wheelchair) to 3:1 commode and use of GB (grab bar) Response to Tx Response to Session Interventions: tolerated well this session . 3/18/2026-Skilled Charting-Writer unable to collect urine sample this shift. Gave report to oncoming Nurse. 3/19/2026-Therapy daily skilled services-Precautions: WBAT Rt LE, cognition .Contraindications = No contraindications present. Pre-Tx Is skilled therapy needed to address pain? = Nursing to address : family present for therapy, recommend wtd (weighted) gloves or universal cuff to help reduce tremors in BL hands during feeding. static standing pt reports pain in r hip when wt (weight) shifting Pt completes functional mob (mobility) taking a few steps with max pa and close wc follow pt unable to complete task 2* (secondary) to pain. UB (upper body) strengthening graded with 1# wt all available joints and planes to increase strength for all functional task . 3/20/2026-Therpay daily skilled services-Precautions Precautions: WBAT Rt LE, cognition . Contraindications = No contraindications present. Pre-Tx Is skilled therapy needed to address pain? = Nursing to address .: static standing at .pt complains of pain wt asked to wt shift, pt unable to task steps 2* to pain. nursing notified. family concerned pt was ambulating a few days ago. Pt completes UB (upper body) strengthening with 1 # wt all planes and joints to increase strength for t/fs (transfers). Pt completes reaching activity and core strengthening . 3/21/2026-Therapy daily skilled services-Precautions Precautions: WBAT Rt LE, cognition . Contraindications = No contraindications present. Patient Goals Patient Remarks/Goals: [daughter in-law] present, states pt c/o (complaints of) more pain today and she wants pt to remain in bed at this for now. Pre-Tx Is skilled therapy needed to address pain? = Nursing to address : gentle positioning for comfort and pain management via elevation changes HOB (head of bed), FOB (foot of bed), float heels, cold pack to R (right) hip . maintain hip precautions due to concern for increased pain Response to Tx Response to Session Interventions: nursing aware of pt increased pain c/o . 3/21/2026 at 10:00 a.m.,-Interact summary for providers-Situation: The change in condition/s reported on this (CIC-change in condition) evaluation are/were: Other change in condition .-Pain status evaluation: Does the resident/patient have pain? Yes .Nursing observation, evaluation, and recommendations are RT hip FX s/p survey. Guest family is at bedside and is requesting a x-ray of rt hip as guest is complaining of more pain and per family she will not let them touch her RLE due to pain. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: STAT (emergent) x-ray rt hip two views . 3/21/2026 at 10:30-Physican's order-STAT xray rt hip 2 views one time only for rt hip pain for 1 Day 3/22/2026-Skilled charting-Guest did not receive shower per family request due to resident having pain in right hip . 3/22/2026-Skilled Charting-Writer call UA C/S this shift. Orders in [name of electronic medical record]. Sampe in 400 hall fridge. 3/22/2026 at 10:57-A physician's order dated 3/22/26 at 10:57 revealed the following STAT xray rt hip 2 views one time only for rt hip pain for 1 Day 3/22/2026-X-Ray Diagnostic-Examination Date: 3/22/2026 at 20:22. Reported Date: 3/22/2026 20:39 .Findings: There is hip arthroplasty with superior lateral dislocation. The prosthetic right femoral head is still properly situated relative to the femoral [NAME]. Pubic rami are normal There is not acute fracture seen. Conclusion: Dislocation of right hip arthroplasty 3/22/2026-Physician's order-UA C/S r/o UTI may straight cath (catheter) to obtain urine one time only for r/o UTI for 2 Days 3/23/2026-at 16:01-Skilled Charting- .Guest had STAT x-ray done, results reviewed by on call order to send gust to ER (emergency room) for further evaluation. Daughter was notified of situation . 3/24/2026-Urine Analysis and Culture Sensitivity Results-Received Date-3/24/2026. Reported Date 3/28/26 .Clarity-Turbid (abnormal) .Nitrite-Positive (abnormal) .Bacteria-Many (abnormal). Epithelial Cells-few (abnormal). Amorphous material-present (abnormal) .Organism > (greater than) 100,000 CFU/ML Hafnia Alvei . Further review of R202's medical record did not reveal any assessments or progress notes from the Nurse on 3/20/26 indicating they had assessed R202's increase in pain as reported by the therapy department or contacted the Physician regarding the change. Further review of R202's laboratory diagnostic results revealed no follow up from Nursing from the urinalysis ordered on 3/16/26 until the second analysis that ordered on 3/22/26 that had a noted reported date of 3/28/26 (approximately five days after the resident was transferred to the hospital).On 5/26/26 at approximately 11:29 a.m., Physical therapy assistant G (PTA G) was queried regarding the presentation of R202 during the therapy session on 3/20/26. PTA G reported that R202 could not walk in therapy that day and was grimacing on their right side that they were in a lot of pain. PTA G indicated that R202 stood up out of the wheelchair but was in too much pian to ambulate. PTA G reported that was a significant change for R202 as they were previously doing well with ambulation on previous days in the week. PTG G indicated they were working with COTA (certified occupational therapy assistant) H (COTA H) that day and that COTA H had informed the day shift Nurse about R202's change in status and increased pain. On 5/26/26 at approximately 11:40 a.m., COTA H was queried regarding the presentation of R202 during therapy on 3/20/26. CTOA H stated that the resident was in too much pain to do therapy in the gym that day and they reported they had spoken to the day shift Nurse reading R202's change in status including increase in pain and unable to do therapy. COTA H indicated they did not follow up at all as they had handed the concern of to Nursing after that to assess R202 to see why they could not ambulate and were having increased pain. On 5/26/26 at approximately 12:22 p.m., Nurse I was queried reading R202's status on 3/20/26. Nurse I indicated that they were informed by the CNA (Certified Nursing Assistant) earlier in the day that R202 was having increased pain and the CNA's were having difficulty transferring her and her not wanting to get out of bed. Nurse I was queried if they had called the Physician regarding R202's increase in pain and they indicated they did not and that they gave R202 their scheduled pain medication. Nurse I reported that they thought they had done a skin assessment to look at the painful area. At that time, a review of R202's medical record was done with Nurse I and they indicated that it wasn't there. Nurse I was queired what they did after COTA H informed them that they couldn't ambulate due pain, and they indicated they did not remember, but that they would have typically called the Physician and done an assessment. No documentation from 3/20/26 was present in the record regarding R202's increase in pain.On 5/26/26, a facility provided folder titled [R202] PNC (past-noncompliance) was reviewed which revealed the following: Statement from (CNA J)-'When I took care of her on 3/20 she had complaints about pain in her right leg. She told me she was in pain when she was lying down right after breakfast, so I left her in the bed. Then her family came around lunchtime and asked for her to be up in the chair so the nurse and I got her up. The only other time she mentioned pain was when I was taking her to the bathroom and the nurse assisted me in taking her each time. She did not have any falls during my shift.' .Background Events: On 3/11/2026, guest fell in in her room rolling from bed to the floor, was found laying on her left side next to her bed. Pain was assessed and none noted. Fall interventions were put in place. Guest continued therapy well for more than a week without complaining of any pain. It was not until 3/19/2026 and 3/20/2026 that guest refused therapy citing pain. Pain medication given around the clock (ATC) was effective in controlling her pain. Nursing pain assessment resulted negative for any pain nor guarding until 3/21/2026 when guest started guarding right hip from family's touch. Per family, they were attempting to assist guest to the bathroom as they do .Nurse immediately assessed after notification by family, pain med administered and ice pack applied-provider was contacted and x-ray ordered that was completed on 3/22/2026-Family agreed with provider that they will take guest to ortho appointment on 3/23/2026-In the morning hours of 3/23/2026, further nursing assessment noted increased pain and guarding of right hip, provider contacted immediately and order given to transfer guest to ER. Family notified immediately. Report from the hospital revealed dislocation of right hip arthroplasty, no fracture was noted .[Name of Facility], PNC March 27 th, 2026 Diagnostic tests: 1.Resident [R202] chart was audited by the DON to ensure diagnostic tests ordered were placed and completed timely. All residents have the potential to be affected. 2. A one-time audit of all diagnostic tests for the last 2 weeks was reviewed by nurse managers and all outstanding tests ordered for completion. 3. All licensed nurses were re-educated on lab diagnostic policy: System change: if diagnostics tests are ordered, nurse must place order immediately into the diagnostic site for completion and notify physician of result immediately it is received. Any non-compliance will result in a 1:1 education. Nurse managers are reviewing diagnostic test orders & progress notes Mon-Friday to ensure all tests are being completed timely.4.The DON/designee will audit 5 charts weekly x12 weeks to ensure all diagnostic tests ordered are completed. 5. All audits will be taken to QAPI, the DON is responsible for sustained compliance On 5/26/26 at approximately 12:43 p.m., during a conversation with Regional Clinical Director A (RCD A) and the Director of Nursing (DON). RCD A regarding the Past noncompliance folder for R202, RCD A indicated the facility had identified deficiencies regarding delays in the diagnostic testing during R202's change in condition. RCD A indicated the Nurse on 3/20/26 should have done a complete assessment and contacted the Physician for orders when R202 was experiencing the increase pain that therapy had notified them of. The DON indicated they had implemented a past-noncompliance with a compliance date of 3/27/26 to ensure all diagnostic testing was being done timely. They indicated that the Nursing staff were educated on correctly processing diagnostics and that chart audits were ongoing. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included.(chart reviews, Nursing education/inservice and audits). The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake: 2711407.Based on interview and record review the facility failed to ensure a Physician evaluation and/or assessment of wounds and failed to follow the facility's policy for Pressure Ulcers for one (R205) of three residents reviewed for wounds. Findings include:A review of a complaint submitted to the State Agency (SA) revealed poor care provided to R205 resulting in the worsening of wounds.A review of the medical record revealed R205 was readmitted to the facility on [DATE], with diagnoses that included: dementia and sarcopenia (age-related progressive loss of muscle mass, strength, and function). A Minimum Data Set (MDS) assessment completed 12/23/25, documented a Brief Interview for Mental Status score of 11 (which indicated moderately impaired cognition). R205 required staff assistance for all Activities of Daily Living (ADLs).A review of the progress notes revealed an identified Stage II pressure wound to the Coccyx and a right elbow abrasion.A review of the medical record revealed R205 was examined by Physician F (the resident attending Physician) on the following dates:12/18/25, 12/19/25 & 12/22/25- none of the examinations noted an evaluation or assessment of the resident wounds.A Nursing note dated 12/24/25 at 6:27 PM, documented in part . Guest verbalized some discomfort on R (right) heel. Site assessed for abnormalities and noted to have a pre-existing ruptured blister. Wound pictures and orders implemented per protocol. All involved party made aware.The medical record revealed R205 was again examined by Physician F on the following dates:12/31/25 & 1/2/26- there was no documentation of the wound to have been examined or assessed.Further review of the medical record revealed no examinations or assessments completed by a Physician, despite multiple wound treatments to have been ordered under the directive of Physician F.A progress note dated 1/2/26 at 4:25 PM, documented the resident to have been transferred to another facility.A review of a facility policy titled Pressure Ulcers/Skin Breakdown. revised October 2012, documented in part . The Physician and staff will examine the skin of a new admission for ulcerations. The physician will help the staff define the type. and characteristics. of an ulceration. The physician will help identify factors contributing or predisposing residents to skin breakdown. The physician will help identify medical interventions related to wound management. During resident visits, the physician will evaluate and document the progress of wound healing.On 4/14/26 at 1:14 PM, the Director of Nursing (DON) was interviewed and asked about the management of wounds in the facility. The DON explained that if a wound is found, pictures are taken and an assessment is completed by the nursing staff. The Physician is notified to initiate treatment. When asked if the Physicians come to assess and evaluate the treatment they ordered to be implemented, the DON stated the Nurses and interdisciplinary team- excluding the Physician- . will review it and if it's not effective we will contact the Physicians. When asked if the Physicians are supposed to assess and evaluate wounds and the treatment, they prescribed the DON stated they could not say if the Physicians did or did not examine or assess the residents. When asked if it is the expectation that the Physicians examine and assess the wounds and document it in the resident's medical record, the DON stated they had no control over what the Physicians document.On 4/14/26 at 1:45 PM, Physician F was interviewed via telephone and asked if they assessed and examined the resident wounds in the facility. Physician F stated Yes, the nursing staff will notify them and they would usually assess them. Physician F was asked to review the medical record of R205 and provide any documentation they found of the resident wounds to have been assessed by a Physician. The Physician stated they would review the record and inform the Administration team if they found the documentation.On 4/14/26 at 2:12 PM, the DON noted they spoke to Physician F who stated he was unable to find any assessment or evaluation of the resident wounds.No further information or documentation was provided by the end of the survey.

This citation pertains to intake(s): 2706041 & 2711391.Based on observation, interview, and record reviews the facility failed to protect the resident's right to be free from misappropriation by a facility staff member, for one (R203) of three residents reviewed for misappropriation and abuse. Findings include:A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) documented in part, . Resident (R203) presented story to both daughter and officer regarding the ring being taken by someone who had covered their face and took the ring off her finger. review of the time frame it was made possible that the perpetrator mentioned above was the first person into room (number) after the daughter had left for the night. Immediately after speaking with officer (name), the facility suspended the employee listed at <sic> the perpetrator above. Around 10:03PM officer (name) called writer back to state ring was in fact taken off guest and pawned the morning of 12/12/2025. The suspect was not fully identified at this time, but was mentioned it was the person this writer described to the officer.The staff member suspended for stealing R203's ring was identified to be Certified Nursing Assistant- CNA A.A review of the medical record revealed R203 was readmitted to the facility on [DATE], with diagnoses that included: senile degeneration of brain and chronic atrial fibrillation. R203 was dependent on staff for all Activities of Daily Living (ADLs) and identified to be on hospice care. The residents daughter (Family Member- FM B) was identified to be the Durable Power Of Attorney (DPOA) for R203's care.Review of the progress notes revealed the following:11/4/25 at 2:33 PM, a Care Transition Note documented in part . she does have some forgetfulness and is hard of hearing. speech is clear and easily understood. She did complete the BIMS (Brief Interview for Mental Status) with a score of 5 (severely impaired cognition).12/15/25 at 9:26 AM, a Physician note documented in part . Chief complaint: Bruising left ring finger. is seen for bruising left ring finger. Patient noted to have small bruise to left ring finger on dorsal side, on exam no local tenderness noted. No swelling of the finger or hand. Will do x-ray of the left finger but clinically do not suspect fracture.Further review revealed no documentation in the progress notes regarding the incident.A review of the hospice notes revealed the following:12/16/25 at 11:30 AM, . Prior to visit, Xray of L (left) hand requested to r/o (rule out) fx (fracture) after incident resulting in bruising/swelling. Xray arrived at end of visit for imaging. bruising to L 4th digit.12/18/25 at 11:00 AM, . L hand x-rays negative. Pt (patient) remains bedbound.On 4/13/26 at 10:41 AM, an interview was conducted with FM B. FM B was asked when they were first notified of the incident. FM B stated on 12/11/25 at 4:15 PM, a nurse called them and asked if they had their mother's ring and they informed the nurse that they did not. FM B stated they told the nurse that the ring was on their mother's finger the night before when they had visited. FM B stated after work they drove to the facility and arrived a little after 4:30 PM. FM B stated immediately after entering their mother's room, R203 told FM B that someone stole her ring and the person had turned off the room lights and covered their face before taking the ring from R203's finger. FM B stated the nurse was in the doorway of the residents room, heard what the resident reported. The nurse informed FM B that they were leaving to report what R203 stated to their Nurse Manager. FM B stated they waited awhile and no one came to the room to follow up. FM B stated initially they were convinced that R203 had lost their ring, because they were never informed of the allegation of someone to have stole the ring off of her mom's finger until R203 informed them. FM B stated after waiting awhile with no further follow up from the facility they decided to call the police. FM B stated the Police came to the facility and started their investigation. FM B stated they were contacted by the Officer the next day about a quarter to 10 AM and informed that the ring was found at a pawn shop. The officer went on to inform FM B that the license provided to the pawn shop to pawn the ring matched that of a CNA who was confirmed to have worked in the facility on the date of the incident. When asked the current status of the case, FM B stated the case remains open and they continue to have communication with the Detective assigned to the case. FM B stated a warrant has been issued for the CNA and an arrest is still pending. FM B stated at this time the Police department had been unable to locate the CNA. FM B stated they had taken pictures of the their mother's bruised finger the next day (12/13/25). Those pictures were submitted to the SA for review.On 4/13/26 at 7:45 AM, an initial request to the Administrator was made to provide the full investigation for review.The investigation contained the following statements: Activities assistant (AA C) - On December 12th when I was in room (number) the resident told me that the day prior in the evening someone came into her room with their face covered up and took her ring from her finger. She reported that she yelled out but nobody heard her. I then let the nurse on duty know.A Nurse statement (later identified as Licensed Practical Nurse- LPN D) documented, I (nurse name) was told today 12/12/25 that the ring worn by the guest in (room number) was missing and not on her finger by activities staff. The statement to me was that somebody took it off, they had something dark over their face and she couldn't see who it was. The last time I recall seeing her ring on her finger was Wednesday 12/10/25 as I did not pay attention to it yesterday 12/11/25. After it was stated to me today that it was missing . I searched the room, bed and guest to look for it. I called her daughter (name) to see if she had taken it and she said no. She did state to me that the ring was starting to fit big but she didn't want to take it off. Guest had a bed bath yesterday and guest daughter thinks that it could have possible come off in her clothes, and went to Laundry.On 4/13/26 at 11:49 AM, AA C was interviewed and asked to read their statement provided for the investigation. AA C reviewed and confirmed everything to be correct as documented. When asked, AA C could not recall the exact time they were informed of the incident but knew it was after lunch and before 4 PM on 12/12/25. AA C said they immediately informed the Nurse (LPN D). AA C was asked if the Administration team followed up with them regarding their statement and AA C replied in part . besides (Director of Nursing - DON name) telling me. that the family got the ring back. no other follow up was conducted.On 4/13/26 at 12:02 PM, LPN D was interviewed and asked to read their statement to confirm accuracy. LPN D read the statement and confirmed the statement was accurate. LPN D was asked why they initially searched for the ring, instead of immediately reporting the allegation to the Abuse Coordinator. LPN D said they wanted to . go through all of my options. before reporting it. LPN D explained after not finding the ring they called R203's daughter (FM B) to see if they had it. LPN D was asked if they informed the daughter of the resident allegation of the ring to have been stolen, LPN D stated they did not. LPN D stated they contacted both the DON and the Administrator and informed them on what the resident reported. LPN D stated the Administration informed them they would look into it. LPN D stated FM B called the police and the police came to the facility. LPN D stated they were interviewed by the police that night. LPN D stated they wrote a statement and slid it under the door of the DON.On 4/13/26 at 1:22 PM, R203 was observed sitting up in bed. An interview was conducted utilizing a white board to ask the resident questions due to the resident hearing loss. When asked R203 stated they were resting in bed when she took the ring off of their finger. R203 said she felt terrible because it was her wedding ring. R203 stated she felt safe in the facility knowing the person is no longer at the facility. On 4/13/26 at 2:03 PM, the facility's Administrator who also serves as the facility's Abuse Coordinator was interviewed. When asked, the Administrator stated the DON was the first to inform them of a person to have covered their (R203's) face and stolen their ring. The Administrator said they had a conversation with the officer who informed them that the ring was located at a pawn shop and the staff member described was the suspect. The Administrator stated the staff was immediately suspended.A review of a facility policy titled ABUSE, NEGLECT AND/OR MISAPPROPRIATION OF RESIDENT FUNDS OR PROPERTY revised 3/15/23, documented in part . will not tolerate.physical. abuse. misappropriation of resident's funds or property by anyone. Freedom from Abuse: Each resident has the right to be free from all types of abuse. Misappropriation means the deliberate. wrongful temporary or permanent user of a resident's belongings. without the resident(s) consent. Mistreatment as defined. means inappropriate treatment. of a resident.

This citation pertains to intake(s): 2706041 & 2711391.Based on observation, interview and record reviews the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act and failed to accurately and timely report findings to the State Agency (SA) for one (R203) of three residents reviewed for Misappropriation and Abuse. Findings include:A review of an initial investigation report submitted to the SA on 12/12/25 at 10:41 PM, documented in part . Guest in (room number and name) mentioned to a staff member that her ring was missing and had been taken off her hand. Guest has a BIMS of 5/15. Staff member notified nurse on unit who notified DON (Director of Nursing). DON then notified abuse coordinator. Nurse called daughter who is POA (power of attorney) to notify her of the situation. Skin and pain assessment completed. Responsible party notified, Authorities notified. Ring has not been located in the facility at this time.A review of the investigation summary submitted to the SA on 12/22/25, documented in part, . Resident involved in incident has severe impairment with her mental capacity as noted by her 5/15 BIMS. On Friday 12/12/2025 around 3:00PM she was taking part in 1 on 1 activities with activity assistant (name). During this time she had made mention that the previous night someone had come in and taken her ring. Upon the activity aide learning of this matter, she had let the nurse assigned to the (number) hallway know immediately. The nurse then searched the room and spoke with the resident regarding the missing ring. The ring was not found in the room and upon negative findings the nurse let the DON (Director of Nursing) know of the situation and then the DON notified this writer/Abuse coordinator know of the situation. Between the time the daughter was contacted and some time around 6:30PM the daughter had decided to notify the authorities. The guest recalled the same story to this writer that she told the officer and her daughter. Skin and pain assessment were completed. MD (Medical Doctor) was notified. Social work was consulted as well and a psychosocial assessment completed.The Activity Assistant was identified as AA C and the Nurse was identified as Licensed Practical Nurse - LPN D.A review of the medical record revealed R203 was readmitted to the facility on [DATE], with diagnoses that included: senile degeneration of brain and chronic atrial fibrillation. R203 was dependent on staff for all Activities of Daily Living (ADLs) and documented to be under hospice care. The residents daughter (Family Member- FM B) was identified to be the Durable Power Of Attorney (DPOA) for R203's care.On 4/13/26 at 1:22 PM, R203 was observed sitting up in bed. An interview was conducted utilizing a white board to ask the resident questions due to the resident hearing loss. When asked, R203 stated they were resting in bed when she took the ring off of their finger. R203 stated she felt terrible because it was her wedding ring. R203 stated she felt safe in the facility knowing the person is no longer at the facility. A review of the facility's investigation identified a skin assessment completed on 12/12/25 that revealed no abnormal findings identified and contained no pictures taken of the resident's hand.A review of the medical record and care transition notes and assessments revealed no psychosocial assessment completed with R203 after the incident as reported to the SA.Further review of the medical record revealed no social work assessments completed in December 2025 or January 2026.A review of a Care Transition Note noted by Social Worker SW E dated 12/15/26 at 12:01 PM, documented . Follow up with guest. She denied any concerns at this time. She had eaten her breakfast. She said that she feels safe in her room.On 4/13/26 at 10:41 AM, an interview was conducted with FM B . FM B was asked when they were first notified of the incident. FM B stated on 12/11/25 at 4:15 PM, a nurse called them and asked if they had their mother's ring and they informed the nurse that they did not. FM B stated they told the nurse that the ring was on their mother's finger the night before when they had visited. FM B stated after work they drove to the facility and arrived a little after 4:30 PM. FM B stated immediately after entering their mother's room, R203 told them someone stole her ring and the person had turned off the room lights and covered their face before taking the ring from R203's finger. FM B stated the nurse (LPN D) was in the doorway of the residents room, heard what the resident reported and LPN D stated they were leaving to report what R203 stated to their Nurse Manager. FM B stated they waited awhile and no one came to the room to follow up. FM B stated initially they were convinced that R203 had lost their ring, because they were never informed of the allegation of someone to have stolen the ring off of her mom's finger, until R203 informed them. FM B stated after waiting awhile with no further follow up from the facility they decided to call the police. FM B stated the Police came to the facility and started their investigation. FM B stated they went home and the Administrator called them approximately a quarter after 9 PM. FM B said they had expressed to the Administrator that it was devastating that their mom said they were screaming and yelling when the person took the ring off of their finger and no staff came to her aide. FM B stated the Administrator informed them that R203 had a bruise identified to their left hand ring finger and that they would take photos of it. FM B stated they were contacted by the Officer the next day about a quarter to 10 AM and informed that the ring was found at a pawn shop. The officer went on to inform FM B that the license provided to the pawn shop to pawn the ring matched that of a CNA who was confirmed to have worked in the facility on the date of the incident. When asked the current status of the case, FM B stated the case remains open and they continue to have communication with the Detective assigned to the case. FM B stated a warrant has been issued for the CNA and an arrest is still pending. FM B stated at this time the Police department have been unable to locate the CNA. FM B stated they had taken pictures of the their mother's bruised finger the next day (12/13/25). Those pictures were submitted to the SA for review. The pictures revealed a dark maroon/purple color bruise to the dorsal left hand 4th digit.A review of a Physician note dated 12/15/25 at 9:26 AM, documented in part . Chief complaint: Bruising left ring finger. is seen for bruising left ring finger. Patient noted to have small bruise to left ring finger on dorsal side, on exam no local tenderness noted. No swelling of the finger or hand. Will do x-ray of the left finger but clinically do not suspect fracture.On 4/13/26 at 11:49 AM, AA C was interviewed and asked to recall the incident. AA C stated they walked into the resident's room and introduced themselves and she (R203) immediately said that her ring was missing and that someone came in with their face covered. The resident reported the room was dark and the person took it off her hand. AA C stated the resident said they yelled for help but no one came. AA C stated they immediately informed the Nurse (LPN D). AA C was asked if they notified the Administrator (who also serves as the Abuse Coordinator) and AA C stated No, they immediately notified the nurse.A review of a facility policy titled Abuse, neglect and misappropriation of property policy (no date noted on the first page provided), documented in part . physical. or misappropriation of property will not be tolerated. Facility staff are required to report any incident or suspicion of abuse, neglect or misappropriation of property to the Executive Director immediately, on in his/her absence the DON.A statement documented by LPN D noted, I (nurse name) was told today 12/12/25 that the ring worn by the guest in (room number) was missing and not on her finger by activities staff. The statement to me was that somebody took it off, they had something dark over their face and she couldn't see who it was. The last time I recall seeing her ring on her finger was Wednesday 12/10/25 as I did not pay attention to it yesterday 12/11/25. After it was stated to me today that it was missing . I searched the room, bed and guest to look for it. I called her daughter (name) to see if she had taken it and she said no. She did state to me that the ring was starting to fit big but she didn't want to take it off. Guest had a bed bath yesterday and guest daughter thinks that it could have possibly come off in her clothes, and went to Laundry.On 4/13/26 at 12:02 PM, LPN D was interviewed and asked to read their statement to confirm accuracy. LPN D read the statement and confirmed the statement was accurate. LPN D was asked why they initially searched for the ring, instead of immediately reporting the allegation to the Abuse Coordinator. LPN D stated they wanted to . go through all of my options. before reporting it. LPN D explained after not finding the ring they called R203's daughter to see if they had it. LPN D was asked if they informed the daughter of the resident allegation of the ring to have been stolen, LPN D said they did not. LPN D stated they contacted both the DON and the Administrator and informed them on what the resident reported. LPN D stated the Administration informed them they would look into it. LPN D said the resident's daughter called the police and the police came to the facility. LPN D said they were interviewed by the police that night. LPN D said they wrote a statement and slid it under the door of the DON.On 4/13/25 at 1:35 PM, the Care Transition Staff (also documented in the medical record as a Social Worker- SW E) was interviewed and asked their involvement with the investigation of the incident that involved R203. CTS E said they followed up with the resident to ask how they were doing and to ensure that she felt safe in the facility. CTS E was asked why a psychosocial assessment was not completed and they replied that the facility did not have an actual assessment, however some could do the PHQ9 (depression scale) questions but they did not do that with the resident.On 4/13/26 at 1:45 PM, the DON was interviewed and asked the date, time and by whom they were first notified of the incident with R203. The DON replied it was the date the facility had just finished their annual recertification survey and they could not recall the exact time. The DON identified LPN D to have called them and reported the missing ring. The DON was asked if LPN D reported the allegation verbalized by R203 of a person to have covered their face and stolen the ring off of their finger and the DON confirmed they did. The DON stated they directed the nurse to look around the room to search for it. The DON was asked why they directed the nurse to look around the room if the resident had already stated that someone covered their face and took the ring off of their finger. The DON replied because of the resident's cognitive state, they wanted to make sure that the resident was not hallucinating or dreaming. The DON stated once LPN D confirmed that they could not find the ring, the DON said they reported the incident to the Administrator. The DON said they obtained statements from the staff and reported it to the Administrator.On 4/13/26 at 2:03 PM, the Administrator was interviewed and asked who conducted the investigation for R203's ring and the Administrator replied they completed the investigation. The Administrator was asked on what date and time they were notified of the resident to have stated that someone covered their face and took the ring off of their hand. The Administrator replied that the DON notified them on 12/12/26 between 3 and 4 PM. The Administrator was asked why they failed to notify the SA timely and notify law enforcement and the Administrator replied in part . Initially it wasn't much concern. The daughter called authorities and I rushed up here as quickly as I could. The initial submission to the SA was reviewed with the Administrator and was asked why they omitted the details of a person coming into the dark room of the resident with their face covered and had taken the ring off the resident and the Administrator stated . again, initially, we thought it was lost. The Administrator was asked even with the resident reporting that someone took it off they hand, they still thought it was lost? The Administrator replied yes. The Administrator was asked about the detail of the omission to the SA of the left hand ring finger to have been bruised and the skin assessment to have noted no findings after the incident occurred. The Administrator stated they were unable to tell, but the finger . was a little swollen that night. The Administrator was reminded that the details was omitted from the investigation report submitted a few days later on 12/22/25, as well. The Administrator was asked why they reported to the SA that a psychosocial assessment was completed and it had not done and the Administrator said they would look into it and follow back up.No further explanation or documentation regarding the psychosocial assessment was provided before the end of the survey.A review of a facility policy titled ABUSE, NEGLECT AND/OR MISAPPROPRIATION OF RESIDENT FUNDS OR PROPERTY revised 3/15/23, documented in part . REPORTING/RESPONSE. For the alleged violation involving. mistreatment, including injuries of unknown source and misappropriation of resident property, the Center will report immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse.

This citation pertains to Intake 2677719Based on interview and record review, the facility failed to protect the residents' right to be free from neglect for 14 residents (R's 3, 5, 7, 25, 26, 39, 66, 70, 72, 88, 97, 103, 104 and 108) of 19 residents reviewed for neglect. Findings include,A complaint was filed with the State Agency (SA) that alleged on 11/23/25 There were no nurses on the 200 and 400 hallway. My family member did not receive their night meds [medications] and other residents did not either. Staff said they called the 'DON' [Director of Nursing] and their managers to get help but no one answered. A review of the November 2025 Medication admission Records [MAR] for residents currently on the 200 and 400 Halls revealed multiple missed medications and treatments for residents on the 200 Hall on the midnight shift 11/23/25-11/24/25. Continued review revealed missed medications and treatments were also missed on the100 Hall on 11/23/25. On 12/10/25 at 1:02 PM, Licensed Practical Nurse [LPN] 'H' was interviewed by phone and asked if she had worked on 11/23/25. LPN 'H' explained she had worked the day shift from 7:00 AM to 7:00 PM on the 200 hallway and Unit Manager [UM] 'B' asked her to stay over and help pass the evening medications, because a nurse had called in for the midnight shift, so she stayed until sometime between 9:00 PM and 10:00 PM. LPN 'H' was asked who took over the 200 Hall when shed had left. LPN 'H' explained there were two midnight nurses and neither one would count her cart [ensure all narcotic medication were accounted for] or take the keys, so she had to reach out to management then LPN 'I' counted the cart with her and she gave LPN 'I' the keys. LPN 'H' was asked who the other midnight nurse was. LPN 'H' explained the other nurse was LPN 'J'. On 12/10/25 at 1:18 PM, LPN 'I' was interviewed by phone and asked about 11/23/25. LPN 'I' explained she worked from 7:00 PM to 7:00 AM that day, and there were call ins, they had been told two managers were going to split the night, but then after the shift started, we found out they had asked a day shift nurse to stay to pass medications on the 200 Hall. LPN 'I' was asked how the Halls were divided between the nurses. LPN 'I' explained LPN 'H' had the 200 Hall until she left, LPN 'J' had the 300 Hall, she had the 400 Hall and they all split the 100 Hall, then when LPN 'H' left she was banned from the 200 Hall, so she could not take that so she took the 100 Hall and LPN 'J' kept the 300 Hall but refused to take the 200 Hall. LPN 'I' was asked who counted LPN 'H's' cart when she left. LPN 'I' explained she had counted the cart because LPN 'J' refused to count it, but she took the keys and left them in the hall. LPN 'I' was asked if she knew about any medications or treatments that had not been done that night. LPN 'I' explained she was sure there were, because LPN 'H' only passed the medications that were due at 9:00 PM. When asked if she had received any education and/or disciplinary action, LPN 'I' explained she had been terminated, but LPN 'J' still worked at the facility. On 12/10/25 at 1:48 PM, LPN 'J' was interviewed by phone and asked about the midnight shift on 11/23/25. LPN 'J' explained LPN 'H' had stayed to help because of a call off and there were only two nurses scheduled, usually the on-call nurse is supposed to come in and take over the slack and stay until 11:00 PM to pass medications, LPN 'H' stayed until 9:00 PM. LPN 'J' was asked how the Halls were split. LPN 'J' explained she was responsible for the 300 Hall and three rooms on the 100 Hall, LPN 'I' had the 400 Hall and six rooms on the 100 Hall, and LPN 'H' had the 200 Hall and three rooms on the 100 Hall; but usually when there are only two nurses, the Halls are split into 100 and 200 for one nurse and 300 and 400 for the other, it was unfair I had 200 and 300, they are the biggest and heaviest Halls. LPN 'J was asked if she knew if medications or treatments that had not been done that night. LPN 'J' explained she knew there were, because when she looked at the computer, all the residents' medications were red [indicating the medication had not been given and was overdue]. LPN 'J' continued to explain she passed the medications due at 6:00 AM [on 11/24/25] for the residents on the 200 Hall. Review of LPN 'I's' employee file revealed a letter of termination dated 11/25/25 that gave the reason for termination as Failure to perform job duties satisfactorily, and according to established job description. Review of LPN 'J's' employee file revealed an Employee Corrective Action form dated 11/24/25 that read in part, .Written Warning. refused to work assigned hall on 11/23 shift directed by DON. refusal by words/actions to comply with a direct order or job assignment. On 12/10/25 at 5:00 PM, the DON was interviewed and asked if she was aware medications and treatments had been missed on 11/23/25. The DON explained she did not know until she came into work on 11/24/25 that medications had been missed. The DON was asked why medications and treatments were missed. The DON explained there was a call in and a day shift nurse stayed to help, then the two midnight nurses refused to take the assignment. The DON was asked why one nurse was terminated and one continued to be employed by the facility. The DON explained they both received written warnings, but it was the final written warning for LPN 'I', so she was terminated. The DON was asked if any medications or treatments should be missed due to only having two nurses working. The DON explained no medication or treatments should have been missed, these were experienced nurses, they should have worked together to get everything completed. On 12/10/25 at 5:14 PM, Certified Nursing Assistant [CNA] 'L', who served as the Scheduler for the facility, was interviewed and asked if she had created a schedule for 11/23/25. CNA 'L' explained as 11/23/25 was on a Sunday, she did not work that day but had made the schedule for three nurses on the midnight shift. when one nurse called in and a day shift nurse stayed to help no one contacted her, if they had, she would have advised them how to proceed with the assignments. CNA 'L' was asked if LPN 'I' had been banned from the 200 Hall. CNA 'L' explained LPN 'I' was not allowed to be assigned to one specific room on the 200 Hall, but when that happened, they would say they could not have the entire Hall. CNA 'L' was asked if LPN 'I' could have given medication to other residents on the 200 Hall excluding that one specific room. CNA 'L' explained she could have. On 12/11/25 at 8:25 AM, UM 'B' was interviewed and asked about the midnight shift on 11/23/25. UM 'B' explained she was the on-call supervisor that day and there had been a call in for days, so she had worked the floor, then there was a call off for midnight. she asked LPN 'H' if she would stay to pass evening medications, she agreed to stay until the 9:00 PM medications were passed. LPN 'H' texted her to say the midnight nurses would not count the cart or take the keys, she advised her one of them had to count with her and take the keys and if they did not, she needed to call the DON. On 12/11/25 at 9:30 AM, the DON was asked if LPN 'H' had contacted her on 11/23/25. The DON explained LPN 'H' had contacted her because the other two did not want to count the cart with her, she spoke with LPN 'I' and told her to count the cart with LPN 'H' and that LPN 'J' was to take over the 200 Hall, it was not until she came in the next morning that she found out that did not happen. Review of time records revealed LPN 'H' punched out at 9:02 PM on 11/23/25. Review of facility provided Past Non-Compliance documents were examined by the survey team; however, due to current neglect concerns the Past Non-Compliance was not accepted. R3 Review of the November 2025 MAR against a Medication Admin Audit Report revealed the following medications were not given per physician orders: Morphine Sulfate ER 30 MG [milligrams] [a narcotic pain medication] was due at 9:00 PM Novolog Insulin sliding scale due at 9:00 PM [it should be noted the blood glucose was not completed to determine the sliding scale amount] R7 Review of the November 2025 MAR against a Medication Admin Audit Report revealed the following medications were not given per physician orders: Budesonide Suspension 0.5 MG/2 ML [milliliters] 2 ml inhale orally [a corticosteroid inhaler for asthma] was due at 9:00 PM Eliquis 5 MG [an anticoagulant] was due at 9:00 PM Enteral Feed Order, administer 960 ml Osmolite 1.5 via pump was due at 8:00 PM Enteral Feed Order, administer free water via pump was due at 8:00 PM The following treatments were not completed per physician orders: Monitor trach [tracheostomy] site due at Night Groin and buttocks, cleanse with soap and water due at Night Monitor PEG [percutaneous endoscopic gastrostomy – a tube passed through the abdomen to the stomach] tube site due at bedtime Vital signs [including pain score] was due at Night R26 A review of the November 2024 MAR/TAR revealed the following omitted medications and/or services on 11/23/25: Blood sugar check 9PM Norco 5-335 mg 9 PM dose. All were omitted and not signed for on the MAR/TAR. The review of the medication audit confirmed the omission. R88 A review of the November 2024 MAR/TAR revealed the following omitted medications and/or services on 11/23/25: Norco 5-325 8PM dose. Gabapentin 100mg 8 PM dose Tramadol 50 mg 8 PM dose Losartan potassium 50 mg 9PM dose All were omitted and not signed for on the MAR/TAR. The review of the medication audit confirmed the omission. R72 A review of the November 2024 MAR/TAR revealed the following omitted medications and/or services on 11/24/25: Cleanse L (left) shin w/ NS (with Normal Saline), apply petroleum gauze and cover w/ foam dressing. every shift. For the day time shift. All were omitted and not signed for on the MAR/TAR. The review of the medication audit confirmed the omission. R5 A review of the November 2024 MAR/TAR revealed the following omitted medications and/or services on 11/23/25: Xanax 0.5 mg 8 PM dose. All were omitted and not signed for on the MAR/TAR. The review of the medication audit confirmed the omission. R104 On 12/9/25 at 11:54 AM, R104 was interviewed about their current stay at the facility. R104, reported that the other day they had to use the restroom themselves (without assistance from staff) because the girls did not have time to take them to the restroom because they were passing breakfast trays. R104 reported that they are able to go to the toilet but they need assistance getting there. R104 reported that, they did not want to use the restroom themselves, but the aids had to pass trays first. Review of medical record revealed that R104 was admitted to the facility on [DATE] with the admitting diagnosis of Bilateral osteoarthritis of the knee and lower back pain and had a brief interview for mental status score(BIMs) of 15. On 12/11/25 at 10:15 AM an interview was conducted with the director of nursing (DON). The DON was asked what the expectation for patient care was during mealtimes, the DON reported that it is expected that the Certified nurse aids (CNA) come in at 7 AM get report, change (residents that are soiled) and get everyone up for the day; by 7:45AM the CNA can be a part of the dining line to help pass trays. The DON was then asked, would she expect someone to be taken to the bathroom or personal care needs be met during mealtimes. The DON reported that patient care should still happen during mealtimes. The DON was then informed of the accident that R104 experienced in the dining room and reported that they would look into it but that incident should have not happened because R104 is alert and oriented able to make their needs known. The DON was also informed that R104 was not the only resident who mentioned not being able to receive assistance during the breakfast meal when the trays are being passed. The DON reported the facility would have to work on their procedures during the breakfast mealtime. R97 Review of R97's November (2025) MAR/TAR revealed the following omitted medications: 11/23/25: Oxycodone – Acetaminophen 5-325 mg (controlled pain medication). 1 tablet every 4 hours for moderate to severe pain (scheduled): 2000 (8:00 PM). Fiber One - 2 tablets by mouth 3x day for constipation (scheduled): 2000 (8:00 PM). 11/24/25: Oxycodone – Acetaminophen, 5-325 mg. 1 tablet every 4 hours for moderate to severe pain. (scheduled): 0000 (12:00 AM) and 0400 (4:00 AM)). Vitals signs every shift (scheduled). R97's medications/treatments reflected were omitted (blank with no explanation) and unsigned, with no explanation regarding the omissions on the MAR/TAR. Review of R97's November medication audit (provided by facility management) confirmed the omissions. Review of R97's pain log entry, dated 11/24/25 at 6:28 (AM), showed increased pain shortly after missing their pain medication of 8/10 (with 10 the worst pain level). R70 Review of R70's November (2025). MAR/TAR revealed the following omitted medications (blank entries): 11/23/25: Gabapentin (nerve medication) 100 mg. 2 tablets 3 x day for wedge compression fracture (nerves/pain). 2000 (8:00 PM). Hydroxyzine (anxiety medication), 25 mg. 1 tablet 4x day for anxiety. 2100 (9:00 PM). Hydrocodone – Acetaminophen Tablet 10 – 325 mg. 1 tablet 4 x day for pain. (scheduled): 2000 (8:00 PM). 11/24/25: Hydrocodone – Acetaminophen Tablet 10 – 325 mg. 1 tablet 4 x day for pain. (scheduled): 0000 (12:00 AM). 0400 (4:00 AM). R70's medications/treatments reflected were omitted (blank with no explanation) and not signed for, with no explanation on the MAR/TAR. Review of R70's November (2025) Medication Audits confirmed the omissions (blank with no explanations). Review of R70's pain log entry, dated 11/24/25 at 11:40 (AM), showed increased pain shortly after missing their pain medication of 9/10. R66 11/23/25: Acetaminophen (OTC – Over the counter) pain medication. 2 tablets 3x day for pain (scheduled). 2000 (8:00 PM). Muscle Rub External Cream 10-15% (Menthol ) Apply to knees 3x day. 2000 (8:00 PM). Monitor skin integrity and circulation to LLE (left lower extremity) every shift. R66's medications/treatments reflected were omitted (blank with no explanation) and not signed for, with no explanation on the MAR/TAR. Review of R66's November (2025) Medication Audits confirmed the omissions. Review of R66's pain log entry, dated 11/24/25 at 7:51 (AM), showed increased pain shortly after missing their pain medication of 5/10. R25 A review of the November 2025 MAR/TAR revealed the following omitted medications and/or services on 11/23/25: Minoxidll 2.5 mg (milligram) tablet for hypertension, 9 PM dose. Clonidine HCl 0.3 mg tablet for hypertension, 8 PM dose. Hydralazine HCL 100 mg tablet for hypertension, 8 PM dose. Blood sugar level for Humalog (insulin coverage), 9 PM dose. All were documented as administered and/or obtained, however when compared to the facility's medication administration audit it revealed the above medications were not administered. R39 A review of the November 2025 MAR/TAR revealed the following omitted medications and/or services on 11/23/25: Fluticasone-Salmeterol inhalation aerosol 250-50 MCG (microgram)/ACT (actual puff from inhaler) one puff every 12 hours for acute and chronic respiratory failure with hypoxia (low levels of oxygen), 9 PM dose. Ipratropium-Albuterol 0.5-2.5 MG/3ML (milliters) via nebulize for COPD, 9 PM dose. All were omitted and not signed for on the MAR/TAR. The review of the medication audit confirmed the omission. R103 A review of the November 2025 MAR/TAR revealed the following omitted medications and/or services on 11/23/25: Blood sugar level for Humalog (insulin coverage) for the 6 PM & 8 PM doses. Both were omitted and not signed for on the MAR/TAR. The review of the medication audit confirmed the omissions. R104 A review of the November 2025 MAR/TAR revealed the following omitted medications and/or services on 11/23/25: Gabapentin 100 mg capsule for idiopathic progressive neuropathy, 8 PM dose. The medication was omitted and not signed for on the MAR. The review of the medication audit confirmed the omission. R108 A review of the November 2025 MAR/TAR revealed the following omitted medications and/or services on 11/23/25: Tylenol Extra Strength 500 mg tablet for pain, 9 PM dose. The review of the medication audit confirmed the omission.

Based on observation, interview and record review the facility failed to provide information regarding an advance directive & failed to offer the resident and/or resident representative the opportunity to formulate an advance directive for one (R56) of one resident reviewed for advance directives. Findings include: A review of the medical record revealed R56 was initially admitted to the facility on [DATE], with a readmission date of 11/7/25. Diagnoses included: chronic kidney disease, colostomy status and sepsis. On 12/9/25 at 10:47 AM, R56 was observed in their room sitting in their wheelchair. An interview was conducted with the resident at that time. Review of the EMR (electronic medical record) revealed R56's brother was documented to be the POA (Power of Attorney) for Care and Financial for R56.A review of the medical record revealed no documentation of the facility staff to have provided information to R56 or R56's brother regarding information on advance directives and no documentation that the resident or their POA was provided the opportunity to formulate an advance directive. On 12/10/25 at 11:17 AM, the Care Transitions (CT) personnel O was interviewed and asked about the facility's policy and their department involvement in providing the residents and/or resident representatives information on advance directives and the option to formulate an advance directive. CT O replied their department only ensured the advance directives are in the medical record and stated it was the nursing department responsibility to provide the information to the residents and/or representatives.On 12/10/25 at 11:21 AM, the Director of Nursing (DON) was interviewed and asked the nursing departments involvement in the education and providing residents and/or representatives the opportunity to formulate an advance directive. The DON stated they would look into it and follow back up with the surveyor. At 12:04 PM, the DON followed back up and stated it is not the Nursing department responsibility to provide information and the option to formulate an advance directive to the residents and/or representatives. The DON stated the social work department (care transitions) is responsible for that. A review of a facility policy titled Advance Directives revised April 2008 documented in part , . Advance directives will be respected in accordance with state law and facility policy. Prior to or upon admission of a resident to our facility, the Social Services Director or designee will provide written information to the resident concerning his/her right to. formulate advance directives.On 12/10/25 at 12:19 PM, a follow up interview was conducted with CT O. CT O stated they called R56's brother and provided them information on the advance directive today (12/10/25). No further information or documentation was provided by the end of the survey.

Based on observation, interview and record review the facility failed to ensure a resident received assistance with their hearing aides to maintain their hearing ability for one (R89) of one resident reviewed for hearing. Findings include: On 12/9/25 at 10:17 AM, R89 was observed lying on their back in bed. An interview was attempted, however R89 stated they were unable to hear the surveyor. A signage on the resident wardrobe was observed to alert the staff that the resident had new hearing aids. The surveyor had to talk into the right ear of R89 to complete the interview. On 12/10/25 at 12:40 PM, R89 was observed lying on their back in bed. An interview was attempted, however R89 stated they were unable to hear the surveyor. The surveyor talked into the right ear of the resident and asked about their hearing aids. R89 stated their hearing aides were in the drawer of their nightstand but could not reach them. R89 stated staff would have to provide them with their hearing aids to put them in.A review of the medical record revealed R89 was initially admitted to the facility on [DATE], with a readmission dated of 6/9/25. R89 was admitted with a diagnosis that included dementia and required assistance from staff for all activities of daily living (ADLs). A review of the medical record revealed no active care plan regarding the R89's hearing deficit and/or the responsibility of which staff to assist with applying the resident's hearing aids. Further review of the medical record revealed no documentation of the resident's hearing aids. On 12/11/25 at 9:23 AM, an interview was conducted with the Director of Nursing (DON). The DON was asked whose responsibility it was to assist R89 with applying their hearing aids daily. The DON responded that the aids or nurses are both capable to assist the resident with their hearing aids. The two above observations were discussed with the DON and the concern of the facility staff failure to assist R89 with the application of their hearing aids. The DON stated they would look into it and follow back up. No further explanation or documentation was provided before the end of the survey.

Based on observation, interview, and record review, the facility failed to provide adequate positioning to prevent the potential for wound development and progression for one Resident (R108) of two residents reviewed for positioning. Findings include: On 12/09/25 at 11:38 a.m., R108 was observed at approximately 11:38 a.m. seated upright in their recline high back wheelchair, dressed, pushing their wheelchair down the hallway. R108 was sacral sitting (sliding forward in their wheelchair seat, onto their sacrum - bone at base of spine). R108 was observed with a full body mechanical lift sling underneath them, with no wheelchair cushion observed. On 12/09/25 at approximately 11:45 a.m., R108's Certified Nurse Aide, (CNA) P, was asked if R108 had a wheelchair cushion underneath them. CNA P confirmed R108 did not have a wheelchair cushion underneath them. R108's room was observed, and there was no wheelchair cushion. Two blue foam heel protectors were observed and an air bed mattress. Review of R108's nursing progress note, dated 12/05/25 at 12:48 p.m., revealed, SW - Skin Issues: #001: New skin Issue. Location: Coccyx. Issue type: Pressure ulcer/injury. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis (middle layer of skin). Wound acquired: In - house (during stay). Wound is new. Signs and symptoms of infection: None. Length (cm - centimeters): 0.59 width (cm): 0.72. Depth (cm): 0. Area: 0.33 (cm2).Surrounding tissue: fragile.Additional care: Mattress with pump.Additional care: Heel suspension / Protection device.Skin Issues Note: Stage 2 to left buttock. Review of R108's physician orders, accessed 12/09/25 at 3:58 p.m., revealed R108 continued to receive wound treatment to their bottom. Wound care orders read as follows: .R (right) buttock wound: Cleanse w/ (with) NS (Normal Saline solution). Pat dry. Skin prep (protective wound covering) to surrounding area (peri-wound). Aquacel ag (antimicrobial treatment used in wound care) to wound bed and cover w/ (with) foam dressing.Active. Start date: 12/05/25 13:45 (1:45 p.m.).End date: (Blank)., showing a current order. This order confirmed R108's pressure ulcer was not healed during the survey. Review of R108's Electronic Medical Record (EMR) revealed R108 was admitted to the facility on [DATE], with diagnoses including diabetes, dementia, falls, and stroke. The EMR revealed R108 was receiving hospice services. Review of R108's Care Plan, accessed 12/09/25 at 3:53 p.m., revealed R108 required assistance with activities of daily living (ADL cares) and had cognitive impairment. The Care Plan further revealed R108 used a high back wheelchair and a full body mechanical lift for transfers. There was no mention of a wheelchair cushion in R108's Care Plan, including in the ADL or skin management section, or throughout their current care plan. R108's Care Plan showed they wore heel protectors when they were in bed, stating, float heels while abed (sic), encourage PRAFO (positioning) boots as ordered. On 12/10/25 at approximately 10:40 a.m., R108 was observed in the dining room with a full body mechanical lift sling underneath them. There did not appear to be a wheelchair cushion underneath R108, as no cushion was observed on either edge of the wheelchair or above or underneath the sling. On 12/10/25 at approximately 10:42 a.m., R108 was asked how they were doing. R108 pointed to their left foot and said it hurt. R108's nursing staff were notified R108 was in pain after the interaction. No heel protector was observed on R108's left foot. On 12/10/25 at approximately 10:52 a.m., R108's CNA, CNA Q, reported they did not observe a wheelchair cushion underneath R108. CNA Q looked in R108's room and reported they did not observe a wheelchair cushion. On 12/10/25 at approximately 1:30 p.m., R108 was observed with Family Member, FM R, who acknowledged R108 had a black wheelchair cushion underneath them which was hard, as felt by FM R' and Surveyor. The cushion did not have adequate pressure relief. No gel or air was felt or observed on the cushion as an overlay. On 12/10/25 at 1:35 p.m., R108's left foot was observed with FM R, with the left foot sliding off the black metal wheelchair footrest foot plate, striking the footplate directly on the left side, on their left lateral heel. R108 was not wearing any heel protectors or PRAFO positioning/offloading boots during the observation. On 12/10/25 at 1:36 p.m., FM R asked R108 how they were doing, and R108 communicated to FM R their right foot was hurting. R108 told FM R it had been hurting for some time but was unable to specify further. On 12/10/25 at 1:38 p.m., FM R removed R108's blue gripper sock. R108's left heel had a half-dollar sized wound on their lateral heel observed where the foot plate was striking their left heel. The wound had a black outer ring, and an inner yellow circle, with a burgundy red center. The wound did not appear to be a new wound as it was covered with thickened skin. R108's entire left foot up to their calf was erythemic (abnormally reddened due to inflammation, injury, infection, or irritation caused by dilated blood vessels). FM R removed R108's right foot gripper sock (for comparison), and there was a demonstrable difference in color. R108's right foot had no erythema and was cream colored in appearance. R108's FM R noted the difference in R108's foot coloration and was concerned about the new wound. FM R reported they had not been made aware of this wound to R108's left foot. Surveyor notified nursing staff of R108's wound, who confirmed this was a new wound and sent for a wound nurse team to assess and treat the wound. Review of R108's EMR showed there was no documentation of R108's heel wound prior to the 12/10/25 observation with FM R and Surveyor. On 12/10/25 at approximately 1:55 p.m., R108 was observed with FM R with their foot positioned on their left footrest foot plate. On 12/10/25 at 2:00 p.m., R108 was observed sliding off their foot at the footrest towards their midline, so their left lateral heel directly struck the right side of the left footrest. R108 was assisted with positioning by FM R to relieve the direct pressure to this area, and the nursing wound staff were made aware of the pressure area and observed R108's positioning when they came to observe and measure the heel wound. Review of R108's Physician Provider Note, by Physician V, dated 12/10/25 at 16:18 (4:18 p.m.), revealed, .(Physician V) received a call from nursing staff regarding elevated blood sugars.Will increase (Brand name) insulin.and continue to monitor blood sugars closely with sliding scale insulin coverage as needed. Patient also has redness to left foot and left lower leg; pictures are reviewed. Patient previously had small callus (thickened skin) type area on the heel in September which has healed and now seems like worsened again. From picture (photo) looks like the patient has callouses which can be painful with the pressure, also discoloration of the left leg probably (due to) underlying peripheral vascular disease (PVD- blood circulatory disorder). Patient is diabetic and (at) high risk of PVD. Will try to keep pressure off, pain management and local care and monitor. Review of the provider note acknowledged R108's wound was related to pressure as well as a likelihood of vascular compromise and R108's unstable blood sugars from diabetes. Review of R108's physician order, dated 12/10/25 at 19:00 (7:00 p.m.), revealed, DM (diabetes mellitus) ulcer/callous at left lateral foot/side of heel: Swab with skin prep, let dry, leave OTA (open to air), monitor site and notify MD (physician) of acute changes. Review of R108's physician order, dated 12/10/25, revealed, Foot buddy (padded wheelchair footrest cradle / overlay) to wheelchair when footrests are engaged (in place) .Review of R108's physician order, dated 12/10/25 at 19:00 (7:00 p.m.) revealed, (Brand name air) cushion to wheelchair; check for inflation and refill (air) cushion as needed. Review of R108's wound note, dated 12/10/25, revealed, Diabetic foot ulcer. Location: Left lateral foot. Onset. New.Side of heel.In-house acquired.Intermittent pain.Sensitive to touch.Measurements: Length: 1.55 (centimeters - cm). Width: 1.12 (cm). Depth: 0. Area: 1.31 (cm) .Exudate (drainage): None.non-pitting edema (swelling) extends 4 cm around wound. This note confirmed R108's wound was new, after being discovered by FM R, with Surveyor present. On 12/11/25 at 12:55 p.m., Registered Nurse (RN) S, R108's hospice nurse, was asked during a phone interview about R108's wounds. RN S acknowledged they were R108's visiting nurse who completed wound care with R108. RN S confirmed during their visit earlier this week, R108 continued to have a Stage 2 pressure ulcer on their sacrum (triangular bone at the base of the spine), which was not infected and smaller than a pencil eraser in size. RN S was asked if R108 had any other wounds and reported they were not aware of R108 having any other wounds, including on their left heel. On 12/11/25 at approximately 2:30 p.m., the Rehabilitation Director, Physical Therapist (PT) U, was asked about R108's positioning in their wheelchair. PT U acknowledged the therapy department had placed the protective blue padded foot board over R108's wheelchair foot plates on 12/10/25. PT U confirmed a screening was requested by nursing management after nursing staff had learned R108 had a new heel wound from a potential pressure area from their left wheelchair footrest. PT U confirmed this was an appropriate intervention, given R108's heel wound. PT U acknowledged this intervention may have prevented the pressure area, when they learned R108's heel was sliding off their left wheelchair footrest. PT U reported they and their department staff had not been made aware of this concern by nursing staff until 12/10/25, after the left lateral heel wound was discovered. On 12/11/25 at 2:44 p.m., the Director of Nursing (DON) was interviewed regarding R108's sacral pressure ulcer and the lack of an appropriate wheelchair cushion. The DON acknowledged the concern and reported a new (Brand name) air cushion was in place underneath R108 currently.On 12/11/25 at approximately 2:50 p.m., the DON was asked about R108's foot slipping off their wheelchair and the blue padded foot board currently over R108's footrests. The DON concurred that this was an appropriate intervention to prevent pressure and slippage and noted R108's heel foot protectors were also in place. The DON reported R108's Physician V had seen R108 on 12/10/25 and documented the heel wound as a diabetic wound, which may have been PVD-related as well as a past wound there. Concerns were shared related to the location of R108's new left lateral heel would and pressure being observed. Surveyor described how R108's foot made direct contact with their wheelchair footrest footplate more than once prior to the preventative positioning intervention newly put in place during the survey. Surveyor also described concerns related to R108 not having a wheelchair cushion or the cushion not providing adequate pressure relief for a Stage 2 sacral pressure ulcer. The DON understood the positioning concerns and confirmed the new interventions would ensure adequate pressure relief for R108's sacral wound and R108's left heel wound, due to their high risk of breakdown, and help prevent wound progression. On 12/11/25 at approximately 2:55 p.m., the DON and Surveyor observed R108's positioning in their high back wheelchair in their room. R108 was seated in their wheelchair, with a (Brand name) air cushion underneath them in their wheelchair. R108 also had the blue padded foot board over their wheelchair footrests and the blue foam pads covering their heels. The footboard prevented R108's feet from sliding off separate footrests as the device covered both footrests to adequately support their feet and lower calves. On 12/11/25 at approximately 3:01 p.m., Regional Nurse Consultant, RN M, the DON, and RN S asked to speak to the survey team regarding R108's wounds and causative factors. RN M and RN S clarified they believed R108's left heel wound was a diabetic wound, and possibly from PVD, which was being evaluated further. This was described related to Physician V's wound assessment/description dated 12/10/25, review of podiatry notes, and their prior wound history of a diabetic heel wound from 3/2025. Surveyor described R108's heel wound was observed directly more than once located in a pressure contact area with their left footrest, however, regardless of the cause, R108 would have benefitted from the padded protective positioning device over their footrests, given R108's vulnerability and subjectivity to skin breakdown. Additionally, Surveyor described R108 would have benefitted from having a pressure relieving wheelchair cushion / air cushion in place, per standards of practice, to prevent the development and/or progression of an existing Stage 2 pressure ulcer on their sacrum. Per Surveyor understanding, the nursing management team understood the positioning concerns however denied any presence of a new pressure ulcer to R108's left heel. RN M clarified they understood both R108's heel and sacral pressure ulcer developed from former wounds which predisposed them to skin breakdown. Review of a policy for skin and wound, titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol. Assessment and Recognition, revised October 2010, revealed the following: 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall assess and document/report the following: a. Vital signs. b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. c. Pain assessment. d. Resident's age and sex. e. Resident's mobility status. f. Current treatments, including support surfaces. g. All active diagnoses. 3. The physician and staff will examine the skin of a new admission for ulcerations or indications of a Stage I pressure area that has not yet ulcerated at the surface. 4. The physician will help the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed, etc.) of an ulceration. Cause Identification 1. The physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes or congestive heart failure, overall medical instability, cancer or sepsis causing a catabolic state, and macerated or friable skin. 2. The physician will help clarify relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, the impact of comorbid conditions on wound healing, etc. Treatment/ Management. 1. The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents . Review of the article, Damiao, J., & [NAME], T. (2024). A systematic review of the effectiveness of pressure relieving cushions in reducing pressure injury. Assistive Technology, 36(5), 373-377. https://doi.org/10.1080/10400435.2021.2010148, . suggest air-cell cushions provide optimal pressure relief and shear reduction. Furthermore, small sample single cohort studies suggest off-loading cushions provide superior pressure relief beyond that of air-celled cushions but require additional research for greater generalizability.

This citation relates to Intakes 2614504 and 2569835. This citation has two Deficient Practice Statements (DPS).DPS #1 Based on observation, interview, and record review, the facility failed to prevent an avoidable accident when one resident, R901, of two residents reviewed for supervision fell out of bed during care. Findings include: Review of a complaint intake, received on 9/10/25 at 3:43 p.m., revealed the complainant reported they received a call from the facility on August 17, 2025, at 11:30 a.m., when they learned R901 rolled off their bed with two people assisting them, which they did not believe was possible. Afterwards, they were told their family member was being changed and fell off the bed. The complainant alleged their family member subsequently developed bruising on their right arm and had head and back pain. They alleged they were not given an explanation of what occurred and were concerned about R901's safety in the facility. Review of R901's Fall Assessment report, dated 8/18/25 at 1:31 p.m., revealed, .Guest (R901) was being assisted via 2pa (two person assist) with brief change, when during the brief change guest rolled from bed and onto the floor guided by staff. Guest was assessed for pain and significant injury, pain reported in head and shoulder. Guest sent to hospital for further evaluation due to being on blood thinners. She returned a short time later with no injury and scans reported to be clear. All parties were notified. Guest is an [AGE] year-old long term-rehab guest. She has a primary diagnosis of ESRD (End Stage Renal Disease - on dialysis) .Root cause was determined to be that the CNA failed to maintain safe bed mobility during routine care. Plan of care updated, and bolsters were added to bed, fall mat at bedside, and nursing staff provided with education regarding appropriate bed mobility. On 9/23/25 at 4:54 p.m., R901 was observed in their hospital bed dressed, appearing clean and well-groomed, with clean hair. R901's nails were observed as freshly painted, with no dirt or residue under their nails. R901 was calm and smiled at surveyor and agreed to an interview. R901 was observed in a bariatric hospital bed with an air mattress, with contoured edges to prevent falls. There was also a geriatric pressure-relieving large lounge chair with cushion in their room, newer in appearance. No bruises were observed. R901's nurse and aide were observed on the unit hall. On 9/23/25 at 4:56 p.m., R901 was asked how they were doing and said, Good. R901 was aware of their name, surroundings, and situation. R901 was able to follow one-step directions to show Surveyor their nails and common room objects. R901 was asked how staff took care of her and said, Good. R901 reported they were treated well by staff. R901 was asked about getting showers and reported they received their showers. R901 was asked if they felt safe in the facility and responded Yes and denied any abuse or mistreatment. R901 was asked about their fall out of bed last month, and said they were not hurt or injured, and denied any bruising. Review of R901's Minimum Data Set (MDS) assessment, dated 7/17/25, revealed R901 was admitted to the facility on [DATE], and was dependent for bed mobility including rolling and transfers. The Brief Interview of Mental Status (BIMS) assessment revealed a score of 7/15, which showed cognitive impairment. Review of R901's Electronic Medical Record (EMR) revealed they had a guardian, and had diagnoses including kidney disease, dementia, depression, anxiety and an above knee left leg amputation. Review of R901's nursing progress note, dated 8/17/25 at 11:00 a.m., revealed R901 was observed on the floor by a Certified Nurse Aide (CNA) with right shoulder, arm, and head pain. Pain medication was administered. R901 was sent to the hospital emergently by their nurse and on-call physician. Review of R901's nursing progress note, dated 8/17/25 at 6:54 p.m., revealed R901 returned to the facility on a stretcher, was alert and oriented x 2-3 spheres, had normal range of motion, no signs of distress, and their CT scan (head) was negative. There was no mention of bruising or other injuries noted, and no new orders reported. Review of R901's shower skin assessment, dated 8/18/25, showed no bruising or other injuries. Review of R901's pain assessment vital log showed R901 had pain 9/10 (10 highest pain) at the time of the incident, however pain decreased to 0 to 3 range (no to low pain) on 8/18/25 and 8/19/25. On 9/23/25 at 5:30 p.m., Registered Nurse (RN) F was asked about R901's fall out of bed on 8/17/25. RN F reported the aides were in the middle of changing R901 when one of them reached for gloves and R901 rolled off the bed. RN F reported they did not know R901's position on the bed, or any other details about the incident. RN F confirmed there were two aides in R901's room when they were changing R901 in the bed, as they observed them enter R901's room together and neither exited the room. After the fall, R901 was observed by RN F sitting on their bottom next to the bed. RN F explained there was no bruising or injury was observed. RN F confirmed the incident was an accident. RN F said R901 denied they hit their head, and they assessed R901, completed neuro (neurological) checks, and sent R901 to the hospital per the physician, since they were on a blood thinner medication. RN F said they called R901's guardian once they had assessed R901 and ensured they were medically stabilized. On 9/24/25 at 9:36 a.m., Certified Nurse Aide (CNA) G was asked to describe what occurred when R901 fell out of bed during cares on 8/17/25. CNA G confirmed an accidental incident occurred when they were washing up R901 with CNA N. CNA G explained R901 required a Hoyer lift for transfers and two-person assistance, which was being provided. CNA G reported they and CNA N were cleaning up R901 in their hospital bed after R901 had a bowel movement when CNA N handed them a bottle of cream, removed their protective gloves, and began leaning away to grab another pair of gloves. R901 was turned on their left side facing CNA N on the door side of the hospital bed, and CNA G was on R901's right side, by the window side of the room. CNA G described CNA N intervened when R901 began to fall and broke her fall by supporting R901 and guiding them to the ground. CNA G reported the air mattress (for pressure relief) was not as stable as a regular hospital bed, and R901 was positioned on their side when the fall occurred. CNA G reported R901 was conversant and calm after the fall occurred, with no observed or reported pain. CNA G reported they believed R901 hit their head, and that was why they were sent out to the hospital, after RN F assessed them. CNA G was asked if anything different could have occurred to prevent the fall. CNA G said they could have laid R901 down on their back and CNA N could have had the gloves in reach. CNA G reported there was no intent or abuse and confirmed the incident was an accident. On 9/24/25 a phone call was made to CNA N during the survey to confirm the incident details. No call was returned by the end of the survey on 9/25/25. Review of CNA N's witness statement, dated 8/17/25, confirmed the incident details as described by CNA G. CNA N stated there once they realized R901 began to fall they eased R901 down to the floor and protected their head from hitting the floor. CNA N described in their statement they immediately notified RN E the incident occurred. Interviews and record review confirmed two CNAs were present when R901's fell out of bed occurred on 8/17/25. On 9/24/25 at 12:09 p.m., CNA I confirmed the incident occurred on 8/17/25 as described to them (on 8/17/25) by CNA G and CNA N, as they observed R901 after the incident occurred and said R901 was pleasant, calm and kept comfortable and denied any mistreatment being reported. CNA I confirmed the incident was an accident. On 9/24/25 at 12:31 p.m., Unit Manager, RN K, confirmed CNA G and CNA N reported to them the incident occurred as described by their witness statement, and there was no abuse, mistreatment, or intent found after their investigation. On 9/25/25 at 1:17 p.m., Regional Clinical Director, RN A, acknowledged the concerns related to R901's safe bed mobility and positioning to prevent an avoidable fall. RN A acknowledged R901 should not have been laying on their side when CNA N stepped away from being in front of them while changing them. RN A showed Surveyor the staff education they provided, including reeducation of CNA G and CNA N in safe bed mobility and positioning techniques. RN A denied R901 was injured during the incident. Review of the education provided by RN A titled, Bed Mobility Education, revealed, When completing ADL (activities of daily living) with guests in bed, verify and confirm that: 1. Guest is a 1 PA (person assist) or a 2 PA with bed mobility; this information is in the Kardex (resident care guide). 2. Ensure you have a 2nd staff if guest is a 2 PA. Never leave the guest on their side if one staff has to leave for any reason to get any supply, especially the staff on the side where the guest is facing. Properly position guest on their back before leaving. SAFETY IS A PRIORITY AND MUST BE MAINTAINED AT ALL TIMES. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included resident assessment, care plan revision, fall audits, nursing staff reeducation on the falls reduction policy with an emphasis on safe bed mobility, nursing bed mobility rounds including care observations, and audit of five falls weekly for 12 weeks by the Director of Nursing (DON), including the QAPI (Quality Assurance Performance Improvement) process. The root cause of the incident was identified as the CNA failed to maintain safe bed mobility during routine care. DPS #2 Based on interview and record review, the facility failed to provide adequate supervision to prevent an elopement for one Resident, R902, of two residents reviewed for elopement. Findings include:Review of a Facility Reported Incident (FRI) received by the State Agency from the facility on 7/13/25 revealed R902 eloped from the facility unsupervised on 7/12/25 at approximately 7:09 p.m., when staff responded they discovered R902 was outside the facility premises at an apartment complex across the street. It was found R902 had eloped from the facility without staff knowledge, and witness statements revealed the resident left the facility with a visitor and was dressed appropriately. The report revealed proper notifications of physician and family representative were completed when the elopement was discovered. Law enforcement reportedly notified and R902 was sent to the hospital as required for assessment, and returned to the facility unharmed, with no change in condition or status. R902 was placed on 1:1 supervision during their remaining stay. Review of R902's Investigation provided by the facility revealed R902 had an unauthorized leave from the facility on 7/12/25, when a well-intended visitor wheeled R902 to the front door of the facility as R902 requested to go outside. The facility pushed R902's wheelchair out the facility front door. It was reported R902's wander guard security alert activated the door alarm; however, staff did not respond timely. Review of R902's MDS assessment, dated 7/01/25, revealed they were admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy (metabolic brain dysfunction) and dementia. The assessment revealed R902 was able to propel their wheelchair with moderate assistance and was dependent for transfers. The BIMS assessment revealed a score of 9/15, which showed moderate cognitive impairment. Review of R902's census revealed R902 was discharged from the facility on 7/17/25. Review of R902's Accident and Incident report, dated 7/12/25 at 6:30 p.m., revealed staff noticed R902 was missing about 7:00 p.m., and had been last visualized around 6:30 p.m. R902 was not located in the facility or perimeter of the building. R902 was found with local police and emergency medical services outside the facility campus. According to the report, R902 was not found injured. Review of Certified Nurse Assistant (CNA) D 's witness statement, dated 7/12/25, revealed, The last time I saw (R902) was between 6:20 - 6:30 p.m.Earlier in the day (R902) had been asking reportedly to go outside, so I took her outside before dinner for about 45 minutes in the middle courtyard.I was assisting 315 (another resident) and went to get her some more water when I heard the alarm as I was going back to (315).I checked 313 (R902's room) and saw that (R902) wasn't in there.I sprinted up front. I did not see her up front so I then called (nurse) at 7:05 and (nurse) ran up front. We walked towards where our cars were parked and I got in my car and drove around the parking lot twice. I heard the sirens and went down towards (local business).and then followed the sirens and that is when I found (R902) with police and the fire crew. (R902) was alert, did not appear hurt and was speaking pleasantly with them. Review of Registered Nurse (RN) C s witness statement, dated 7/13/25, revealed, .I saw (R902) shortly before then around 6:20 (p.m.).When I came out of the room, I saw a visitor with (R902) and the visitor was pushing her wheelchair. I assumed it was a family member of (R902's). A CNA came in around 1904 (7:04 p.m.) and let me know that one of my residents was outside. I told her, 'Yeah, she's with someone.' (CNA D ) was down in 315 providing care and the next thing I know (CNA D) was running down the hall and she told me 'It's ok.' She then called me at 1905 and told me that she was looking for (R902) and that she was told they were outside. (CNA D ) told me she heard the alarm and when she passed 313 and saw she wasn't in her room she realized it was going off because of her. I met (CNA D ) up front and we both walked around the building together. I told (CNA D ) to get in her car to see if she could find her. We both heard sirens at that time and (CNA D ) got in her car and drove off to look for (R209). (CNA) D) then called me at 1913 to let me know she found (R902) with the police and fire crew. On 9/24/25 at 10:16 p.m., CNA D reported the incident occurred on 7/12/25 as described in their witness statement, and said they told RN C R902 was missing at approximately 7:15 p.m. and found them shortly afterwards. CNA D acknowledged they turned the wander guard alert door alarm off, as they did not see a resident and had earlier seen R902 with a visitor, so they had not realized R902 had left the premises. CNA D reported R902 was dressed appropriately for a warm summer evening, wearing a T-shirt, pajama pants, and shoes. They understood the concerns and reported they had received a reeducation from the administration to not turn the door alarm off, until every resident in the facility was accounted for. Review of additional investigation staff witness statements provided by the facility investigation showed a few staff had observed R902 on the campus premises unsupervised and had not followed facility policy to verify R902 was able to be outside unsupervised. The investigation revealed all staff had received a reeducation regarding the elopement and Code Pink policy. Review of R902's nursing assessment, dated 7/12/25 at 7:33 p.m., revealed R902 had increased exit seeking behaviors due to confusion. Review of R902's nursing progress note, dated 7/09/25, revealed R902 had exit seeking behaviors, with staff redirection provided. Review of R902's nursing progress note, dated 7/12/25 at 7:32 p.m., confirmed R902 eloped from the facility, and was sent to the hospital for evaluation. A wander guard was ordered and added. Review of R902's nursing progress note, dated 7/12/25 at 8:00 p.m. revealed no skin concerns during shower. Review of R902's nursing progress note, dated 7/13/25 at 2:33 a.m., revealed R902 returned to the facility from the hospital with no new orders, and was placed on 1:1 supervision. Review of R902's nursing progress note, dated 7/13/25 at 3:07 a.m., revealed no bruising, open areas, or injuries. Review of R902's physician progress note, dated 7/16/25 at 1:51 p.m., revealed resident assessment and no new concerns.On 9/24/25 at approximately 4:39 p.m., Regional Clinical Director, RN A, acknowledged the concerns related to R902's elopement from the facility unsupervised, discovered beyond the perimeter of the facility campus, and staff not following the elopement policy and process including not responding appropriately to the wander guard alert door alarm, and observing R901 unsupervised outside beyond the facility entry door. Review of the policy, Elopement, revised December 2008, revealed, .(highlighted) 2. If an employee observes a resident leaving the premises, he/se should: a. Attempt to prevent the departure in a courteous manner; b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises.(highlighted) 4. If an employee discovers that a resident is missing form the facility, he/she shall: a. Determine if the resident is out on an authorized leave or pass; b. If the resident was not authorized to leave, initiate a search of the building (s) and premises; (handwritten). Call code Pink (alert) - 600 (hall) phone. c. If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials.d. Provide search teams with resident identification information, and e. Initiate an extensive search of the surrounding area.(Wander guard books are located at Front Desk and both Team rooms). Review of the facility Code Pink process, undated, revealed the facility had a clear process for what to do when door alarms sounded, calling a Code Pink overhead, performing a head count, searching including interior and perimeter ground search, and beyond if indicated, notification of the Sheriff's department as needed, resident assessment when found, proper notifications, and completing an incident report and the appropriate documentation. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included R902 was medically assessed, proper notifications were completed, and R902 was placed on a 1:1 supervision. A one-time audit of residents was completed to ensure wander risk assessment needs were place, code alert bracelets were in place and functioning, and staff were reeducated on code alert bracelets and checking them every shift. Licensed nurses and nursing assistances (CNAs) were educated to ensure timely response to code alert bracelet alarms with compliance assured. The DON/designees conducted elopement drills weekly for 12 weeks to provide monitoring and ensure staff were checking and responding timely to code alert and door alarms, with the QA (Quality Assurance) process ensuring compliance.

This citation pertains to Intake Number(s): MI00153363. Based on interview and record review, the facility failed to treat the resident's high blood sugar in a timely manner for one (R902) of one resident reviewed for diabetes management. Findings include: A review of a complaint submitted to the State Agency (SA) revealed an allegation that R902's blood sugar was 452 at 9:00 PM, he needed an insulin shot, and did not receive treatment until 2:00 AM the next day. On 6/4/25 at 9:15 AM, an interview was conducted with R902. When queried about any concerns about his care in the facility, R902 reported a recent issue with his blood sugar. R902 explained his blood sugar was 452 one evening at 9:00 PM. He pressed the call light and a nurse came in. He informed the nurse he needed insulin and she told him she could not give it without a physician's order. R902 further explained at 12:00 AM, the nurse came back and said the physician never called back so she could not give him additional insulin. R902 reported he was irritated because at home he managed his own insulin and the doctor who managed his diabetes gave him specific instructions on how to monitor his blood sugar and administer insulin when needed. R902 reported the facility was not following the same regimen. R902 had his own personal glucose monitoring device in his room and reported he checked his own blood sugar levels in addition to the nurse. R902 said on the evening when his blood sugar was high, he was not able to receive additional insulin until 2:00 AM and then his blood sugar started to come down. R902 reviewed some notes he had and said the date of the event was 5/24/25 and he discussed his concerns with the Administrator. A review of R902's clinical record revealed R902 was admitted into the facility on 5/16/25 with diagnoses that included: type 2 diabetes. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R902 had intact cognition. A review of R902's Physician's Orders revealed the following orders: Insulin Aspart (fast acting insulin) 100 units/milliliter (ml) - inject 12 units subcutaneously four times a day (QID) Insulin Glargine (long acting insulin) 100 unit/ml - inject 16 units in the morning A one time order for Insulin Aspart ordered on 5/25/25 at 2:16 AM A review of R902's Medication Administration Record (MAR) for May 2025 revealed on 5/24/25 at 9:00 PM, R902's blood sugar was recorded as 420 mg/dl (milligrams per deciliter) by Licensed Practical Nurse (LPN) 'C', which indicated R902's blood sugar was very high. A review of R902's progress notes revealed a Skilled Charting progress note dated 5/25/25, written by LPN 'C' that read, .He had c/o (complained of) a high BS (blood sugar). Writer collected guest BS, results were 420, writer administered 12 units long-acting insulin as ordered. Writer notified on call HCP (Health Care Provider), after an hour no response. Writer recheck guest BS results were 412. Guest was insisting writer give him more insulin. Writer as well as the supervisor informed guest that the HCP was notified and we were waiting on a response. Writer and supervisor also explained that he was given a long-acting insulin and we could not just inject him with more because it could drop his sugar too low (R902's order for long acting insulin was for the morning). The supervisor than <sic> called the HCP, no answer. Writer rechecked guest BS at (1:24 AM) reading was 337. A review of a Skilled Charting progress note dated 5/25/25 at 2:21 AM revealed, On call HCP gave order for 6 units of Novolog (insulin aspart), recheck BS in 2 hours. It should be noted that that order was received five hours after R902 first notified the nurse of the high BS and it was recorded on the MAR as 420 mg/dl. A review of R902's care plan for diabetes mellitus revealed interventions initiated on 5/16/25 that read, Obtain blood sugar results, sliding scale as ordered by MD (physician). Notify MD of any abnormal results (It should be noted R902 did not have sliding scale insulin ordered) and Follow diabetic protocol as per MD order. Notify MD if any abnormals occur (It should be noted there were no specific parameters included in the physician's orders). On 6/4/25 at 3:16 PM, an interview was attempted with LPN 'C' via the telephone. However, LPN 'C was not available for interview prior to the end of the survey. On 6/4/25 at 3:20 PM, an interview was conducted with the Administrator. When queried about what R902 told him about his concerns regarding the way his high blood sugar was managed on 5/24/25, the Administrator denied R902 reported anything to him and said Unit Manager, Registered Nurse (RN) 'B' talked to R902 regarding his medications before. On 6/4/25 at 3:36 PM, an interview was conducted with RN 'C'. When queried about the process for addressing a resident's high blood sugar, when all ordered insulin had already been administered, RN 'C' reported the medical providers were typically very responsive and it would be expected that the nurse contacted the provider via the facility's text messaging system. RN 'C' reported there was always an on-call provider available after hours. When queried about what timeframe would be reasonable to wait for the provider to call back, RN 'C' reported about 30 minutes. When queried about what the nurse should do if the provider did not call back, RN 'C' reported they could always contact the provider again or contact another provider. RN 'C' denied having knowledge of R902's concern about his blood sugar management on the evening of 5/24/25. When queried about whether five hours was a reasonable amount of time to wait for the provider to call back, RN 'C' reported it was a long time, but he wasn't symptomatic. On 6/4/25 at 4:00 PM, an interview was conducted with the Director of Nursing (DON). When queried about what would be considered a timely response in regards to a physician calling back after being notified of a change in resident's condition, specifically, an elevated blood sugar that potentially needed to be treated with insulin, the DON stated, A half hour to an hour. When queried about the process for notifying the medical provider, the DON reported the facility had an on-call Nurse Practitioner (NP) after 7:00 PM and the attending physicians were included in the text messages that were sent out. When queried about the five hour delay in getting a hold of the medical provider when R902's blood sugar was high, the DON stated, They could have contacted the provider. A review of a facility policy titled, Nursing Care of the Resident with Diabetes Mellitus (undated) revealed, in part, the following, .Glucose Monitoring .Normal ranges are approximately 70-130 mg/dl before meals and (less than) 180 mg/dl after meals . A review of a facility policy titled, Acute Condition Changes - Clinical Protocol (undated) revealed, in part, the following, .The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status .The staff will notify the Medical Director for additional guidance and consultation if they do not receive a timely or appropriate response .

This citation pertains to Intake Number(s): MI00152206. Based on observation, interview, and record review, the facility failed to provide care according to the preference of the resident's legal decision maker for one (R901) of two residents reviewed for care planning and activities of daily living. Findings include: A review of a complaint submitted to the State Agency (SA) revealed an allegation that R901 was not getting two showers per week. On 6/4/25 at 9:10 AM, R901 was observed sitting up in bed. R901 appeared to have a language barrier, but seemed to understand some questions. When queried about when she received showers, R901 asked on which days was she was supposed to get them and said she thought Monday and Thursday. R901 was unable to clearly answer questions regarding showers and bathing. On 6/4/25 at 10:05 AM, an interview was conducted with R901's family member (FM), FM 'A'. FM 'A' reported they were the legal decision maker for R901 and they wanted R901 to get full showers at least two times a week and bed baths were not to be given in place of a shower. R901 reported on Monday, 6/2/25, R901 received a bed bath instead of a shower. R901 further explained they reported their concern to the Administrator and they arranged a time for FM 'A' to be present in the facility the following day, 6/3/25 at 2:00 PM to ensure R901 received a shower. FM 'A' reported they arrived at the facility at 2:00 PM and was informed R901 received a shower before lunch. FM 'A' reported the facility told her R901 refused showers at times, but FM 'A' told them to contact her so that she could attempt to communicate with R901 in her language to help convince her to shower, as she may not understand what the staff wanted to do. On 6/4/25, the Administrator was asked to provide any grievance/concern forms for R901 since March 2025. The Administrator reported he talked to R901's family on a daily basis and did not document all concerns on forms, but would provide evidence of other forms of communication. A review of copies of email conversation between FM 'A' and the facility provided by the Administrator revealed the following: On 6/2/25 at 7:48 PM, an email was sent to the Director of Nursing (DON) by FM 'A' and it read, Why is my grandma (R901) still getting bed baths? I was told she got a bed bath today by the nurse because you guys are short staffed! I don't know how much more clear I need to be that my grandma is to always get a full shower not bed baths for any circumstance or I need to be called. I am sick and tired of her not getting her full showers . The DON responded and said they would look into the concern. On 6/3/25 at 5:09 PM, an email was sent to the DON by FM 'A' and it read, .I have also spoke with the new u it <sic> manager and made it very clear to him that we want her to get full showers twice a week and no bed baths if there are any issues I'm always available to call or Face Time via her phone . A review of R901's clinical record revealed R901 was admitted into the facility on 7/5/24 and readmitted on [DATE] with diagnoses that included: End Stage Renal Disease (ESRD) and Parkinson's Disease. A review of R901's Minimum Data Set (MDS) assessment dated [DATE] revealed R901 had severely impaired cognition, was dependent on staff for showers and baths, and was not assessed for tub/shower transfers due to it being not applicable. A review of R901's Tasks (where the Certified Nursing Assistants - CNAs document the care they provided) revealed a task for Bathing/Showers: Monday and Friday AM Shift NO BED BATHS. The last documented shower for R901 was on 5/26/25. It was documented on 5/30/25 that R901 refused a shower. However, there was no further documentation of a shower after that date. According to R901's Monday and Friday schedule, R901 should have received a shower on 6/2/25. A review of R901's care plans revealed no intervention to specify R901 should receive full showers and not bed baths on their scheduled shower days. An intervention was initiated on 7/5/24 that read, Assist the pt (patient) with showers/bed baths. A review of a Skilled Charting progress note dated 5/30/25 at 2:00 PM revealed, Guest refused shower x 2. Unit manager and 2 CNAs present. Guest stated she got cleaned up in the morning and would take a shower on Monday. On 6/4/25 at 2:30 PM, an interview was conducted with the Administrator. When queried about how the facility ensured R901 received full showers instead of bed baths per the family's preference, the Administrator reported they initially switched the showers to be scheduled on days R901 did not go to dialysis and continued to educate staff. The Administrator reported the staff on R901's hallway were not always consistent so they offered a room change to a different hallway but FM 'A' refused. The Administrator reported the plan of care should be followed regardless of whether the staff think they are short of staff. The Administrator reported on 6/2/25, the CNA gave R901 a bed bath instead of a shower and CNA was provided with education. The Administrator stated, We try our best and if a shower cannot be given, a bed bath should always be offered. When queried about where showers were documented, the Administrator reported in the CNA Task. When queried about what happened on 6/3/25 with R901's shower, the Administrator reported they scheduled a time with the family so they could come to the facility when R901 received her shower, but the nurse had an opportunity to give her a shower and did it before the family got there. When queried about where that shower was documented, the Administrator did not offer a response. A review of an Employee Corrective Action form dated 6/2/25 revealed CNA 'D' received education regarding the following: .Guest received bed bath on 6/2 .Guest .is to have showers only as stated in the Kardex (CNA care guide) and shower schedule .

This citation pertains to Intake #: MI00150503. Based on observation, interview, and record review facility failed to investigate an incident of hot liquid spill (unknown resident) and failed to implement interventions/supervision related to falls for two (R801 and R803) of four residents reviewed for accidents resulting in a fall with major injury and hospitalization (R803); with potential for continued falls for R803. Findings include: A complaint received by the State Agency read in part, (R801- name omitted) had a fall and sustained a hip fracture. Complainant also states the (R801- name omitted) had a laceration on head .was found in the lunch area after fall. R801 R801 was admitted to the facility on [DATE] after a hospital stay from 11/4/24 to 11/10/24. R801 was living at home with their family member prior to admission to the hospital and was admitted to hospital after a fall. R801's admitting diagnoses included wedge compression of lumbar spine due to fall, mixed Alzheimer's disease and vascular dementia, mood disorder, anxiety, and history of mini strokes and falls. Based on the Minimum Data Set (MDS) assessment dated [DATE], the Brief Interview for Mental Status (BIMS) assessment was scored a 1/15, indicative of severe cognitive impairment (when manually added the assessment scores). Review of MDS assessment dated [DATE] did not reflect R801's fall history and their fracture prior to recent admission to facility. An interview with the complainant was completed on 3/13/25 at approximately 1:15 PM. During the interview the complainant reported that R801 sustained a left hip fracture after their fall in the facility lunchroom on 2/20/25 and they were transferred to the hospital, after their request. Staff were not going to send their mother to the hospital until they had insisted to transfer them. They added that their mother had multiple falls at the facility, in their room and in the dining room. They added that their mother kept trying to stand up; that facility knew that they were a fall risk. They added that there were no staff members watching their mother when they were in dining room and their mother had fallen in the dining room prior to this incident on 2/20/25. They reported that their mother was receiving hospice services during their stay at the facility. They also added that they started taking their mother to an adult day care facility on Fridays approximately 3 weeks prior to the transfer to the hospital and their mother was staying at the other facility for about 6 hours at a time. A follow up interview was completed with a family member was completed on 3/13/25 at approximately 1:45 PM. The family member reported that they visited their family member regularly at the facility. They added the residents would sit in the dining room after lunch and the facility staff were not monitoring them. They reported that in December (approximately before Christmas) they were in the lunchroom and a resident spilled coffee on themselves and they had to find a staff member and got assistance as there were no staff in the dining room. They identified the staff member as the therapist, who came and assisted the resident. (This incident was confirmed by a facility staff member). Review of R801's hospital records dated 2/20/25 revealed that they were admitted to the hospital after a fall at the facility and they were diagnosed with a closed and displaced fracture of the left femur and head injury to the left forehead. Review of R801's admission fall risk assessment dated [DATE] reveled a score of 16, indicative of high risk for falls. Review of R801's care plan revealed the following interventions that were initiated on 11/10/24 and read: Administer medications as ordered by physician; evaluate lab test and x-ray PRN (as needed); neuro-checks per protocol; reinforce the need to call for assistance; requires 1-person assist with transfers, non-ambulatory. It must be noted that R801 had significant cognitive deficits. R801 did not have any other resident specific fall prevention interventions in place based on their admission fall risk assessment, their diagnosis, cognitive and physical limitations with history of falls. Review of R801's hospital records (prior to admission to hospital) revealed a care management note dated 11/5/24. The note read patient currently has a sitter for safety .referral sent to (Skilled Nursing Facility name omitted) - will need 24-hour sitter for acceptance . Review of R801's physical and occupational therapy evaluation dated 11/8/24 revealed significant deficits with safety due severe cognitive impairment. Review of R801's Electronic Medical Record (EMR) revealed the nursing progress note dated 2/20/25 at 17:17 (5:17 PM) that read in part, CENA (Certified Nursing Assistant) approached the writer asking for assistance with change in elevation in the dining room. Writer entered the dining room and observed a staff member supporting guest .laceration noted to left temple, blood beginning to clot .left lower extremity (LLE) range of motion (ROM) impaired with decrease ROM noted .son arrived and requested guest to go to hospital. At that time multiple nurses notified the son (name omitted) that hospice would be sending someone to evaluate. Son insisting guest to go to hospital . Review of the fall care plan dated 2/20/25 included the intervention that read Activities to notify nursing when activity has ended and guest will be unattended in the dining room. A request was sent to facility administrator to provide all the incident and accident (I&A) reports for R801 from 11/10/24 to 2/20/25. Received I&As for the following dates: 11/24/24, 12/16/24, 1/2/25, 2/25/25, and 2/20/25. Review of I&A reports revealed that R801 had falls in the common area (s) on 12/16/24, 2/5/25 and 2/20/25. I&A dated 12/16/24 read, Guest was observed lying on her left side on the floor in front of her w/c (wheelchair) next to the couch in the common area outside of the north team room, it appears that the guest was trying to self-transfer from the w/c to the couch . I&A dated 2/5/25 read, Nurse was notified by activities aide that resident was on the floor in the dining room. She states that she did not see her fall. Resident observed on the floor in the dining room lying on her left side between the tables . I&A dated 2/20/25 read, CENA approached writer asking for assistance w/ (with) change in elevation in dining room. Writer entered dining room and noted staff member supporting guest who was positioned on buttock w/ legs stretch outward and flat. Wheelchair w/in reach and to the front/left of guest. Dining room chair to the right of guest . Review of the statement from the facility administrator dated 2/21/25 read, I was rounding the north side of the building just before 4pm on Thursday 2/20 and was walking through the dining room coming from the 700-hallway side and just finished talking to (name omitted) briefly. When walking through the dining room I saw a blur out of my peripheral and heard a thud. I turned and (R801's name omitted) was on the floor and her dining room chair was fallen over backwards. I went to her and kneeled down behind her and tried to prop her head up off the ground I called out for (CNA) A and LPN B- name omitted). Both came to the north dining room and assisted with getting (R801) back into the wheelchair. An interview with LPN B was completed on 3/14/25 at approximately 10:30 AM. LPN B was called to complete the assessment on R801 after their fall in the dining room on 2/20/25. LPN B reported that they recalled the incident and they were notified by the Certified Nursing Assistant (CNA) that R801 was on the floor in the North dining room and they completed the initial assessment. They were not assigned to the unit and they were notified of the fall and they did the assessment. An interview with CNA A was completed on 3/14/25 at approximately 12:20 PM. They reported that they had been working at the facility for 2 years. They were queried about R801's fall on 2/20/25. They reported that they remembered the incident. They reported that they were walking down the dining room and they heard someone calling. They observed R801 was on the floor in the dining room and the administrator was holding R801 in back. They went and notified LPN B and they had both assisted R801. R803 R803 was a long-term resident of the facility. R803 was originally admitted to the facility on [DATE]. R803's admitting diagnoses include dementia, stroke, visuo-spatial neglect after stroke, history of falls, mood disturbance and anxiety. Based on the Minimum Data Set (MDS) assessment dated [DATE] R803 had a BIMS score of 2/15, indicative of significant cognitive impairment. An initial observation was completed on 3/13/25 at approximately 3:05 PM. R803 was observed sitting in their wheelchair in the room. R803's bedside table was in front of their wheelchair. R803's call light was laying on their lap and the clip to secure call light was broken. R803 had their bed against the wall on the right side and had perimeter mattress. R803 was sitting in a regular wheelchair with a cushion. The wheelchair did not have any safety devices (anti-tip and dycem - nonslip sheet). The back of the wheelchair had rubber tips on both sides (which had to be removed to install the anti-tips). R803 was sitting on a cushion and there was no dycem visible on top or below the cushion on the corner. R803 was able to answer simple questions. Later that day a follow up observation approximately at 3:30 PM. R803 was observed sitting in their room in their wheelchair. Call light was on lap with broken clip. There were no anti-tips attached to their wheelchair. Follow-up observations were completed on 3/14/24. During an observation completed at approximately 7:30 AM, R803 was observed outside of their room in their wheelchair with a staff member. The staff member was assisting R803 to the dining room for breakfast. R803 was observed sitting in the same wheelchair. There were no anti-tips attached to the wheelchair. The call light was on their bed and the clip was broken. At approximately 7:50 AM, a staff member was assisting R803 with their breakfast in the dining room. At approximately 7:55 AM, staff member assisted R803 back to their room. R803 was sitting in their wheelchair in front of their bed facing the television on the wall. The call light (with a broken clip) was on R803's bed. R803's wheelchair did not have any anti-tips and there was no dycem on top of the cushion and they were not visible under the cushion on the corners. Review of R803's fall risk assessment dated [DATE] revealed a score of 16, indicative of high risk for falls. Review of R803's care plan revealed a fall care plan that included the following interventions: 2 PA (person assist) for transfers; non ambulatory; administer medications as ordered by physician; anti-tips applied to wheelchair (initiated on 4/3/24); dycem to wheelchair (initiated on 3/10/24); encourage and assist guest to common area/dining room for activities and meals, winged mattress for perimeter awareness, bed in low position etc. An interview was completed Licensed Practical Nurse (LPN) E on 3/14/25 at approximately 7:45 AM in the hallway where R803 was residing. LPN E was the nurse assigned to care for R803 during that shift. LPN E' was queried about the fall preventions interventions they had in place for R803 and where did they find the information. LPN E had their computer on wheels in the hallway and they had checked R803's Electronic Medical Record (EMR) and pulled up the orders for R803 and they reported that they would find the interventions under orders. They were notified that all interventions were not under physician orders and asked if they were able review the care plan for R803. They reviewed the EMR for a few seconds and reported that they did not how to review the care plans and they needed to check with someone and they had left the unit for a few minutes. At approximately 8 AM in the hallway, a follow-up interview was completed with LPN E. They were queried about R803's care plan and if they were able to check with anyone. They reported that they had checked and they pulled up the care plan for R803. They read the interventions listed under the care plan. They were asked if they could show the anti-tip bars and dycem on R803's wheelchair. LPN E reported that R803 got anxious and they were falling risk and that is why they had the device in the wheelchair. LPN E walked in the room and checked the wheelchair and stated it was supposed to be in the back of wheelchair and they were not sure. Throughout this time R803 was in the room by themselves with a call light with a broken clip was on their bed that was behind the wheelchair. LPN E stated that they needed to go check with someone and had left the room/unit. At approximately 8:10 AM, LPN E returned to the hallway with Regional Nurse Consultant (RC) C. LPN E reported to RC C that R803 did not have their anti-tips. RC C confirmed that there were no anti-tips to the wheelchair. RC C reported that R803 might have just received this wheelchair and they were notified that R803 had been sitting in the same wheelchair since yesterday and were notified of the observations. They were also notified of the concern with dycem and RC C was notified of the prior observations. RC C reported that R803 would get easily agitated and they needed the device (s) and they would follow-up. They were also notified of the dycem that was not in wheelchair. RC C was also notified of the broken call light clip and the call light that was not within reach, in the bed. They picked up the call light from bed and confirmed that it was broken and they would follow up. At approximately 8:50 AM (on 3/14/25) RC C came over and reported that they understood the concerns and they had changed R803's care plan to have anti-roll back and they had provided the dycem. An interview with Physical Therapist Assistant (PTA) D' was completed on 3/14/25 at approximately 10 AM. They were queried that if they recalled an incident that happened in the dining room when a family member of a resident had called to assist another resident who had spilled hot coffee. PTA D reported that they remembered the incident and it was a few months ago. They reported that this was a resident with cognitive deficits who had spilled coffee in the dining room. They were walking by and they were asked by another family member to assist. PTA D reported that they did not know the name or the room number for this resident. They added that the coffee was warm and they had spilled it on their thighs. They added that they took this (unknown) resident to the nurse and they believed it was the 400-hall nurse, but they were not able confirm. They also believed that this resident was no longer at the facility. They did not have any other specifics. An initial interview with the Director of nursing (DON) was completed on 3/14/25 at approximately 10:15 AM. During the interview there was another staff member in the room. They were queried about if they were aware of an incident where a resident had spilled hot coffee in the dining room. The DON reported that they did not recall any incident. They were notified that the incident was witnessed by a facility staff member, who assisted the resident. They were queried of their protocol for residents that have spilled hot beverages on them. The DON reported that their staff were expected to notify them any such incidents with any injures. They were not aware of any such incidents and they would check if they had any investigations. An interview Unite Manager (UM) F was completed on 3/14/25 at approximately 12 PM. UM F reported that they covered 3 units (500, 600 and 700 hallways). They were queried about their expectations/facility process for admission fall risk assessment and implementation of resident specific interventions for their new residents. UM F reported that upon admission the admitting nurse completed a fall risk assessment and implemented generic fall interventions for all new residents admitted to the facility. During their stay if residents had falls or there were any changes they added additional interventions. UM F was queried further if the initial interventions were resident specific based on their admission fall risk assessment i.e. would there be any additional resident specific fall prevention interventions implemented for a high-risk resident (s) that would be different from a moderate or a lower risk resident, they reported that their initial interventions were generic, the same for all their new residents. They did not provide any rationale on why they were not resident specific based on their assessments. UM F was queried about what generic interventions were ordered for their new residents. They checked the EMR and shared the following interventions: administer meds, evaluate labs and test x-rays, transfer status, neuro check per protocol, ambulation/transfer. They added that additional interventions were added after root cause analysis after an incident. UM F was queried about R801's (who was a high-risk for falls on admission, with diagnosis of fracture and severe cognitive impairment) fall preventions interventions upon admission to facility. They checked the EMR and reported that R801 had the generic interventions (as above) were ordered upon admission in addition to an intervention reinforce need to call for assistance. It must be noted that R801 had severe cognitive deficits and may not be able to call for assistance due to confusion. A follow up interview was completed with the DON on 3/14/24 at approximately 12:30 PM. The DON was queried about their staff expectations for fall risk assessments and implementation of interventions upon admission. The DON reported that admitting nurses were completing admission fall risk assessments and implemented standard interventions for residents who were at risk. They were queried if the fall preventions interventions were resident specific based on their admission risk assessment and they reported that admission interventions were only generic/standard regardless of their risk level and they added additional resident specific interventions were added as need based on root cause analysis if they had any incidents during their stay. The DON was queried about the purpose of the admission fall risk assessment if admission interventions were generic; not resident specific, they did not provide any explanation. The DON was queried about R801 who had a sitter in the hospital prior to discharge and why they did have any additional resident specific interventions. The DON reported that they were not aware R801 had a sitter at the hospital and usually their admissions team reviewed hospital documentation, not the clinical team. The DON was queried on what their expectations were to ensure all fall prevention intervention(s) were in place as ordered/recommended. They reported that the nurses, unit managers, and clinical leaders were supposed to check during their daily rounds.The DON was notified of concern related to R801's resident specific fall prevention interventions and R803's interventions that were not in place. They reported that they understood the concerns. A follow-up interview with RC C was completed on 3/14/25 at approximately 1 PM. RC C confirmed that their team was unaware of staff witnessed incident of an unknown resident who had spilled coffee in the dining room that was also witnessed by another family member. RC C was notified of the concerns with R801's fall prevention interventions that were not resident specific and R803's fall prevention interventions that were not in place. They reported that they understood the concerns and they would follow up. Review of facility provided document titled Accidents and Incidents - Investigating and Reporting with a revision date of 2011 (revised approximately [AGE] years ago) read in part, All accidents or incidents involving residents, employees, visitors, vendors, etc. occurring on our premises shall be investigated and reported to the administrator. The document did not address facility process on fall risk assessment on admission, implementation of resident specific meaningful interventions, and process to monitor the implemented interventions were in place.

This Citation pertains to intake MI00148469 Based on [observations/interviews/record review], the facility failed to protect the resident ' s (R402) right to be free from mental and physical abuse by staff (CNA B). Findings include: On 11/27/24 a complaint was submitted to the State Agency for alleged verbal and physical abuse to R402. On 2/12/25 at 9:42 AM, Family Member (FM) A was interviewed. FM A was asked about the alleged abuse that R402 had gone through. FM A reported that on 11/27/24 at around 5:30 AM, a Certified Nursing Assistant (CNA) B had hit R402 on the hand and degraded a demented resident when they called R404 Grumpy several times. FM A reported that the night before 11/26/24 they placed a camera in the room because there was suspicion of abuse. A review of the video camera footage revealed that CNA B entered R402's room told R402 Happy Birthday and proceeded to change and get them dressed for the day. CNA B started a brief change on R402 when CNA B was observed shoving R402's hand away and began calling R402 Grumpy. Throughout the video CNA B called R402 Grumpy and said Happy Birthday Grumpy. As the video continued R402 was pulling away from CNA B and CNA B made an intimidating gesture towards R402. A record review revealed that R402 was admitted to the facility on [DATE] with a medical diagnosis of dementia, major depressive disorder, and anxiety disorder and received hospice services. R402's Minimum data set (MDS) revealed R402's Brief Interview For Mental Status Score (BIMs) of three, indicating severe cognitive impairment. On 2/12/25 at 11:57 AM, an interview with the Administrator was conducted. The Administrator was asked what the outcome of the investigation for R402 was. The Administrator reported that cameras are not a part of corporate policy but we did educate CNA B on how to talk to individuals, on the company policy for abuse, peri care and, quality of care. The Administrator was asked if they were able to see the video footage and if so what were their thoughts on how the CNA interacted with R402. The Administrator reported that they did see the video footage and that was why CNA B was reeducated. There was no additional information provided by exit of the survey.

Based on observation, interview, and record review, the facility failed to safely assist with a transfer to the toilet, wheelchair, and bed, complete a thorough and timely investigation to determine the root cause of injuries and accidents, and implement effective interventions to prevent multiple falls for four (R9, R8, R25, and R35) of seven residents reviewed for accidents, resulting in R9 falling during a transfer to the toilet and sustaining a tibia fracture that required surgery, R25 sustaining a hematoma that required treatment in the hospital after being injured during a mechanical lift transfer and two additional hospitalization s regarding hoyer lift injuries, and R35 sustaining abrasions to the legs and face after falling. Findings include: Resident #9 (R9) On 9/9/24 at approximately 1:00 PM, R9 was observed sitting up in bed. An immobilizer brace was observed on R9's right leg which extended from the ankle to above the knee. When queried about what happened, R9 reported she fractured her tibia (shinbone) when being assisted onto the toilet. R9 reported Licensed Practical Nurse (LPN) 'B' assisted her in the bathroom. R9 reported she stood up by pushing up on the arm rests of the wheelchair, then grabbed the assist bars, and began to pivot to move onto the toilet, but started slipping. R9 further explained LPN 'B' then grabbed her under the arms but could not prevent her from falling. R9 stated, I felt so bad. I took her (LPN 'B') out. R9 reported she was transferred to the hospital expecting to get a cast and instead I ended up with three and a half hours of surgery. R9 reported she experienced a lot of pain since the fracture and had to keep her leg straight. When queried about whether LPN 'B' used a gait belt to assist with the transfer, R9 stated, I don't' think so. A review of R9's clinical record revealed R9 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Right tibia fracture (7/16/24). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R9 had intact cognition, was not assessed for toilet transfers, and was dependent on staff for transfers to chair from the bed/bed to chair with no history of falls. Review of a significant change MDS dated [DATE] had one sided impairment to the lower extremity, was dependent for transfers, toilet transfers were not attempted, and had recent orthopedic surgery to repair fractures. It was documented R9 did not have any falls since the last MDS assessment. A review of a progress note written by LPN 'B' on 7/10/24 at 10:58 AM revealed, During transfer to toilet guest right knee buckled. Guess assisted to floor by writer .ROM (range of motion) intact .Guest assisted back to bed . A review of a SBAR (Situation Background Appearance Review and Notify) Communication Form dated 7/10/24 revealed the physician ordered a STAT (right away) X-ray. On 9/10/24 at 7:48 AM, incident reports and any associated investigations for R9 were requested from the Administrator. A review of a Fall incident report for R9 dated 7/10/24 at 10:48 AM revealed, Writer assisted resident to toilet. During transfer guest right knee buckled. Writer assisted resident to floor. It was documented R9 reported her knee buckled and it was the first time that happened. It was documented ROM (range of motion) was intact with decrease in the RLE (right lower extremity). R9 was assisted back to bed by writer and orders for stat X-ray were obtained. R9's documented pain level was seven out of 10. There were no documented statements. In the notes section (which was explained to be the facility's investigation), the following was documented, Reviewed report that guest was being assisted to the toilet by nurse. Guest was at the time a 1pa (one personal physical assist) with transfers and non ambulatory. During the transfer the guest felt her knee buckle and she was lowered to the floor. She was assessed for pain and injury, pain noted in her leg, ROM within her normal limits .Physician ordered stat x-ray which came back positive for leg fracture. Guest was then sent to the hospital for further evaluation. Root cause determine to be that guest being transfer as ordered with 1pa and at this time her knees buckled from under her and she was lowered to the floor. Plan of care updated to have guest become a 2pa for transfers for safety. There was no additional information provided. On 9/11/24 at 11:02 AM, an interview was conducted with LPN 'B' regarding R9's fall on 7/10/24. LPN 'B' reported she was helping out and took R9 to the bathroom after putting her in the wheelchair. LPN 'B' reported R9 required assistance from one staff member for transfers. Once in the bathroom, LPN 'B' locked the wheelchair, R9 stood up and held on to the assist bars and LPN 'B' grabbed the back of her (R9's) pants to help her pivot to the toilet. LPN 'B' explained that while pivoting to the toilet, R9's leg gave out and she had to help lower the resident to the floor by grabbing her underneath the arm pits. LPN 'B reported she did not use a gait belt to assist with the toilet transfer. LPN 'B' reported she received education regarding properly transferring residents. When queried about how R9 got up from the floor, LPN 'B' reported a Certified Nursing Assistant (CNA) assisted her by lifting R9 from under her arms and putting her into the wheelchair. LPN 'B' said R9 was then transferred from the wheelchair to the bed by her arm pits and her pants. Further review of R9's progress notes revealed R9 was readmitted into the facility on [DATE] with a Closed fracture of right tibia. On 7/19/24, R9 was seen by a medical provider for uncontrolled pain and additional pain medication was added for breakthrough pain. A review of an OT (Occupational Therapy) Discharge Summary for dates of service 4/30/24 through 7/10/24 revealed on 6/29/24 R9 was evaluated as needing max pa (maximum physical assist) at parallel bar, max pa with increased difficulty to pivot feet for Pt (patient) will demo toilet transfer and hygiene with set up assist in bathroom. It was documented R9 was discharged from OT due to being transferred to the hospital on 7/10/24. On 9/11/24 at 12:26 PM, an interview was conducted with the Director of Nursing (DON) and Nurse Manager, Registered Nurse (RN) 'C'. When queried about the proper technique for transferring a resident who required maximum assistance from one person, no response was given. When queried about the facility's policy on the use of gait belts, the DON reported gait belts were not typically used unless therapy recommended it. When queried about what was done to look into R9's fall that occurred in the bathroom on 7/10/24, the DON reported that R9's leg buckled during a transfer and that the appropriate assistance was provided. When queried about whether residents should be transferred by holding on to the back of their pant and/or under their arm pits, no response was given. On 9/11/24 at 12:50 PM, an interview was conducted with the Director of Therapy who confirmed R9 was max assist for toilet transfers at the time of the fall on 7/10/24 based on the last documented assessment. When queried about the use of gait belts, the Director of Therapy reported that would have to be discussed with the facility staff, but from a therapy perspective a gait belt should always be used for safety for residents who require assistance with transfers. 34275 R25 A complaint was filed with the State Agency (SA) that alleged R25 was dropped during a Hoyer lift transfer and/or injured by the Hoyer lift on more than one occasion. Following each accident R25 had to go to the hospital due to pain and injury. On 9/9/24 at approximately 10:50 AM, R25 was observed lying in bed. The resident was alert and able to answer most questions asked. When asked about care provided in the facility and if they had had any falls and/or accidents, R25 reported that they had. R25 stated that a few weeks ago they fell from the Hoyer lift during a transfer and hit their head and had to go to the hospital. They also noted they had another incident just a few days prior to that incident involving the Hoyer lift. Also, they had another incident a few months ago. R25 noted that the girls were not using the chair and lift correctly. A review of R25's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: type II diabetes, morbid obesity and unspecified dementia. A review of the resident's Minimum Data Set (MDS) indicated the resident had a Brief Interview for Mental Status (BIMS) score of 8/15 (moderately cognitively impaired). Further review of the resident's record indicated the resident required a Hoyer lift for transfers. Continued review of R25's clinical/hospital records, revealed, in part, the following: 5/17/24 (12:05 AM)-Total Body Skin Assessment: .Skin Color .Normal .Temperature: Warm(normal) .Condition (normal) . 5/17/24(2:06 PM)-Skilled Charting: Noted an elevated bruised skin on the right lower leg of unknown origin, is tender and painful, informed NP (nurse practitioner) and got order for an x-ray . Authored by Nurse I. *It should be noted that there was no further assessment noted in the resident's clinical record pertaining to the unknown injury noted above. Further it was reported that Nurse I no longer works at the facility. 5/20/24-Skilled Charting : new order for Doxycycline 100 mg BID (twice per day) for cellulitis . 5/20/24-Skilled Charting: Writer spoke with guest regarding bruise on her right lower extremity(RLE). She stated her leg bumped into the mechanical lift during transfer to her chair last week. She reported this was accidental . 5/24/24-Skilled Charting: RLE (right lower extremity) swollen, warm to touch and redness with moderate pain 5/10 transfer guest to ER (emergency room ) for evaluation .transferred to (name redacted) Hospital . 5/24/24 (Hospital Records): ED (emergency department) .R25 presents with leg pain. It started a few days ago after an injury at her facility. Swelling continues to worsen which prompted her visit .swelling and hematoma noted to lower leg patient states several days ago, staff was attempting to use the Hoyer lift to move her out of bed when it swung around and hit her R (right) leg to the arm of the lift. She states then she had severe pain in her leg extending from her R ankle to her R thigh. She describes the pain in her leg as a burning sensation .Discharge Summary (6/3/24) .Injury of right lower leg .Hematoma of right lower leg . *It should be noted that the Hospital records included a photograph of R25's right lower leg that displayed a large black/purple bruise that appeared to be caused by trauma. 7/29/24 (Skilled Charting): During rounds it was brought to this writers attention that earlier today when staff was attempting to transfer the guest (R25) to the chair, during the transfer .while pulling her back the Hoyer titled, they had to bring down quickly to avoid a fall and, in the process, she bumped the top of her head, forehead, numbness to lower face and lips, pain in b/l (bilateral) ribs left more than right .Guest was sent out to (name redacted hospital) for further evaluation . 7/29/24 (Hospital Records): .ED (emergency department) .Chief Complaint: Head Injury .patient presents to the Emergency Center today .with reports of head injury .it is reported that the patient was being transferred from chair back to bed when a part of a Hoyer lift fell out and hit the left/top side of patient's head. The patient reports this occurred around 2 PM .and specifies that the bar that holds the bands from the lift struck the side of her face on the left .patient also mention that when she was being lifted, she was hit on the left arm . 8/8/24 (Skilled Charting): Guest being transferred from bed to wheelchair by the Hoyer with two aides assisting. During the transfer the Hoyer began to lean over causing guest to fall Doctors order to send guest out to ER for a cat scan of her head. Guest was complaining of head pain 8/10. 8/8/24 (Hospital Records): .Chief Complaint: FALL from Hoyer lift at (name redacted) Facility when being attempted to be lowered into a chair .hit head twice on large beam that lowers Hoyer, rates head pain 8/10 .left-sided headache and bilateral shoulder pain s/p (status post) being hit by a Hoyer lift around 11:00 AM today .she was being lowered into a chair by care staff .when became destabilized and impacted her head and shoulders bilaterally on the beam of the Hoyer lift .nose feels numb . On 9/10/24 at approximately 10:58 AM, a request was made for all Incident and Accident (IA) reports pertaining to R25 including but not limited to all documentation that accompanied the investigation. No IA was provided for the incident noted on 5/17/24 (injury of unknown origin). As for the IA for the incidents that occurred on 7/28/24 and 8/24/24 the following information was provided and reviewed: 7/29/24-IA: .Date: 7/29/24(2:00 PM) .Resident (R25) .Person Preparing Report (Nurse K) Nursing Description: While transferring guest into Hoyer with the assistance of other aides, the Hoyer hit guest in the head as they were bringing her down. CNA let writer know. Writer observed and assessed guest .Immediate Action Taken: Guest let writer know she had a headache and would like a pain pill .Notes (7/31/24): Reviewed report that guest was being transferred by three CNAs by Hoyer lift from her bed to chair. During the transfer, the Hoyer lift titled .In the process the Hoyer lift made contact with her head .Hoyer lift was checked and found to be in working condition .Hoyer lift can accommodate up to 600 lbs.(pounds) to be used for her transfer and coaching given to all parties involved . *It should be noted that no accompanying documents were provided for this IA. There was no indication in the IA document as to the staff involved in the transfer of R25 or interviews involving R25. On 9/11/24 at approximately 12:08 PM, an interview was conducted with Nurse K. When asked about the incident that occurred on 7/29/24 and the staff that were involved, Nurse K stated that they were not in the room when the accident occurred but recalled being told by a CNA that R25 hit her head on the Hoyer lift. Nurse K was not able to provide the name of any of the staff that were involved in the incident, including the name of the CNA who reported the incident to her. 8/8/24-IA: .Date: 8/8/24 (12:00 PM) .Resident (R25) .Incident Description: Guest was being transferred to the Hoyer from bed to chair when lift tipped over causing guest to fall on her broad chair. Guest also landed on top of one of the aides that was assisting with the transfer .Immediate Action Taken: .after reports of hitting head, she was sent to the hospital .450 lb. Hoyer removed from room, replaced with 600 lb. Hoyer .Level of Pain: 8 Notes: .Root cause determined to be that during transfer using the 450 lb. lift the lift malfunctioned and tipped causing the guest to fall into the back of the broad chair which then tipped over. The 450 lb. Hoyer lift is no longer safe for guest 450 lb. Hoyer lift was removed from use for guest and replaced with 600 lb. Hoyer . On 9/10/24 at approximately 2:34 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the incident that occurred on 5/17/24 and lack of any IAs. The DON reported that an IA was not completed and was not aware of the staff involved in the incident. The DON was then asked if there were any accompanying documents that would indicate who was involved in the incident that occurred on 7/29/24. The DON reported that they were not certain and did not believe there was any further investigation documentation. When asked about the incident that occurred on 8/8/24 the DON noted that they believed they had additional documentation to provide. The DON returned after the interview noted above with additional information. Again, the DON reported that an IA was not done for the incident on 5/17/24 and noted that the wording injury of unknown origin was written incorrectly by Nurse I . The DON did provide a half one-page document (dated 5/20/24) that they had authored that read: .On 5/17/24, nurse noted an elevated bruise on RLE (right lower extremity) that was tender and painful. Guest said she bumped it during a transfer to from bed to W/C by mistake on the transfer equipment. Guest could not remember exact date or time .she said it was sometime last week .Nurse assessed RLE .guest was diagnosed with RLE cellulitis which was treated with ABX (antibiotics) . It is inconclusive if the bruise is a result of a bump or from RLE cellulitis. The second document provided by the DON included a handwritten and signed statement by Nurse J. The statement read, in part, the following: On 8/8/24 I was taking care of R25 .I asked another co-worker to help me .we got the wheelchair positioned .We pushed the Hoyer under the bed and hooked up the Hoyer sling .we pushed the Hoyer under the bed and hooked up the Hoyer sling that was under her. We then proceed to move R25 toward the chair. We had to turn the Hoyer one time after we lifted her from the bed .Head was facing the window .my co-worker then continued to help position her over the wheelchair. My co-worker was at the top of the wheelchair. I was at the side operating the Hoyer and guiding it into the chair. R25 was halfway into the wheel and the wheelchair and Hoyer began to tip backward. The weight of guest and Hoyer tipping caused the wheelchair to tip as well . On 9/11/24 at approximately 11:35 AM, a phone interview was conducted with Nurse J. Nurse J reported that they had been employed by the facility for three years. When asked about the incident that occurred on 8/8/24, Nurse J reported that they were acting as a CNA on that day due to staffing and worked along with CNA G. They confirmed that when transferring the resident, the Hoyer started to tip over and then the wheelchair tipped over causing the resident to fall. When asked about the Hoyer that was used, Nurse J reported they just grabbed the first Hoyer that they saw. Nurse J noted that they must have used a lift applicable for 450 lbs. and indicated the resident's weight was under 450lbs. Nurse J was asked if there was any documentation in R25's chart that indicated a Hoyer lift that would accommodate resident up to 600 lbs. needed to be used during transfers. Nurse J responded that they were not aware at the time as to what Hoyer to use. On 9/11/24 at approximately 12:00 PM, an interview was conducted with CNA G. CNA G reported that at the facility for about six months. When asked as to the incident involving R25, they reported that they had worked with R25 just a few times and was assigned to the resident on 8/8/24 and was asked to assist Nurse J. CNA G stated that during the transfer something happened to the lift, and it tilted and so did the resident's chair. They indicated that the resident fell partially on them, and they were also injured. CNA G was asked about the Hoyer lift that was used. CNA G noted that they were not aware that they should have used a Hoyer lift that would accommodate residents up to 600lbs. Review of the facility policy titled, Safe Lifting and Movement of Residents (): Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniquest and devices to lift and move residents .Staff will document resident transferring and lifting needs in the care plan. Such assessments shall include .Residents size .Staff responsible for direct resident care will be trained in the use of .mechanical lifting devices .Mechanical lifts shall be made readily available and accessible to staff 24 hours a day .Maintenance shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order .all equipments design and use will meet or exceed guidelines and regulations concerning resident safety and use of restraints .Safe lifting and movement of residents is part of an overall facility employee health and safety program .provides training on safety, ergonomics and proper use of equipment . 49083 Resident #8 This citation pertains to Intake: MI00145995 A review of a complaint filed with the State Agency included an allegation that R8 was sliding down in their chair and staff pushed the resident without adjusting resident and caused leg pain. Clinical record review revealed R8 was admitted to the facility on [DATE] as a transfer from another Skilled Nursing Facility for Long Term Care. R8 has a medical history which includes, Parkinson's (disease that affects the nervous system), dementia, depression, absence of left leg above the knee, heart failure, diabetes with neuropathy (nerve damage), chronic kidney disease, and requires hemodialysis ( a procedure to externally remove waste from the body). R8 is verbal in native language, speaks limited English. The Brief Interview Mental Status (BIMS) dated 7/19/24 scored 4/15 indicating R8 has severe cognitive impairment. On 9/5/24 at 9:59 AM, a telephone interview was conducted with the complainant and stated that on 7/28/24 while on the phone (Facetime) with R8, they observed the staff were transferring R8 by pulling the reclining wheeled chair, her bottom was falling off and was screaming of leg pain. The complainant called the police, a report was made, and called 911 for R8 to be transported to the Emergency Department for evaluation. Progress Note dated 7/28/24 documented while the family was speaking to R8 in native language, R8 complained of 10/10 leg pain while being transferred via Hoyer lift to stretcher and required pain medication. 9/11/24 at 09:00 AM, an interview with the Nursing Home Administrator confirmed that two of the facility's Certified Nursing Assistants (CNA) were transporting R8 in the wheeled chair improperly. The NHA remarked there was video of the incident, but it has since been wiped out and unable to retrieve for review. The NHA confirmed the transfer was not dignified, the resident was being pulled, not pushed. The NHA, confirmed the family was on Facetime, translated for R8, which then lead to calling the Police. Family was concerned of leg trauma and was sent to the ED per family request for evaluation. An inquiry for medical documentation from ED Visit was requested, and the NHA was unable to provide the ED after visit summary. On 9/11/24 at 12:09 PM, an interview was conducted with CNA G. Per CNA G, R8 was in a reclining wheeled chair, and recalled R8 was slipping down into the chair and was then pulled up. CNA G indicated the chair is difficult to maneuver and while transporting, R8 started yelling of leg pain, was taken back to their room and informed the assigned nurse. Resident #35 A clinical record review revealed R35 was admitted to the facility on [DATE] with medical history of hypertension, respiratory failure, repeated falls, muscle weakness, malnutrition, sacral pressure ulcer, atrial fibrillation (abnormal heartbeat) and colon resection with colostomy placement (bag appliance attached to the outer abdomen to collect waste). A Brief Interview of Mental Status (BIMS) score revealed 1/15 indicating severe cognitive impairment. Record review revealed on 7/12/24 at 5:34 AM, R35 was found on the floor. A skin assessment discovered an abrasion on the left scalp. R35 indicated to nursing staff that they rolled out of the bed and hit their head hard on the floor. Root cause determined that R35 had poor cognition and safety awareness. Record review revealed on 7/24/24 at 2:20 AM, R35 was found lying on their right side on the floor, and the bed was elevated to its highest position. R35 sustained abrasion injuries to the right buttock, right knee, face, and left outer ankle. Root cause determined R35 raised the bed to highest position, has poor cognition and safety awareness, and rolled out of the bed. On 7/24/24, Plan of care was updated to include bolsters to the side of the mattress to prevent from rolling out of bed. Record review revealed on 8/25/24 at 1:00PM, R35 was observed laying on their left side on the floor. R35 had sustained trauma, redness and swelling to their left eye. Root cause determined poor cognition and safety awareness, restless when in room. Plan of care updated to include encouraging guest to be in common areas while awake and in chair. Record review revealed on 9/7/24 at 6:44 PM, R35 was observed on the floor and reported rolled out of bed. Root cause was determined R35 becomes restless if in bed to eat, has poor cognition, impulsive, and would benefit to eat in the dining room. Plan of care updated to include and encourage guest to go to dining room. On 9/9/24, Prior to morning care, R35 was observed lying in bed in the high position. R35 was observed asleep in the fetal position facing the wall, brief on, legs very thin, floor matt noted next to bed, tray table middle of room, oxygen delivered via nasal canula not on correctly and laying on top of forehead. On 9/10/24 at 10:14 AM, R35 was observed asleep, with television on. The tray table with three full beverages and television remote were observed in the middle of room out of reach for resident. On 9/10/24 at 11:28 AM, R35 was observed in wheelchair propelling out of room independently, repeating I am going to fall oxygen tubing was off and on the floor in room. Assigned Licensed Practical Nurse (LPN) M was observed assisting R35 and redirecting for lunch and encouraged R35 to go to dining room for lunch. R35 agreed and was wheeled to dining room. On 9/10/24 at 11:57 AM, R35 was observed in the dining room with one other resident at table both waiting for lunch to be served. R35 was observed calmly moving backward from the table and propelled self towards the middle of dining room. Moments later, Registered Nurse (RN) L was observed speaking with R35, then observed RN L wheeling R35 out of the dining area prior to meal delivery and opportunity to eat. On 9/10/24 at 12:08 PM, R35 was observed alone in the middle of the 300 hallway. After minutes of observation, RN L was observed walking toward R35 and overheard asking if they want to go watch the birds. On 9/10/24 at 12:40 PM, R35 was observed lying in bed assisted by CNA O eating a peanut butter sandwich and bacon. When inquired why R35 was not eating in the dining room, CNA O replied I don't know. LPN M was also inquired why R35 did not remain in the dining room for lunch. LPN M replied in a frustrated tone that R35 should not be eating in bed, should have remained in dining area but RN L Took Over and that is why R35 is eating in bed. 09/10/24 at 2:45 PM, an interview was conducted with the Director of Nursing (DON) who was aware R35 has had four episodes of being found on the floor since admission on 7/11/24. The DON acknowledged they have implemented interventions to prevent falls, but R35 continues to be found on the floor. When inquired what measures were being implemented, the DON stated more frequent brief changes and commented Activities was involved but if R35 wants to go back to bed, that is their choice. The DON referenced other possible interventions could involve Hospice & Palliative services, and further stated that gets complicated when a Guardian is involved.

Based on observation, interview, and record review, the facility failed to identify and treat new venous ulcers, ensure physician oversight, and accurately assess a change in skin condition for two (R21 and R12) of three residents reviewed for non-pressure skin conditions. Findings include: Resident #21 (R21) On 9/9/24 at 9:14 AM, R21 was observed seated in a wheelchair with her feet flat on the ground. R21's legs were very swollen. The right leg was observed unwrapped with no dressing and the skin was bright red and peeling. The sock on R21's right foot was stained with tan colored drainage and the top of the foot appeared swollen. R21's left leg was covered by her pant leg. There appeared to be a tight bandage near the ankle and the skin below it was bright red. R21's sock on the left foot was falling off and revealed her foot which was very swollen and red. On 9/9/24 at 11:18 AM, R21 was observed seated in a wheelchair with her feet flat on the ground. R21's left leg was observed wrapped with an elastic bandage that was visibly saturated with drainage and appeared tight at the bottom of the leg due to swelling. R21's sock on the right foot remained saturated with what appeared to be dried drainage and the sock on the left foot remained falling off of R21's foot. At 1:11 PM, R21 remained seated in a wheelchair with her feet on the ground with the bandage and socks in the same condition as documented above. On 9/9/24 at 1:30 PM, a review of R21's active physician's orders revealed R21 had an order to clean the bilateral lower extremities with soap and water, apply an antimicrobial dressing, where indicated, cover with a multi-layer compression bandage system used to venous leg ulcers, secure with a woven gauze dressing, and cover with an elastic skin protection sleeve. There were no physician's orders for any treatment to R21's feet. On 9/9/24 at 1:30 PM, a review of R21's Wound Evaluation assessments revealed R21 was evaluated on 9/5/24 and had a blister to the left lateral calf. In the picture of the left lateral calf, R21's right foot is visible which shows an open area to the top of the right foot. A review of a Total Body Skin assessment dated [DATE] revealed R21 did not have any new wounds identified. A review of a Physician Progress Note dated 9/9/24 at 8:36 AM revealed no documentation of wounds to R21's legs or feet. It was documented in the progress note that R21 had, .significant swelling both legs. Patient very noncompliant with elevating legs .+2-3 edema both legs .Patient is very noncompliant with elevating legs, and is also aware. Patient always refuses to elevate her legs . Further review of Physician Progress Notes revealed no documentation of any venous wounds to her legs or feet. On 9/9/24 at 3:36 PM, an observation of R21's legs and feet was conducted with Unit Manager, Licensed Practical Nurse (LPN) 'A'. LPN 'A' asked R21 if she could observe her legs and feet. R21 agreed, but asked that she not unwrap the bandage on the left leg. When LPN 'A' removed the sock from R21's left foot, five shallow, open areas, weeping with clear drainage were observed on the top of the foot. R21's left foot was very swollen on the top from the ankle to the toes. When LPN 'A' removed the sock from R21's right foot, she verbalized it was, wet. An open area, resembling a ruptured blister was observed to the top of the right foot and the foot was swollen, shiny, and red from the ankle to the toes. LPN 'A' reported R21 often refused care when queried about the lack of dressings on R21's right leg and bilateral feet. When asked to describe the areas identified on the tops of R21's feet, LPN 'A' did not offer a response and said she was going to have LPN 'D' (R21's assigned nurse) dress the wounds. On 9/9/24 at approximately 3:50 PM, LPN 'D' reported R21 refused to allow her to do wound care. When queried about the open areas to the tops of R21's bilateral feet, LPN 'D' reported R21 refused wound care that morning (9/9/24) and did not assess her feet that day. LPN 'D' explained that if new skin alterations were identified, they notified the physician and the Director of Nursing (DON). When queried about what was on the tops of R21's feet, LPN 'D' reported she was not qualified to assess the wounds and it would be deferred to the DON. On 9/9/24 at 4:20 PM, an interview with the DON was conducted. When queried about the facility's process when new wounds were identified on a resident, the DON reported nurses should document the wounds, notify the physician and family, and take a picture of the wound. The DON reported the facility did not employ a Wound Nurse and did not contract with an outside wound provider. The DON reported she was responsible to review the photos taken and sign off on the assessment of the wound and the attending physician provided oversight of wounds. At that time, an observation of R21's feet was conducted with the DON. When asked to describe the open areas to R21's bilateral feet, the DON said they must be new and did not give a description. When queried about where new skin impairments would be documented, the DON reported she would have to look into it but usually in the progress notes or the Wound Evaluation. Further review of R21's clinical record revealed R21 was admitted into the facility on [DATE] with diagnoses that included: congestive heart failure and peripheral vascular disease. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R21 had moderately impaired cognition, no behaviors including rejection of care, and had one venous ulcer. A review of a Wound Note dated 9/5/24 and written by LPN 'D revealed, Heels intact pink and blanchable with edema noted .Wound orders in and pics updated . There was no documentation in the progress note or the Wound Evaluation of the open area to the top of R21's right foot that was visible in the photo from the 9/5/24 Wound Evaluation of the left leg. A review of a progress note written by LPN 'D' on 9/9/24 at 8:33 AM revealed R21 refused to have her dressings changed. There was no documentation that R21 refused to have her pants and socks that were saturated with drainage changed. On 9/10/24 at approximately 10:00 AM, the DON and Regional Clinician, Registered Nurse (RN) 'E' followed up and reported R21 was seen by the physician on the morning on 9/9/24 and he did not document any new skin impairments. In addition, no skin impairments were documented on the skin assessment dated [DATE]. When queried about whether the physician physically assessed R21's skin, the DON reported sometimes R21 did not let him look at her skin. When queried about whether it should be documented if she refused a skin assessment, the DON reported the physician documented R21 was noncompliant about elevating her legs. The DON reported the open areas identified on the tops of R21's bilateral feet must have developed between the time she was seen by the physician at 8:33 AM and 3:36 PM when LPN 'A' removed the socks. There was no explanation given regarding the photo of R21's right foot in the 9/5/24 Wound Evaluation of the left leg. Further review of R21's clinical record at that time, revealed no documentation of R21 refusing to allow her saturated pants and socks to be changed or the physician evaluation of her skin. A review of facility policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol (focused on the physician's involvement in skin management) revealed, in part, the following, .During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or non-healing wounds . No other skin management policies were received. 49083 Resident #12 Clinical record review revealed R12 was admitted to the facility on [DATE] with medical diagnosis that included: hyperlipidemia, gastro-esophageal reflux disease (GERD), hypothyroidism, asthma, heart disease, and diabetes. R12 has anxiety, depression, bipolar, and dementia without behavioral disturbance. The Brief Interview for Mental Status assessed in July 2024 scored 12/15 indicating R12 has moderate cognitive impairment. On 9/9/24 at 1:47 PM, R12 was observed, neat, clean, well-groomed sitting in the Bistro area watching television. Upon initial interview, R12 was very pleasant and capable of holding conversation appropriately. After introductions, R12 was questioned if they had any concerns. R12 replied (in a frustrated tone) that for the past three weeks, they have been complaining of abdominal itching and groin irritation and needed an antifungal powder. R12 specifically mentioned the medication Nystatin (a medication used to treat fungal infections). R12 commented that the skin issue has happened before and that was the medication that was used. According to R12, they have told many nursing staff about the irritation, they did not do anything or look at it. R12 remarked there was conversation with a Doctor and the Doctor instructed R12 to tell the nurse and have the nurse call. During the end of the interview, R12 asked to be provided with Nystatin. On 9/11/24 at 10:08 AM, With permission from R12, a skin assessment observation was made with Registered Nurse (RN) F of R12's abdominal folds, and peri-area. Upon observation, the abdominal fold was raised and identified within the left mid medial area, multiple raised red, and white colored scaly patches. R12 admitted that the area is itchy, and that Nystatin Powder was needed. Upon further observation of the peri area, RN F wiped the area upon inspection and R12 stated Ouch! That hurts. The entire groin and peri-area was observed to be red indicating it was not a recent/new developed irritation. When asked a second time if the nursing staff was aware, R12 replied the exact answer as she disclosed on Monday 9/9/24. That the nurses were told, nothing has been done, and nobody has looked at it. R12 further commented again about how the Doctor was informed and the Doctor instructed to tell the nurses which R12 stated they told the nurse. RN F reviewed R12's medications after the skin observation and confirmed no orders were implemented for the skin and commented the Doctor will be contacted the findings from the observation. On 9/11/24 at 11:26 AM, an Interview with the Director of Nursing (DON) was completed, the DON was made aware of the skin observation with RN F and replied, This is the first I am hearing of any of this. On 9/11/24 at 12:54 PM, The DON commented that R12 was assessed by the Facility Nurse Practitioner and informed the DON all skin impairments were new. The DON further commented that R12 had episodes of impaired cognition and must not remember things .The DON further commented that R12 has a history of using Nystatin that's why R12 knew the name of the medication.

Based on observation, interview and record review the facility failed to ensure nursing staff correctly provided residents with their physician ordered medications for three (R25, R30 and R45) out of three residents reviewed for professional standards. Findings include: On 9/9/25 at approximately 10:33 AM, R30 was observed sitting in their wheelchair in their room. When asked about care provided in the facility, R30 reported that at times they do not receive their medication timely. On 9/9/24 at approximately 10:50 AM, R25 was observed lying in bed. The resident was alert and able to answer most questions asked. When asked about care provided in the facility, R25 reported that they had been dropped and hit by a Hoyer lift and indicated that they felt staffing needed additional training in certain areas. On 9/10/24 at approximately 10:58 AM, Incident and Accident (IAs) reports were requested for R25 and R30. The facility was asked to include all documentation that accompanied the investigation, including interviews with staff and residents. No IA's were provided for R30. IAs were provided for R25 that included a report dated 7/4/24. Review of the IA revealed, in part, the following: Medication Error .Date: 7/4/24 .Resident: R25 .Person Preparing Report: Nurse F .Incident Description: Writer administered wrong medication to guest, physician, DON (Director of Nursing) and guest notified. Immediate Action Taken: Nursing 1:1 education between writer and DON .Notes: Reviewed report that the nurse administered incorrect medication in error .Root cause determined to be that nurse was preparing medication for two guests at one time. Nurse was educated/coached on proper med pass processes . *It should be noted that the IA did not contain any documentation as to the other Guest/Resident, nor did it provide the name of the medication given in error. A record of R25's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: type II diabetes, morbid obesity and unspecified dementia. A review of the resident's Minimum Data Set (MDS) indicated the resident had a Brief Interview for Mental Status (BIMS) score of 8/15 (moderately impaired cognition). R25 did not have an order for Xanax. Continued review of R25's clinical record showed no notes that indicated the resident was given the wrong medication or that the resident was notified. On 9/11/24 at approximately 2:12 PM, an interview was conducted with Nurse F. Nurse F was asked about the incident that occurred on 7/4/24. Nurse F reported that they had worked a long shift and when it came time to pass medication, they mistakenly gave R25 medication that should have been given to another resident. Nurse F was not able to provide the name of the resident but noted their room number. Confirmation regarding rooms indicated the resident at issue was R30. When asked what type of medication was given, Nurse F reported that did not recall the exact name but believed it was an antianxiety medication. Review of Nurse Personnel record revealed a document titled, Employee Corrective Action. The document noted the following: Date: 7/6/24 Employee Name: Nurse F .Job Title: RN (registered nurse) .Describe situation and/or concerns: On 7/4 and 7/5 employee had med errors involving two different guests. Employee had prepared two guest medications at the same time and administered wrong meds to 1 guest. On 7/5 employee administered incorrect med and dose to 1 guest .Supervisor's signature: DON (Director of Nursing) . On 9/11/24 at approximately 2:35 PM, an interview was conducted with the DON. When asked about the medication errors involving Nurse F, the DON indicated they were aware of the incidents. The DON reported that on 7/4/24, Nurse 'F gave R25, R30's Xanax. The DON noted that when Nurse F knew that she had made the error, they went and gave R30 their ordered dose as well. As for the incident that occurred on or about 7/5/24, the DON indicated that they believed it involved R45 but was not able to provide an IA. The DON stated that they believed Nurse 'F gave R45 an extra dose of their ordered Ativan and failed to give them their ordered Trazadone. A review of R30's clinical record noted the resident was initially admitted to the facility on [DATE] with diagnoses that included: type 2 diabetes, major depressive disorder, adjustment disorder with mixed anxiety. A review of R30's MDS, noted a BIMS score of 15. R30 had an order for Xanax Tablet .25 MG (milligrams), give 1 tablet by mouth two times a day related to adjustment disorder with anxiety. A review of R45's clinical record noted the resident was initially admitted to the facility on [DATE] with diagnoses that included: acute respirator failure, type II diabetes and peripheral vascular disease. A review of R45's MDS, noted a BIMS score of 15/15 (cognitively intact cognition). R45 had an order for Lorazepam/Ativan give 1 MG (milligram) tablet by mouth two times per day related to anxiety disorder. A review of the facility policy titled, Adverse Consequences and Medication-Related Problems revealed, in part .Policy Statement: The facility evaluates medication usage to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions .the staff .shall strive to minimize adverse consequences by .Following relevant clinical guidelines and manufacturers specifications for use, dose, administration, duration, and monitoring of the medications .

This citation pertains to Intake MI00145482 Based on interview and record review, the facility failed to ensure controlled substances were stored in locked compartments in the 400-Hall. This deficiency had to ability to affect all residents with prescribed controlled substances residing on the 400-Hall. Findings include: A Facility Reported Incident (FRI) was filed with the State Agency that alleged in part, .there was a discrepancy with the count of a controlled substances . the 400-hall controlled count sheet was off for (room) 402 klonopin (a Schedule IV anti-anxiety medication). The count went from 25 to 22 with no signature accounting for its administration . The date of the occurrence was documented as 6/18/24. Review of facility provided nursing schedules for 6/18/24 and 6/19/24 revealed for the 400 Hall Licensed Practical Nurse (LPN) A had been the day shift (7:00 AM-7:00 PM) nurse on 6/18/24 and 6/19/24, Registered Nurse (RN) G and RN E had been the midnight shift (7:00 PM-7:00 AM) on 6/18/24, and LPN B had been the midnight shift nurse on 6/19/24. On 7/16/24 at 12:48 PM, RN E was interviewed by phone and asked about the controlled substances in the 400-Hall on 6/18/24. RN E explained that was the one and only shift she had worked at the facility . before her shift started, she was talking to the day shift nurse who told her the lock was broken on the controlled substance box and the Director of Nursing (DON) was aware and a work order had been put in . but all the controlled substances were still in the box, they were not moved to a box that would lock . she decided then she would just get through that 12-hour shift, but this facility was not the place for her. RN E was asked if she had given any controlled substances that night. RN E explained RN G did not let her remove any controlled substances, RN G would remove them then give the medication to her to give to the residents. On 7/16/24 at 1:17 PM, LPN A was interviewed and asked if the lock on the controlled medication box had been broken on 6/18/24 and/or 6/19/24. LPN A explained she knew it had been broken, but did not remember when. LPN A was asked if she had told RN E or RN G that the lock was broken. LPN A denied she had told either RN E or RN G the lock was broken. When asked if she had talked to RN E before RN G got there, LPN A explained she had chatted with RN E. On 7/16/24 at 1:57 PM, LPN B was interviewed by phone and asked if the controlled medication lock box had been broken when she worked on 6/19/24. LPN B explained she could not remember if it was broken or not. On 7/16/24 at 2:44 PM, the Maintenance Director was interviewed and asked if the lock on the controlled box had been reported as broken. The Maintenance Director explained he had replaced the lock on that box . The Maintenance Director was asked for the work order that had been put in for that lock. Review of a work order created by the DON on 6/20/24 at 5:00 AM read in part, .400 hall control cabinet lock is broke . The work order documented I replaced both of the locks on 6/20/24 at 3:50 PM. On 7/16/24 at 2:49 PM, RN G was interviewed by phone and asked if the lock on the controlled substance box was broken on 6/18/24. RN G explained she had gotten in report when she came on that the lock on the box was broken and that the DON had said to just keep an eye on the box. On 7/16/24 at 3:43 PM, the DON was interviewed and asked when she had been informed the lock on the controlled substance was broken in the 400 Hall. The DON explained she put in a work order when she heard about the lock being broken. The DON was asked where should the controlled substance medications be kept if the lock on the box was broken. The DON explained if the lock was broken, all the medications should be moved to a box that had a working lock. Review of a facility policy titled, Medication Storage In The Facility dated 9/1/23 read in part, .Schedule II-V controlled substances and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications .

This citation pertains to Intake MI00145482 Based on interview and record review the facility failed to prevent misappropriation of a controlled substance medication for one (R401) of three residents reviewed for misappropriation of resident property. Findings include: A Facility Reported Incident (FRI) was filed with the State Agency that alleged in part, .there was a discrepancy with the count of a controlled substances that belonged to the resident . the 400-hall controlled count sheet was off for (R401's) klonopin (a Schedule IV anti-anxiety medication). The count went from 25 to 22 with no signature accounting for its administration . Review of a facility policy titled Abuse, Neglect and/or Misappropriation of Resident Funds or Property revised 3/15/23 read in part, .Misappropriation means the deliberate misplacement, exploitation, or wrongful temporary or permanent user [sic] of a resident's belongings or money without the resident(s) consent . Review of the clinical record revealed R401 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: generalized anxiety disorder, dementia with behavioral disturbance and bipolar disorder. According to the Minimum Data Set (MDS) assessment dated [DATE], R401 had moderately impaired cognition and received anti-anxiety medications. Review of R401's physician orders revealed an order with a start date 5/13/24 for clonazepam (klonopin) 0.5 MG (milligrams), give 1 tablet by mouth at bedtime. Review of a Controlled Substance Proof-Of-Use Record (count sheet) for R401's clonazepam 0.5 MG revealed there were 29 tablets dispensed by the pharmacy on 6/11/24. One tablet was removed on 6/14 at 8:00 PM for a count of 28 tablets. One tablet was removed on 6/15/24 at 9:00 PM for a count of 27 tablets. One tablet was removed on 6/16/24 at 9:00 PM for a count of 26 tablets. One tablet was removed on 6/17 at 9:00 PM for a count of 25 tablets. One tablet was removed on 6/18 at 9:30 PM for an unknown amount of tablets. The next line on the count sheet was dated 6/19 at 7:17 PM had actual count written twice then had 22 circled with two initials next to it. There was no documentation on how the number of tablets remaining went from 25 to 22 with only one line in between. Further review of the count sheet for R401's clonazepam 0.5 MG revealed on 6/18/24 the amount of tablets remaining difficult to verify as a possible 22 appeared to have been written over another number that could not be deciphered. On 7/16/24 at 1:17 PM, Licensed Practical Nurse (LPN) A was interviewed and asked about R401's clonazepam count sheet. LPN A explained she had been R401's assigned day shift nurse on 6/18/24 and 6/19/24 and had counted the controlled substances with the midnight shift nurse, Registered Nurse (RN) G at the end of her shift on 6/18/24 and the count was correct . then when she came in the next morning and counted with RN G, she had the blister pack with the tablets in it and RN G had the count sheet . RN G read there were 22 tablets and that is what was in the blister pack . then when she counted at the end of her shift on 6/19/24 with LPN B she had the count sheet and could not make out the number of tablets remaining, there should have been 24, but there were 22 in the blister pack. When asked why she had not noticed the discrepancy during her 12 hour sift, LPN A explained she never gave any of the medication as R401 only gets the clonazepam at night. On 7/16/24 at 1:57 AM, LPN B was interviewed by phone and asked about R401's clonazepam count sheet. LPN B explained when she and LPN A were counting the controlled substances at the beginning of her midnight shift on 6/19/24, LPN A said she could not read the number on the sheet, so she looked at it, and could not read it either and wrote the actual count of tablets remaining on the count sheet and she and LPN A signed their initials on the sheet and notified the Director of Nursing (DON). On 7/16/24 at 2:49 PM, RN G was interviewed by phone and asked about R401's clonazepam count sheet. RN G explained she had not noticed the number was off when she gave R401 the tablet, she just wrote the number down . she did not notice the count was off until she and LPN A were counting the medications RN G was asked what she did when she saw the count was off from the count sheet. RN G explained she had told LPN A to report it to the DON, but she had not stayed because she was going on vacation. Review of a 6 Panel urine drug test that had been performed for RN G on 6/21/24 at 10:11 AM revealed the 6 Panel test did not include testing for benzodiazepine (drug classification of clonazepam). Review of the facility's FRI investigation of R401's missing clonazepam revealed the investigation was inconclusive as to who diverted R401's medication, however, it was concluded there were two clonazepam tablets that were unaccounted for. On 7/16/24 at 3:43 PM, the Administrator and DON were interviewed and asked why the urine drug test ordered for RN G did not test for benzodiazepine. The Administrator explained somehow the test had not been ordered correctly. The Administrator was asked if there was any further investigations or documents related to R401's missing clonazepam. No additional information was provided before the end of the survey. Review of a facility policy titled, Medication Storage In The Facility dated 9/1/23 read in part, .A controlled substance count sheet is prepared by (Contracted Pharmacy) or the facility for all Schedule II-V medications . At each shift change or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed nurses and is documented .

This citation pertains to Intake Number(s): MI00143710. Based on observation, interview, and record review, the facility failed to identify and treat a wrist fracture in a timely manner for one (R701) of three residents reviewed for changes in condition. Findings include: A review of a complaint submitted to the State Agency revealed allegations that R701 fell and the facility did not seek timely treatment afterwards. On 4/15/24 at 11:35 AM, R701 was observed lying on his back, sleeping. A cast was observed on R701's left arm. On 4/15/24 at 2:00 PM, an interview was conducted with R701. When queried about what happened to his left arm, R701 stated, I fell . When asked it was painful, R701 reported he experienced pain when he did not take pain medication. A review of R701's clinical record revealed R701 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: a fracture of the left wrist and hand (dated 4/10/24) and a displaced fracture of the left ulna (the long bone in the forearm) (dated 4/10/23). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R701 had moderately impaired cognition, a pain level of three (out of 10 with 10 being the most severe pain), and no history of falls. A review of a Skilled Charting progress note dated 2/6/24 revealed R701 fell from the bed. A review of a Physician Note dated 2/7/24 revealed R701 was forgetful and does not recall multiple falls. A review of a eMAR (Electronic Medication Administration Record) note revealed R701 received two tablets of acetaminophen after he complained of pain to the left upper extremity. A review of a Facility Reported Incident (FRI) submitted to the State Agency by the facility for R701 revealed on 2/24/24 at 12:38 PM, R701 alleged he was abused over night during his care (on the midnight shift of 2/23/24. A review of the Investigation Summary revealed R701 told the Administrator he was hit and fell to the floor hurting his wrist. A review of a written and signed statement by Licensed Practical Nurse (LPN) 'B' revealed, Guest told aide he was picked up and slammed by a tall big guy the night before and that his arm hurt. I went into room to assess guest and some swelling was present to his left lower arm but no bruising. When asked what happened, patient states he stood up and a guy pulled him down by his arms back into the bed. Patient was unable to give any other details. A review of a statement given by Certified Nursing Assistant (CNA) 'H' on 2/24/24 revealed R701 told her he got his ass beat last night. By some tall guy . A review of a Physician Note dated 2/25/24, written by Physician 'D', revealed R701 had left wrist bruising and swelling. It was documented R701 did not recall any trauma or injury. However, it should be noted that the previous physician evaluation on 2/7/24 revealed documentation that R701 was forgetful and did not recall a fall he had the day prior. The 2/25/24 note revealed, Large bruise on the left hand/wrist dorsal (back) side noted with edema (swelling) but no tenderness. Range of motion of the left wrist is normal and no pain with deep palpation or range of motion. Unclear etiology, patient does not recall trauma or injury but cannot rule out patient bumping his hand into the bed railing or furniture leading to possible small hematoma and bruising. Clinically do not suspect fracture and do not think patient needs x-ray, continue monitors closely . There was no documentation in that note that indicated the physician was aware that R701 made an allegation of physical abuse or that he may have fell . A review of a Skilled Charting progress note dated 3/9/24 revealed R701 was observed on the floor during breakfast. The following was documented, Left wrist appears to be swollen, guest states it was from him falling previously. No new orders. A review of a Skilled Charting progress note dated 3/10/24 revealed R701 fell in his room. There was no documentation of the appearance of R701's left wrist. A review of a Skilled Charting progress note dated 3/30/24 revealed R701 complained of pain to his left wrist which was five out of 10 pain level. R701 requested Motrin instead of Tylenol. It was documented by the nurse that Wrist is visibly swollen. Guest denies injury to wrist. On call physician notified. New order received for Motrin . A review of a Physician Progress Note dated 4/1/24 revealed the following, Patient is complaining of left wrist pain, denies any recent fall/trauma or injury (It should be noted that R701 had three previous falls prior to that date and made an allegation of abuse). On exam swelling the left wrist noted but no bruising or signs of trauma noted. Unclear etiology but most probably osteoarthritis .Will do X-ray of the left wrist but clinically do not suspect fracture . A review of a Skilled Charting progress note dated 4/2/24 revealed R701 had an X-ray done for his left wrist on 4/1/24 which was positive for a radial fracture (wrist). R701 was sent to the hospital. A review of R701's hospital records revealed the following: An ED (Emergency Department) Note dated 4/2/24 documented, .presents to the Emergency Center today for evaluation after a fall. Patient reports he fell a few days ago and landed on his left wrist .He currently has left wrist pain .He has an obvious deformity and edema to the left wrist .No ecchymosis to left forearm or wrist .Left wrist and forearms x-rays .IMPRESSION: Comminuted (broken into multiple fragments), impacted (when the bone gets compressed or squashed causing the broken ends to push into each other), and angulated (a specific type of fracture where the normal axis of the bone has been altered, causing the distal portion of the bone to point off in a different direction. It is usually caused by landing on the bone at an angle after a fall or being hit suddenly from an angle) fracture distal radius .Displaced fracture ulnar styloid (injury involving the end of the bony part of the wrist) .Multiple attempts to reach ECF (extended care facility) unsuccessful, did reach receptionist once but was unable to speak with nursing/care staff. Spoke with pt's (patient's) son who states he saw pt on Saturday (3/30/24) noted wrist deformity and was told by nurse who reviewed records last fall was March 10th, son noted wrist was deformed with no bruising or redness . A History and Physical evaluation noted, .patient was found to have a left wrist fracture .insist that he does not have any fracture patient has dementia and is poor historian .: Further review of R701's clinical record revealed he was readmitted into the facility on [DATE]. The Admission Summary noted, .Guest has c/o (complained of) pain being a 10 on a scale of 0-10 in his wrist. Guest describes the pain as sharp and the pain is constant. Guest states that moving his wrist makes it worse and resting and ice helps it feel better . A review of R701's physician orders and MAR revealed he had an order for hydrocodone-acetaminophen (a narcotic pain medication used to relieve moderate to severe pain) 5-325 milligrams every 6 hours as needed which was started on 4/10/24. R701 received the pain medication one time on 4/11/24, 4/12/24, 4/13/24, and 4/15/24 and two times on 4/14/25 with pain levels between three and eight. On 4/15/24 at 1:34 PM, a telephone interview was conducted with LPN 'B'. When queried about what happened with R701 on 2/24/24, LPN 'B' reported that the day shift CNA said R701 alleged a big guy kicked my ass last night. When LPN 'B' assessed R701, he complained of pain to his left wrist which originally did not have any bruising but explained by the following day He definitely had bruising and swelling, but I wasn't his nurse that day. On 4/15/24 at 1:38 PM, a telephone interview was conducted with R701's family member who reported on 3/30/24 he visited R701 and immediately noticed his right forearm was deformed and swollen. When R701's family member asked R701 what happened, R701 said he fell and he thought his wrist was broken. R701's family member addressed the issue with the assigned nurse who went to the room to assess R701's arm. At that time, R701 told the nurse that his arm hurt. The nurse reviewed R701's clinical record and told R701's family member that R701 fell , but it was on 3/10/24 which would have been 20 days earlier. When R701 inquired about whether an X-ray was done, the nurse told him he had to talk to Administration who was not available that day. R701's family member explained that R701 was discovered to have a wrist fracture and the ER doctor was concerned that the injury appeared to have gone on for a significant amount of time. On 4/15/24 at 2:40 PM, a telephone interview was conducted with LPN 'C', the nurse who was assigned to R701 on 3/30/24 when R701's family member was visiting. When queried about what occurred with R701's wrist on 3/30/24, LPN 'C' reported R701 complained of pain in his wrist and R701's family member reported pain to her. LPN 'C reported she contacted the physician and reported that R701's wrist was swollen and painful and the physician changed R701's Tylenol order to Motrin per the resident's request, but did not order an X-ray. On 4/15/24 at 3:26 PM, a telephone interview was conducted with Physician 'D'. Physician 'D' was familiar with R701. When queried about whether he was aware of R701's falls that occurred on 2/6/24, 3/9/24, and 3/10/24 and that R701 made an allegation of abuse on 2/24/24, the day before he documented bruising and swelling to R701's wrist, Physician 'D' reported he did not remember the abuse allegation and knew that he had multiple falls. When queried about why no X-ray was done to rule out a fracture when there was bruising, swelling, and deformity (according to the hospital records), Physician 'D' reported there was swelling, but no bruising, and he could not produce any palpable pain. Physician 'D' reported he was surprised R701's wrist was fractured when he received the results on 4/2/24 because he has never seen a fracture that did not produce some kind of pain. On 4/15/24 at approximately 3:45 PM, an interview was conducted with the Director of Nursing (DON) who reported she was aware of R701's wrist being swollen, his falls, and the allegation of abuse. When queried about the lack of X-ray completed, the DON reported they followed the physician's orders and he did not think R701 needed an X-ray. A review of a facility policy titled, Acute Condition Changes - Clinical Protocol revealed, in part, the following: .Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician .The nursing staff will contact the Physician based on the urgency of the situation .The Nurse and Physician will discuss and evaluate the situation .The Physician should ask questions to clarify the situation .The nursing staff and physician will discuss possible causes of the condition change based on factors including resident history, current symptoms, medication regimen, and existing test results .If necessary, the Physician will order diagnostic tests or evaluate the resident directly .The Physician will help identify and authorize appropriate treatments .

Based on observation, interview and record review the facility failed to ensure appropriate interventions and treatments were in place to prevent the development/worsening of a heel ulcer for one resident (R38) of three residents reviewed for pressure ulcers, resulting in R38 obtaining a stage 3 pressure ulcer on their right heel. Findings include: On 8/1/23 at approximately 10:07 a.m., R38 was observed up in a geriatric chair (medical reclining chair) No heel protector boots were observed to be on R38's right heel. On 8/1/23 the medical record for R38 was reviewed and revealed the following: R38 was initially admitted to the facility on [DATE] and had diagnoses including CVA (stroke) and Hypertension. A review of R38's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/11/23 revealed R38 was dependent on staff for most of their activities of daily living. R38's BIMS score (brief interview for mental status) was four indicating severely impaired cognition. A Physician progress note dated 7/24/23 revealed the following: Assessment/plan:.Cellulitis of left lower leg/foot .Patient has wound to the left heel which is declining/worsening slowly now has surrounding erythema (redness) with foul smell to it possible cellulitis (infection). Start patient on Keflex 500 mg (milligrams) four times a day for 10 days and monitor. Pressure ulcer left heel unstageable (pressure wounds are staged from one to four, stage four being the worst wound involving all layers of skin/fat/muscle)-Patient has left heel pressure ulcer unstageable (wound bed cannot be staged due to unviable tissue covering the wound bed) has slough at base, also surrounding erythema and cellulitis. Patient is at high risk for worsening wounds and nonhealing because of poor nutritional status and patient's overall decline. Continue local wound care, try to keep pressure off the heels and floaters . A wound note dated 7/27/23 revealed the following: Guest skin assessment completed. Guest has breakdown/open areas on both heels . TX (treatment) completed for Bilateral Heels. Guest also has a red area on her L (left) rear thigh. Chamosyn applied. Braden score 14. All bony prominences free of skin breakdown. Denies pain. Will continue with current plan or care. A second wound note dated 7/27/23 revealed the following: Writer noted open area on Guest R (right) Heel. Writer cleaned open area with NS (normal saline), applied santyl (ointment used to remove nonviable skin) and a ABD (abdominal) pad. Also wrapped the R (right) Heel in kerlix. Guest son notified, MD (Medical Doctor) notified, Don (Director of Nursing) notified. A skin & wound evaluation dated 7/27/23 revealed the following description of R38's right heel pressure ulcer: Type-Pressure .Stage-Stage 3 (damage extends through all layers of skin, into the muscle): Full-thickness skin loss .Acquired-In-House Acquired .Staged by-In-house nursing .Wound measurements-Area-1.3 cm. Length-1.5 cm. Width-1.2 cm .Wound bed-[Not indicated] .Exudate-[Not indicated] .Periwound-Edges: Attached: Edge appears flush with wound bed or as a sloping edge .Surrounding Tissue-Dark reddish brown. Fragile: Skin that is at risk for breakdown .Treatment: Cleansing Solution-Normal Saline . Debridement-Biologic .Secondary Dressing-Dry .Additional Care-Heel Suspension/Protection device .Progress: New . A review of R38's Physician orders for the treatment of R38's right heel wound identified on 7/27/23 revealed no treatment orders for their Right heel were put into place until 8/1/23 which indicated the following: Right heel: cleanse with normal saline, apply skin prep and leave OTA (open to air) No Physician order was noted in the order history that pertained to the Santyl and ABD pad indicated on the Nursing note dated 7/27/23. A review of R38's July and August 2023 Treatment Administration Record (TAR) and Medication Administration Record (MAR) revealed no treatments were provided to R38's open area on their right heel in July and the first treatment that was completed on the right heel was not until 8/1/23. No documentation of administration that the Santyl and ABD pad treatment indicated on the Nursing note dated 7/27/23 were present in the administration record. Further review of R38's Physician ordered interventions to prevent breakdown of R38's heels revealed no orders for heel protectors until 8/1/23 which revealed the following order Foam heel protectors as tolerated. A review of R38's comprehensive plan of care revealed the following: Focus-The resident has actual impairment to skin integrity r/t (related to) fragile skin, incontinent of bowel & bladder w (with) incontinent products, uses hoyer lift, fragile skin r/t age and terminal condition, DTI (deep tissue injury) to Left Heel, R heel IAD (incontinence associated dermatitis) to Right thigh -Terminal Dx (diagnosis):late effects of cerebrovascular dse (disease) on Hospice Date Initiated: 09/29/2022 Revision on: 07/28/2023 .Interventions-Heel boots while in bed & geri-chair as tolerated. Date Initiated: 08/01/2023 . On 8/2/23 at approximately 1:23 p.m., during a conversation with Medical Director/Physician C (MD C), MD C was queried regarding the identification of R38's wound on the right heel on 7/27/23. MD C reviewed the record and reported that the order for treatment was to be Santyl QD (every day) at that time MD C was informed that their were no Physician orders in place to treat R38's right heel wound until 8/1/23 and they indicated that orders should have been implemented when the wound was found for treatment every day. MD C was queried regarding the preventative interventions to prevent heel breakdown since R38 already had a skin impairment on their left heel and they indicated that boots should be worn. MD C was informed that no orders for foam protectors had been implemented until 8/1/23 and they reported that they should have had them on before that. On 8/02/23 at approximately 2:30 p.m., Nurse O was queried pertaining to the identification of R38's right heel wound on 7/27/23 and the subsequent orders for treatment. Nurse O reported that they had called the on call provider and got the order for the Santyl dressing. Nurse O was queired regarding the lack of Physician orders for the Santyl dressing and they indicated that they must have forgot to put it in. They indicated they have been busy and that they were gone for a few days. Nurse O was queried regarding the process to ensure wound care orders are implemented and they reported that they should have put in the Physician's order at the time it was found and that the facility did not have a wound care doctor or wound care nurse to follow up on orders and new wounds. On 08/03/23 at approximately 10:29 a.m., during a conversation with Nurse Manager B (NM B), NM B was queried regarding the pressure relieving interventions for R38's heels. NM B indicated they thought R38 had heel protectors on them and an Alternating pressure mattress. At that time, NM B was queried for documentation of heel protectors and they indicated they did not have any orders for them prior to 8/1/23. NM B indicated that R38 should have had the Physician's order for the heel protectors prior to 8/1/23. NM B was queired regarding the lack of administration of R38's Right heel pressure ulcer until 8/1/23 and they indicated that Nurse O should have put the orders in place when the wound was identified. On 8/03/23 at approximately 11:43 a.m., R38's right heel wound was observed to have the following description. R38's right heel wound was an open wound approximately nickel sized with a dime size gray wound bed noted with surrounding skin appeared ok, with the exception of approximately 2 centimeters of gray/white (nonviable) skin being observed. R38's Wound bed could not be visualized, due to gray dime sized area noted in the center of the wound. On 8/3/23 a facility document titled Pressure Ulcers/Skin Breakdown-Clinical Protocol was reviewed and revealed the following: Assessment and Recognition-The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition, the nurse shall assess and document/report the following .b.Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .f. Current treatments, including support .Treatment/Management-The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents .

This citation pertains to intake MI 039. Based on interview and record review the facility failed to consistently investigate the root cause analysis of falls for one (R#601) of three residents reviewed for accidents, resulting in multiple falls, failure to consistently implement and/or modify interventions, which required hospitalization for an acute cervical sprain; [MEDICATION NAME] head trauma; closed traumatic displaced fracture of distal end of left radius and a laceration of forehead (requiring stitches). Findings include: A complaint submitted to the State Agency documented a concern regarding multiple falls and an injury. A review of the clinical record revealed the following: R#601 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3 (indicating severely impaired cognition) and required assistance for all activities of daily living. The DPOA documents were reviewed and documented in part, My patient advocate or successor patient advocate shall have power to make care, custody, and medical treatment decisions for me if my attending physician and another physician or licensed psychologist determine I am unable to participate in medical treatment decisions . The document was signed 8/22/14. The DON typed statement documented in part, . 8/8/20 (R#601 name redacted) deemed incompetent . On 8/8/20 the DPOA became effective, indicating resident was her own decision maker until that date. A Nursing note dated 4/24/20 at 6:56 am, documented in part . Guest observed by the staff on the floor between her wheelchair & table @ (at) 0550am, per guest statement, she just used the bathroom. Guest was assisted back in bed by the staff, She had an abrasion on her forehead, cleansed with NS (normal saline) & cold compress applied . denies pain as of the moment. She was last observed by the nurse & staff about 0530am resting comfortably in her bed. MD (medical doctor) & Family notified. Care plan will be updated, will continue to monitor. A facility fall incident report dated 4/24/20 at 6:50 am, documented in part, . Nursing Description: Guest was observed by the staff on the floor between her wheelchair & table @ (at) 0550am, per guest statement, she just used the bathroom. She was last observed by the nurse & staff about 0530am resting comfortably in her bed, she denies <sic> needs at that time. Last toileted approximately 0400. Non-skid footwear on, using walker. Resident Description: Guest statement: She just used the bathroom and fell on returning to her bed . Guest was assisted back to bed by the staff, after she was assessed for injuries & pain. VS (vital signs) were taken, + shallow abrasion on forehead, cleansed with NS (normal saline) and cold compress applied, neuro checks initiated. MD (medical doctor) & Family notified. Immediate intervention: requested UA (Urinalysis) . Injury Type - Abrasion . Injury Location - Top of Scalp . Mental Status- Oriented to person (is checked off) . Predisposing Physiological Factors - Drowsy, Gait Imbalance, Impaired Memory . Predisposing Situation Factors - Ambulating without Assist . Predisposing Situation Factors - Using Walker . No Witnesses found . R#601 was identified to only be oriented to person, with impaired memory. An Investigative Summary note documented by the Director of Nursing (DON) on 4/27/20 at 2:34 pm, documented in part . IDT reviewed incident and care plan. Guest had UA (urinalysis) completed r/t suspected UTI (urinary tract infection) causing urgency and frequency. UA was negative. Will continue other interventions per care plan. Guest is resistive to therapy services, guest, and daughter decline restorative. Due to Covid restrictions we are unable to encourage guest to eat in the dining room or spend time in common areas. Guest with no s/s (signs/symptoms) acute injury post incident. The IDT team failed to implement and/or modify the resident interventions to prevent further falls. A care plan titled Risk for fall r/t (related to) Cardiovascular diagnosis, History of falls, [MEDICAL CONDITIONS], weakness, nerve pain to lower back, [DIAGNOSES REDACTED], routine use of narcotic [MEDICATION NAME], Overactive bladder. Prefers to not call for assistance, prefers to be independent. Guest will get up unassisted without using her call light. Guest will also tell her daughter that her call light is not near her even though the call light is clipped next to her and within reach. Guest will remove her call light from her person and self-ambulate in room and to the bathroom without asking for assistance. (Date Initiated 9/1/18 and revised on 8/4/20). Further review of the resident care plans revealed no care plan implemented for an actual fall (only a risk for fall care plan) and no new or modified interventions implemented after the 4/24/20 fall. A Nursing note dated 4/30/20 at 11:22 am documented in part, . Resident assessed by NP (Nurse Practitioner) d/t recent fall, no concerns. Resident self-transfers to toilet many times throughout day, not always voiding. Denies pain or burning. NP would like to start resident on [MEDICATION NAME] ER 5mg daily. Daughter notified, awaiting a response. A facility fall incident report dated 4/30/20 at 6:46 am documented in part, . while doing my med (medication) pass guest seemed alert sitting up in her wheelchair. Meds were passed and she continued to watch TV. I continued to do my morning med pass; when I heard her say help. Upon entering the room, she was lying on the floor near her chair. Guest was toileted last at approximately 0600 when she got up for the day. When asked what she was trying to do, guest said she was returning from the rest room and fell . Immediate Action Taken . Resident was assessed, VSS (Vital Signs Stable) 134/77, 17, 79, Neurochecks WNL (Within Normal Limits). ROM (range of motion) intact. Helped back into her chair. Continued to monitor for safety. MD and daughter notified. Intervention: Requested MD or NP visit to evaluate the frequent need for toilet . Mental Status (left blank) . Predisposing Physiological Factors - Gait Imbalance . Predisposing Situation Factors - Ambulating without Assist, Using Walker . No Witnesses found . The resident care plan titled Risk for fall . was reviewed and revealed the following implemented intervention . Requested NP to visit and assess for medication for OAB (overactive bladder), bladder spasms. Daughter refused medication. Offered bladder training/patterning and daughter refused. Daughter educated on risks (dated 4/30/20) . Further review of the care plan revealed no new and/or modified interventions implemented. An Investigative Summary note documented by the DON on 5/1/20 at 5:05pm, revealed in part . IDT (Interdisciplinary team) reviewed incident and care plan. Root cause seems to be r/t guest having OAB. NP in to evaluate and ordered medication to treat OAB. Guest's daughter refused medication changes. Educated her on the fall risk and the relation to the frequent attempts for self-toileting, guest daughter states she prefers her mom fall over having medication side effects from new medications. Discussed a bladder patterning/training routine but guest daughter declined this citing it would cause too much stress for guest, again educated on the purpose of the proposed interventions and the risk of injury r/t falling. Recommended interventions still declined. Per IDT we will continue current interventions. Despite the offered recommendations being declined by the daughter (per facility), the IDT failed to implement new and/or modified interventions. A Nursing note dated 7/16/20 at 10:07 pm, documented in part . at 8:55 pm, called by staff on duty. Observed guest on the floor in prone position next to her bed. Noted guest bleeding from left eyebrow area and left side of the head due to abrasion and skin tear. Pressure with gauze, ice applied and cleansed with NS (normal saline). Bleeding stopped. Guest able to move BLE (bilateral lower extremities), right arm without any discomfort, but had pain/discomfort to left arm and guest was unable to move her left arm. Guest was unable <sic> clearly to communicate what happened and why she got out of bed without using the call light or seeking assistance . guest was sent 911 for further eval (evaluation) and tx (treatment). Guest left the building on a stretcher accompanied by paramedics . A facility fall incident report dated 7/16/20 at 8:55 pm, documented in part, . pain/discomfort to left arm and guest was unable to move her left arm. Guest last observed by writer around 2000 in bed with call light and walker in reach . Resident Description: guest was unable clearly to communicate what happened and why she got out of bed without using the call light or seeking assistance . Description: Guest assessed, pressure applied to bleeding areas, cleansed with NS (normal saline), ice applied, and called 911 for transportation to ER (emergency room ). MD (medical doctor) and daughter notified, daughter to meet her at the ER . Mental Status - Oriented to Person, Oriented to Place, Oriented to Situation . Predisposing Physiological Factors - Drowsy, Gait Imbalance, Weakness/Fainted, Impaired Memory . Predisposing Situation Factors . Ambulating without Assist . Other Info - guest got out of bed without using her call light, without asking or seeking assistance by staff on duty . No Witnesses found . Documentation from the hospital with an Arrival Time: 7/16/2020 21:39 (9:39 pm) documented in part, . Call your healthcare provider right away if these occur: . Stitches come apart or fall out or surgical tape falls off before 5 days . Diagnosis: [REDACTED]. The resident care plan titled Risk for fall . was reviewed and revealed the following implemented intervention, . Discussed with daughter changing HS (hour of sleep) routine and medication times to a later time to decrease chance of guest falling asleep too early then waking up to toilet. Daughter declined changes (dated 7/17/20) . Requested MD to review medications and schedule (dated 7/17/20), (revised 7/17/20) Environmental Modification: clutter free pathways, adequate lighting, frequently used items within reach on right side of guest, bed in low position at HS, (revised 7/17/20) when rounding at night, ensure guest is centered in the bed . On 12/22/20 the DON was queried on what actual new and/or modified interventions were implemented to prevent further falls after the 7/16/20 fall and provided a typed response of changes made by the facility after each fall. The 7/16/20 (fall) documented, . 7/16/20 medication change of [MEDICATION NAME], therapy evaluation. Again, recommended medication for OAB and declined. IDT RCA suspect OAB, risk vs benefit discussed with daughter, offered for daughter to discuss this medication recommendation with Medical Director - declined. Guest states she agrees with whatever daughter says. Also discussed changing HS routine as guest may be going to bed too early - declined . Although the DON typed response documented proposed interventions, review of the resident's care plan revealed ineffective revised changes, with no further new and/or modified changes to the resident's interventions to address the root cause of the resident's falls. At 8:44 am, the Director of Therapy (DOT) I was asked to provide documentation on the therapy evaluations and/or assessments completed for R#601 status [REDACTED].#601 after any of her falls at the facility. When asked what the therapy department did for the resident regarding falls, DOT I stated in part, . Our recommendations was that she had increased supervision. We verbally told the DON . A facility fall incident report dated 7/31/20 at 4:51 pm, documented in part, . After handing up the phone with guest's daughter, I entered guest's room to assist her with her phone as her daughter was going to call her, guest was observed kneeling at the end of the bed. Non-skid footwear in place, call light was lying on the right arm of her sitting chair. Guest was previously seen by the assigned RN (Registered Nurse) approximately 15 min (minutes) prior, seated in her chair eating yogurt . Resident Description: I fell after I used the toilet . Immediate Action Taken . Guest assessed for ROM (range of motion) and pain, she was assisted up to chair with 2 PA (person assist). Daughter was notified and physician notified. ROM and neuro check at baseline. Intervention: MD to evaluate guest . Mental Status (left blank) . Predisposing Physiological Factors - Drowsy, Weakness/Fainted, Gait Imbalance . Other info - Guest had appointment with ortho earlier in the day and had a new cast placed. Guest is non-compliant . No Witnesses found . Review of the resident's clinical record revealed no nurses note documented for the 7/31/20 fall. The resident care plan titled Risk for fall . was reviewed and revealed the following implemented intervention . Discussed with daughter that guest may need alternative placement for closer supervision due to continued attempts at ambulation without assist, self-transfers, falls. Daughter declines (dated 7/31/20). The DON was queried on this intervention and confirmed that they did propose to the resident's daughter for the resident to be moved to another facility for closer supervision. Again, the facility failed to implement new and/or modified interventions to prevent further falls and address the root cause of the resident falls. A Incident Note dated 9/13/20 at 1:16 pm, documented in part . Guest observed on the floor of her room, positioned on her left side, steps from the bed. Guest conscious and following commands. Guest assisted into wheelchair. Guest able to move extremities, discomfort noted when attempting to move left arm. Abrasion and hematoma also noted to left forehead and arm. Physician made aware; order received for an X-ray of the left arm . Guest reinforced the importance of pushing the call light. Guest currently in chair, call light, bedside table and phone within reach . A facility fall incident report dated 9/13/20 at 8:15 am, documented in part, . Guest observed by staff on the floor of her bedroom, positioned on her left side, steps from the bed. Guest is conscious and following commands. Guest was just observed approximately 30 min prior, in bed asleep, she did not want to get up at that time. Guest was last toileted this morning around 0630 . Resident Description: Guest states that she was trying to get to the bathroom before the fall . Immediate Action Taken . Description: Guest assisted up and into wheelchair. Range of motion and skin assessment performed. Abrasion and hematoma noted to left forehead. Vital signs obtained . Mental Status - Oriented to Person, Oriented to Place . Predisposing Physiological Factors - Weakness/Fainted, Gait Imbalance, Impaired Memory, Recent change in Medications/New . No witnesses found . The resident care plan titled Risk for fall . documented no new and/or modified interventions implemented. On 9/20/20 at 6:18 pm, the DON documented in part . IDT reviewed incident and care plan. Updated care plan to have w/c placed near bed at HS so if guest gets up without assistance (this intervention was not added to the care plan as documented), she will transfer to w/c instead of trying to ambulate . Guest continues to self-transfer when up in chair. Bladder scans done per MD to see if there is PVR causing frequent attempts to use restroom, results insignificant. IDT still recommends OAB medication as it was noted effective but daughter continues to decline. Administration did discuss this concern with ombudsman. On 12/22/20 at 9:07 am, the DON was queried on if the resident was ever assessed for Dementia/Alzheimer's (noting multiple documentation of impaired mental status for the resident and the resident's ability to comprehend their fall interventions). The DON was also asked to provide all documentation and/or explanation of the lack of realistic and/or interventions implemented for the falls on: 4/24/20, 4/30/20, 7/16/20, 7/31/20 and 9/13/20. The DON was also queried on the IDT meeting and if Quality Assurance Performance Improvement (QAPI) had discussed the resident falls at the meetings. The DON returned at 10:17 am with a typed-up explanation of interventions after each fall. The DON stated QAPI meets monthly regarding all falls and declined to provide any notes pertaining to R#601 falls. The typed explanation provided documented in part, . 4/24/20 UA complete to rule out UTI causing frequent attempts to urinate. 4/30/30 recommended OAB medication, bladder training/patterning. Declined . 7/31/20 MD spoke with guest and daughter, ordered [MEDICATION NAME] for OAB. Discussed with daughter that guest may need alternate placement for closer supervision. Declined. 9/13/20 place w/c (wheelchair) next to bed at HS so guest will attempt to transfer to w/c as opposed to ambulating if she gets up (not documented on the care plan) . The DON was queried on how the resident's daughter was able to dictate the care provided to the resident (before the DPOA - Durable Power of Attorney- became effective) and the DON did not offer any further explanation. At this time, the facility fall policy was requested. A facility policy titled Falls Reduction Program revised 9/25/16 documented in part, . Purpose: To provide a safe environment for residents, modify risk factors, and reduce risk of fall-related injury . Implement and indicate individualized interventions on Care Plan . If fall occurs Charge Nurse to complete the following: . Immediate interventions as identified by physical assessment and environmental observation . Therapy screen, as applicable . Initiate safety interventions and update care plan as applicable . IDT to review each incident to complete root cause analysis . Discuss and determine root cause, Summarize IDT analysis in the incident report . Identify any additional interventions in the Care Plan . Determine the need for ongoing assessments/interventions based on MDS reviews, fall risk history, and IDT member recommendation . Trends/patterns will be evaluated by the QAPI committee to establish new facility strategies towards improvement in the Falls Reduction Program .

This citation pertains to Intake Number: MI 509 Based on interview and record review, the facility failed to obtain a STAT X-ray in a timely manner and contact the physician regarding swelling and pain for one (R#703) of three residents reviewed for change in condition, resulting in increased pain and a delay in treatment for [REDACTED]. Findings include: A complaint was submitted to the State Agency that alleged the facility did not properly assess and/or monitor R#703 after a fall and did not transport the resident to the hospital in a timely manner. A phone interview with the complainant was conducted on 8/28/19 at 8:48 [NAME]M. The complainant reported R#703 fell in the bathroom while waiting for help off of the toilet and attempting to transfer herself. The complainant reported a nurse heard R#703 yell out and said it looked worse than it actually was. Another nurse (identified as Nurse Q) determined it was not broken but no x-ray was ordered. According to the complainant, it wasn't until the Administrator was notified that an X-ray was ordered. The complainant further reported that the X-ray was not completed until after 5:00 P.M. and during that time R#703 was in a tremendous amount of pain. It was not until Saturday night when she was told not to bear any weight because her ankle was broken. The complainant reported a family member came to see the and she was writhing in pain and her ankle and leg was black and blue and swollen from the ankle to the knee and was surprised she wasn't sent to the ER (emergency room ). A family member had EMS called to take R#703 to the ER and found out there was a fracture in two places. The complainant reported R#703 required surgery, was in pain worse than labor according to (R#703) and was only receiving (brand name for [MEDICATION NAME]). An unannounced, onsite investigation was conducted at the facility on 8/28/19 and 8/29/19. R#703's clinical record was reviewed and revealed the following: R#703 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#703 had intact cognition and required extensive one person assistance for transfers and toilet use. A progress note dated 8/2/19 at 2:51 AM written by Nurse A documented, Guest was toileted by CNA (certified nursing assistant). Loud scream was heard and staff rushed to resident room. Guest found in front of toilet on her back with no socks. Call light was not used prior to fall. Guest states slight pain in L (left) ankle and nowhere else. Guest was then helped in to chair . A progress note dated 8/2/19 at 6:14 P.M. written by Nurse Q documented, .Stat (right away) X-Ray was ordered for guest left ankle . There was no documentation between 2:51 [NAME]M. and 6:14 P.M. that indicated why the STAT X-ray was needed. A progress note dated 8/3/19 at 1:00 [NAME]M. written by Nurse B documented, Received call back from (name of radiology company) tech to arrive by 2:30p. A progress note dated 8/3/19 at 12:18 P.M. written by Nurse B documented, Resident experienced recent fall. c/o (complains of) pain to L ankle, appears swollen. Prn (as needed)Tylenol given, ice applied. stat x-ray ordered yesterday, not completed at this time. (name of radiology company) notified, no estimated time of test given, awaiting call back. Resident updated. A progress note dated 8/3/19 at 3:21 P.M. written by Nurse B documented, (Name of radiology company) called second time after lunch requesting estimated time of x ray. Still awaiting call back. Resident and daughter updated. A progress note dated 8/3/19 at 3:25 P.M. written by Nurse B documented, Received call back from (radiology re: x ray at approx. 1:00 stating tech would be here by 2:30 pm. At 3:30 not yet here, explained to resident they should be here soon. A progress note dated 8/3/19 at 5:37 P.M. written by Nurse B documented, X-ray to L ankle complete, awaiting results. A progress note dated 8/4/19 at 6:57 [NAME]M. written by Nurse D documented, Results in for Xray of left ankle, fx noted. MD notified of results. Guest non weight bearing on left ankle at this time, MD recommended app (appointment) with ortho. Guest made aware of condition. Will continue to monitor and report any changes. There was no documentation of the appearance of R#703's leg or pain level reported to the physician. A progress note dated 8/4/19 at 1:46 P.M. written by Nurse B documented, Resident continues to have increased pain and swelling to L ankle. Ice applied and pain medication given as ordered. Prn Tylenol given for breakthrough pain, ace bandage wrapped to L ankle per dr. order. Family arrive and requesting resident be transferred to (hospital name redacted) for eval (evaluation)/ treatment. Dr. notified, order obtained. Resident transferred by ambulance at 13:45. A progress note dated 8/4/19 at 5:13 P.M. documented, Resident returned from hospital. Confirmed fracture to fibula, ankle. Ice injury 4x day for 20 minutes at a time. Leave splint in place until f/u (follow up) with ortho. NWB (non-weight bearing) to LLE (left lower extremity) at this time, may continue with therapy as tolerated. (Narcotic pain medication) 5/325 give <sic> at hospital at 1556. Elevate LLE when resting. Treat pain. Family to set up ortho appointment. Phone numbers given to family for w/c transport. An Investigative Summary dated 8/5/19 written by the Director of Nursing (DON) documented, Guest was assisted from the bed to the bathroom by CN[NAME] Guest had used call light to request assistance to the bathroom. Guest did not call for assistance to get off the toilet. Staff heard yelling from the guests room, upon entering the room guest was observed on the floor of her bathroom. Guest stated she slid down and did not fall. Guest BIMS 15/15 (which indicates R#703 was cognitively intact). Guest was educated to call for assistance with transferring and she verbalized understanding. Guest states she prefers the privacy when she is in the bathroom and does not want staff to stay in the bathroom with her. IDT (interdisciplinary team) review agrees with intervention of reinforcing need to call for assist. Guest reported increase pain to her ankle the evening post fall. XRAY was ordered which resulted a non-displaced fracture which was casted in the ER. A Radiology Results Report revealed the X-ray was completed on 8/3/19 at 3:40 P.M. and the results were reported at 4:09 P.M. The report documented the results were not reviewed until 7:09 [NAME]M. on 8/4/19 by Nurse D. The results documented, Non-displaced [MEDICAL CONDITION] L fibular shaft with adjacent soft tissue swelling. The nursing schedule/assignment sheet for 8/1/19 (which included the midnight shift going into 8/2/19) revealed Nurse A was assigned to R#703 on the 7P-7A shift and CNA C was the CNA assigned to R#703 on the midnight shift. Nurse Q was assigned to the resident on the 8/2/19 7A-7P shift, Nurse D was assigned to the resident on the 8/2/19 7P-7A shift, and Nurse B was assigned on 8/3/19 7A-7P shift. On 8/28/19 at 1:05 P.M., CNA C (the CNA who was assigned was contacted via the telephone for an interview and was unable to talk at that time. A second attempt was made to interview CNA C via the telephone on 8/28/19 and there was no answer. CNAC was unavailable for interview prior to the end of the survey. On 8/28/19 at 1:15 P.M. and 3:05 P.M., Nurse B was contacted via the telephone for an interview. On both occasions, using different telephones, the number provided alerted that calls were not allowed from this line. There was no option to leave a message. Nurse B was unavailable for interview prior to the end of the survey. On 8/28/19 at 1:20 P.M., Nurse D was contacted via the telephone for an interview. There was no answer. Nurse D was not available for interview prior to the end of the survey. On 8/28/19 at 3:30 P.M., the DON was interviewed. The DON was asked if the physician would be notified if a STAT X-ray was delayed by approximately 19 hours and the resident was experiencing pain and swelling. The DON stated, You are confusing me. It seems like you are trying to twist this into something. At that time, R#703's physician's phone number was requested from the DON. At approximately 4:00 P.M., the DON and the Administrator provided the following information: The Administrator reported R#703's family member wanted the resident to have an X-ray so he had the physician order [REDACTED].#703) did not have increased pain, the nurse called the doctor and interventions were put into place. When asked if the physician was notified of any swelling or a delay in X-ray, the DON did not offer a response. The DON and Administrator were asked why the family had to request a transfer to the hospital after a fracture to R#703's fibula was confirmed, the Administrator stated, The family has the right to take the resident to the hospital. The DON stated, She was going to therapy and everything. On 8/29/19 at 9:04 [NAME]M., Nurse A was interviewed via the telephone. Nurse A reported that R#703 was nearing the end of her stay on the day she fell . Nurse A stated, Aide (CNA C) took her to the toilet and gave me the pager and went on a 15 minute break. I was waiting, but did not get alerted of a call light going off. Then I heard her yelling 'help!' When I got there she had already fallen. There was no call light on. I was able to help her back into the chair. She said her ankle was hurting. Nurse A reported there was slight swelling and R#703's range of motion was a little limited and her pain was at about a 3 or a 4 (on a scale of 1-10 with 10 being the worst pain). Nurse A further reported that he texted the doctor, offered (brand name for [MEDICATION NAME]), and reassessed in the morning and her pain wasn't as bad, only about a 3. Nurse A stated, I found out later that it was broken, but it didn't seem as bad as it was when I assessed it. Nurse A reported no X-ray was ordered at that time. A review of R#703's Medication Administration Record [REDACTED] On 8/2/19 at 1:49 P.M., R#703 had a pain level of '3', on 8/3/19 at 9:21 [NAME]M. R#703 had a pain level of '4', on 8/4/19 at 12:15 P.M. R#703 had a pain level of '5'. R#703 was given [MEDICATION NAME] at the above times. The MAR indicated [REDACTED].M. The (MONTH) 2019 MAR for R#703 documented occasional [MEDICATION NAME] administration and pain levels never documented above '3'. The narcotic pain medication was given once in (MONTH) on 7/10/19. Physical Therapy progress notes were reviewed for R#703 for dates of service 7/30/19-8/5/19. The progress note documented, .Precautions: LLE NWB sec (secondary) L distal fibula fx (fracture) .Patient was making good progress but sec fall on 08/02/19 during self transfer patient sustained L distal fibula fx and LLE NWB at this time. Physical Therapy Treatment Encounter Note(s) were reviewed and revealed R#703 received physical therapy services on 8/2/19 and 8/3/19. Comments documented, .Patient had a fall last, was attempting to self transfer from toilet to WC (wheelchair). Nursing assessed the patient and deemed she was able to participate with therapy. No X-Rays were ordered Therapy administered ice with 20 minutes on, 20 minutes off of L ankle . On 8/3/19 (signed off on 8/5/19 at 12:47 P.M.) the treatment note documented, .Noted swelling and heat on L ankle, ice applied .Nursing has ordered an X Ray . Physical Therapy Discharge Summary documented R#703 could ambulate 150 feet with assistance at baseline on 7/9/19 and on 8/5/19 (after the fall with fracture) was total dependence w/o attempts to initiate). At discharge on 8/6/19 resident was not ambulatory. Hospital records for R#703 were reviewed and revealed the following: An Emergency Department Report dated 8/4/19 documented R#703 was admitted into theER on [DATE] at 2:08 P.M. The report documented, .chief complaint of a injury to the left ankle that occurred 2 days ago .Patient does admit to pain both the medial lateral aspects of the left ankle .Patient does have some mild swelling down to left ankle. Does have some minimal tenderness to the medial and lateral malleolus (ankle) .Patient has been splinted .She is advised to follow-up with orthopedics over the next 2 days . A radiology report from an X-ray completed at the hospital on [DATE] documented, .FINDINGS: Minimally displaced oblique fracture of left distal fibula (lower portion of the fibula near the ankle) is seen with associated minimally displaced [MEDICAL CONDITION] proximal (upper portion of the fibula) . A Discharge and Transfer Summary dated 8/7/19 documented R#703 had an open reduction and internal fixation of left distal fibula fracture. An Operative and Procedure Report dated 8/7/19 documented INDICATIONS FOR PR[NAME]EDURE .Review of X-rays showed a nondisplaced proximal fibula fracture on the left lower extremity as well as a distal fibula fracture with displacement and widening of the mortise (gliding joint between the distal ends of the tibia and fibula) . On 8/29/19 at approximately 3:15 P.M., a policy or contract regarding the timeframe for a STAT order to be completed was requested from Regional Nurse Consultant (RNC) N. RNC reported the facility did not have a policy regarding STAT orders but provided the Service Hours form from the consulting radiology company that documented, .STAT response time is approximately 4-6 hours .

This citation pertains to Intake Number MI 708. Based on interview and record review, the facility failed to implement interventions to prevent the development of a pressure ulcer, and accurately identify, assess, and treat an existing skin alteration for one (R#704) of three residents reviewed for pressure ulcers, resulting in moisture associated skin damage worsening into an unstageable pressure ulcer (Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) that required surgical debridement (removal of necrotic tissue) and the placement of a [MEDICAL CONDITION] (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall). Findings include: A complaint was submitted to the State Agency that alleged the facility failed to prevent and treat a pressure ulcer, failed to turn and reposition R#704, and failed to notify the family of a pressure ulcer. A phone interview was conducted with the complainant on 8/28/19 at 9:00 [NAME]M. The complainant reported R#704 had a necrotic bed sore to the tail bone that was discovered when R#704 was admitted into the hospital for an unrelated condition. The complainant reported the facility informed the family that R#704 had a little rash on his bum but not a pressure ulcer. The complainant reported R#704 was admitted into the hospital due to [MEDICAL CONDITION] ([MEDICAL CONDITION] - blood clot) and had to stop treating the [MEDICAL CONDITION] in order to treat their pressure ulcer and received a [MEDICAL CONDITION] to promote healing of the pressure ulcer. Hospital records for R#704 were reviewed on 8/28/19 and revealed the following: An Emergency Department (ED) Note dated 7/11/19 documented R#704 was admitted to the ED for anticoagulation and a cardiology consult for acute [MEDICAL CONDITION]. An ED Nurse Note dated 7/11/19 at 11:55 [NAME]M. documented, .Noted pressure injury at coccyx (tailbone), appears necrotic. Wound consult ordered . A W[NAME] (Wound, Ostomy, and Continence) Nursing Note dated 7/11/19 at 2:14 P.M. documented, .Consult for pressure injury, POA (present on admission) .mostly bedridden at (name of nursing home redacted) .Wound to sacrum noted .Unstageable wound - sacrum 8.5 cm (centimeter) x (by) 11 cm. Wound bed is 40% pink tissue, 60% black eschar (dead tissue), moderate serosanguineous (serum mixed with blood) drainage. Periwound non-blanchable [DIAGNOSES REDACTED] (redness) . .Stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed without slough) left buttock. 0.5 cm x 0.7 cm . .Interventions/Plan .Wound care to sacrum and left buttock .Turn and reposition every 2 hours . Photographs taken during the wound consultation revealed a black center of the wound with redness surrounding A consultation by Plastic/Reconstructive on 7/13/19 documented, .Found to have unstageable coccyx pressure wound. Consulted for possible debridement. Wife states it has been there for more than a week .The central eschar is intact but starting to slough (detach) .continue current plan .Will need debridement at some point but given that he has been on blood thinners (That were held only today) and that his Hgb is .low and .trending down and that the wound appears nontoxic at present, would hold off on debridement for now. The eschar should separate more on its own & it would be a much less bloody debridement . A Progress Note from the attending physician documented, .SACRAL DECUBITUS ULCER /ESCHAR APPRECIATE PLASTICS NEED FOR DEBRIDEMENT? WILL RE-ASSESS TOMORROW, PREFER DEBRIDEMENT , OK TO PR[NAME]EED OFF (brand name for apixaban, an anticoagulant medication), CAN GIVE ONE UNIT PRBC (a transfusion of packed red blood cells) IF PLASTICS DECIDED FOR DEBRIDEMENT . A progress note written by the plastic and reconstructive surgery physician dated 7/15/19 documented, .Unstageable pressure wound: Mild sharp debridement performed today at bedside . A general surgery consultation note dated 7/17/19 documented, .The wound does not appear infected to me currently. My biggest concern with the wound is the proximity to the anus. I had a lengthy discussion with him and his wife regarding the wound, its location and expected healing. I have recommended a diverting [MEDICAL CONDITION] to prevent spillage of stool in the wound and help prevent recurrent infections. He will still require daily wound care and I would expect the wound to take at least several months to heal (if it heals). I have also explained that if he chooses not to proceed with a diverting [MEDICAL CONDITION], he may have recurrent infections of the area which could be life threatening . A general surgery operative report dated 7/22/19 documented, .PREOPERATIVE Diagnosis: [REDACTED]. Slough and/or eschar may be visible) coccygeal pressure ulcer extending to the anus. POSTOPERATIVE Diagnosis: [REDACTED]. OPERATION PERFORMED: 1. Diagnostic laparoscopy. 2. Exploratory laparotomy with lysis of adhesions. 3. Primary repair of small-bowel injury. 4. Sigmoidectomy. 5. Creation of end-[MEDICAL CONDITION]. 6. Debridement of stage IV coccygeal wound .recently underwent a [MEDICAL CONDITION] several months ago and has been in rehab where he developed a large coccygeal wound. This was debrided by Plastic Surgery several times, and then recommendations were for General Surgery to see the patient. Upon my evaluation, the wound was quite deep, stage IV, and extending down to the level of the anus, which was present at the inferior aspect of the wound. He is having frequent infections of this and difficulty to take care of the wound secondary to his constant soiling from incontinence. Therefore, I recommend undergo diverting [MEDICAL CONDITION] to help keep the wound clean and prevent infectious complications . On 8/28/19, R#704's clinical record at the facility was reviewed and revealed the following: R#704 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#704 had severely impaired cognition, required extensive physical assistance from at least two people for bed mobility and transfers, and was admitted without any pressure ulcers. An admission progress note dated 6/24/19 documented, .coccyx red . A Wound Note dated 7/7/19 documented, Resident noted to have redness and wound to buttock, coccyx area. Discoloration, bleeding present. Area cleansed, protective ointment applied. Resident repositioned to prevent further pressure. Skin prep to heels and prafo boots on. physician's orders [REDACTED].#704 required transfers using a mechanical lift, skin assessments every seven days, and weekly assessment, measurement, and document of wounds. physician's orders [REDACTED]. Reposition q (every) 2hrs. (hours) to prevent pressure to coccyx/ buttock area, also check and change q2hrs and prn (as needed). and Buttocks/ coccyx area: cleanse area, apply protective ointment bid (two time a day) and after peri care. Reposition q2hrs. Two times a day. A progress note dated 7/9/19 documented, .guest has MASD (Moisture Associated Skin Damage) on his coccyx. Writer cleaned wound with normal saline and than pat dry. Writer applied [MEDICATION NAME] to wound then applied skin barrier peri wound and then put on ABD pad to cover. Guest left heel has a small redden area. Writer applied skin prep to that area. Guest also has an redden area by his big toe on his left foot on the inside. Writer applied skin prep to that area as well. all other boney prominence are free from breakdown. A Late Entry progress note written by the Director of Nursing (DON) on 7/10/19 for 7/8/19 documented, Guest has some skin alteration in the coccyx slit and bilateral buttock, photo sent to MD who states appears as MASD/denuded (excoriated) due to incontinence. Staff to check and change Q2H. Guest has been on air mattress since admit r/t poor mobility. Enteral feed is provided in addition to oral intake. Protein supplement to be added to aid in healing and reduce risk for further breakdown, tx initiated, continue air mattress. Family aware of P[NAME] . A care plan for R#704 did not document an intervention to turn and reposition resident prior to 7/7/19. R#704's Treatment Administration Record (TAR) for (MONTH) 2019 was reviewed and revealed R#704 had a physician's orders [REDACTED].M. and 9:00 P.M.) The TAR documented that Nurse P provided the treatment on 7/10/19 at 9:00 P.M. The 9:00 P.M. treatment was left blank which indicated the treatment was not completed (there was no corresponding progress note to explain the blank in the TAR). On 8/28/19 at 10:40 [NAME]M. the DON was interviewed. The DON reported the protocol for skin management was to assess residents' skin on admission, conduct an assessment for risk of development of pressure ulcers, take a picture of any skin alterations, and implement an intervention if needed. The DON reported the physician would be notified of any skin alterations and to get a treatment order and that a picture of the wound would be sent to the physician, but the resident did not require a physical examination by the physician at that time. The DON stated, The physician will see the resident's wound when they come for regular visits and would see if the wound was an issue. When queried about the protocol for identifying, treating, and assessing the worsening of a wound, the DON reported it would be identified by nurses and they would contact the physician. It was reported that the floor nurses at the facility provided wound treatments. When queried about what was in place for skin management for R#704 upon admission to the facility, the DON stated, He had an air mattress on admission. The DON explained after 7/7/19, protein supplements were an added intervention. When queried about whether or not R#704 had any pressure ulcers on admission, the DON stated, Redness. When queried about the additional interventions and treatment on 7/7/19, the DON stated, (R#704) had some moisture associated [MEDICAL CONDITION]. When queried about the unstageable pressure ulcer to R#704's coccyx identified on admission to the emergency department at the hospital, the DON stated, It could have happened on the way to the hospital. He didn't have it when he was here. At that time, the photo from the hospital records that showed a black necrotic area to R#704's coccyx was reviewed with the DON. When asked if that should have been identified by the facility, the DON did not offer a response. The DON stated, You can get an unstageable pressure ulcer in six hours. A review of the facility's nursing schedule (assignment sheet) for the 7:00 P.M. to 7:00 [NAME]M. shift on 7/10/19 indicated that Nurse H was the nurse assigned to R#704 on 7/10/19 and who would have been responsible for providing wound treatment to the coccyx at 9:00 P.M. On 8/28/19 at 3:15 P.M., Nurse H was contacted via the telephone for an interview. Nurse H was not available for an interview prior to the end of the survey. A facility policy titled Wound Management dated 3/15/17 documented, .Charge nurse is responsible for .monitor skin changes during routine daily care (CNA - certified nursing assistant) .If pressure ulcer identified: .Notify the MD for appropriate treatment options .Develop an individualized plan of care .Verify resident specific care plan interventions are in place .

This citation has two deficient practices. Deficient practice #1 This citation pertains to Intake #MI 839 Based on interview and record review the facility failed to use a slide board for transfer based on the residents assessed needs for one (#601) of four residents reviewed for accidents, resulting in the resident sustaining a laceration to the right leg requiring hospitalization , 22 stitches and a decline of mobility. Findings include: On 3/18/19 a record review was conducted. During the review, it was discovered R#601 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment, R#601 scored 15/15 on the Brief Interview of Mental Status (BIMS) exam, indicating intact cognition. The MDS assessment also indicated R#601 required the extensive assistance of two + person physical assist for all Activities of Daily Living (ADL's) including transfers. A review of R#601's clinical record revealed a nursing progress note written by Licensed Practical Nurse (LPN) 'E' dated 1/31/19 at 7:20 PM that read, Guest (R#601) sustained significant wound to RT (right) calf during transfer d/t (due to) severe [MEDICAL CONDITION] and compromise skin. Bleeding controlled. MD and daughter contacted. Guest transferred to (hospital name redacted) via (name redacted) EMS. A further review of R#601's clinical record revealed a wound care note dated 2/2/19 that included a picture of R#601's right calf. The laceration was revealed to be 'L' shaped with stitches holding the skin edges together. There appeared to be a small hole at the point of the 'L' where the skin was open. On 3/18/19 at 1:42 PM, the Administrator was asked for Incident & Accident (I&A) reports on R#601. The Administrator indicated there were no I&A's for R#601, and stated, There was no investigation, we know what happened, the nurse was helping transfer (R#601). The Director of Nursing (DON) was also present, and stated, (R#601's) leg split open due to [MEDICAL CONDITION]. There is a progress note detailing what happened. A review of R#601's hospital discharge paperwork revealed a Trauma History and Physical note dated 2/1/19 that read, Complex laceration of the right lower extremity. Results of an X-Ray performed at the hospital read, Findings: AP (anterior and posterior) and lateral views of the right tibia/fibula (lower leg) were obtained. Soft tissue defect noted along the lateral aspect of the right lower leg . There is diffuse [MEDICAL CONDITION]. There is no soft tissue gas. On 3/18/19 at 2:07 PM, an interview with LPN 'E' was conducted. During the interview LPN 'E' was queried about R#601's laceration. LPN 'E' stated, We were in report, the CNA (Certified Nursing Assistant) came and got me to help transfer the resident. We stood her up, pivoted her and sat her back down. (CNA 'F') said 'Oh', I though something happened to her (CNA 'F). She said the resident was bleeding. I called for help, then called 911. Her leg had a lot of [MEDICAL CONDITION], I think it split open. On 3/18/19 at 2:56 PM, a phone interview with CNA 'F' was conducted. During the interview CNA 'F' was queried about R#601's transfer on 1/31/19. CNA 'F' stated, (R#601) was a two person transfer, so I got (LPN 'E') to help me. When we were moving her, I felt something wet on my leg, I look down. It was blood, it was gushing. I don't know what happened. On 3/18/19 at 3:04 PM, an interview with the Therapy Manager was conducted and revealed R#601's transfer status was a two person with a slide board. On 3/18/19 at 3:08 PM, an interview with Physical Therapy Assistant (PTA) 'I' was conducted. During the interview, PTA 'I' was asked how R#601 transferred. PTA 'I' stated, (R#601) was a two person slide board. She was not able to bear weight on one leg, just toe touch. She cold not stand to pivot. On 3/18/19 at 4:40 PM, an interview with the DON was conducted. During that interview, the DON stated, (R#601) was only a slide board after she came back from the hospital. Before that she was only a two person transfer. A review of R#601's clinical record revealed a nursing progress note dated 1/24/19 that read, .Guest is a 2PA (two person) for transfers and uses sliding board . Other nursing progress notes dated 1/25/19, 1/27/19 and 1/29/19 read, .ADL's needs 1-2 persons to assist, for transfer -sliding board . On 3/18/19 at approximately 5:00 PM, the Administrator and DON were again asked about an investigation into R#601's laceration. The Administrator stated, Why would we do an investigation when we know what happened. The DON was asked why the wound was 'L' shaped if it had split open from [MEDICAL CONDITION]. The DON had no reply. Deficient practice #2 This citation pertain to Intake #MI 363 Based on interview and record review the facility failed to maintain safety precautions needed to prevent a fall from a therapy table for one (#603) of four resident reviewed for falls, resulting in the resident falling and sustaining a laceration to the head requiring emergency hospitalization . On 3/18/19 a record review was conducted. During the review it was revealed R#603 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission MDS dated [DATE], R#603 scored 9/15 on the BIMS exam, indicating moderately impaired cognition. The MDS assessment also indicated R#603 required the extensive assistance of two people for all ADL's. A review of a facility provided I&A dated 2/27/19, revised 2/28/19 revealed, Incident Description: Per occupational therapist (OT) during therapy guest fell forward from the therapy mat guest was seated at the edge of the therapy mat with a standing mirror in front of her and the OT standing in front of the guest blocking both knees. Guest began to lean to the left, OT attempted to grab the gait belt from around guests chest but 'she fell too quickly.' Immediate Action Taken: RN assessed guest, first aid provided to laceration on the left forehead, neurochecks WNL (within normal limits) for guest . guest kept in position lying on left side until EMS arrived and placed c-collar . EMS transferred guest to stretcher and transported to ER for evaluation of laceration and need for CT Scan due to being on blood thinners . On 3/18/19 at 1:45 PM, an interview with OT 'C' and Licensed Physical Therapy Assistant (LPTA) 'D' was conducted. During the interview OT 'C' and LPTA 'D' were queried about R#603's fall. OT 'C' stated, (R#603) was on the therapy mat (large padded table that can be raised and lowered). Her knees were at 90 degrees, so the mat was approximately 2 feet high. At this time, LPTA 'D' stated, I agree with the 2 foot high. OT 'C' continued, I was standing directly in front of her, blocking her knees, my knees were touching her knees. The mirror was in front of her, she was doing exercises using the mirror to help her see her arm movements. She suddenly fell to the left and fell off the mat onto the floor. (R#603) said, 'I'm OK' and tried to roll over. (LPTA 'D') came over and stayed with her, I ran to get a nurse. LPTA 'D' stated, I came over and told her not to move, she was bleeding where she had hit her head. OT 'C' was asked if R#603 had been able to sit on her own. OT 'C' stated, Yes, she could sit. She never did anything like this before. OT 'C' was asked how the resident fell when she was directly in front of the resident, knees touching. OT 'C' stated, It happened so fast, one minute she was sitting there, then she leaned over and fell off the mat. On 3/18/19 at 3:30 PM, a observation of the therapy room was conducted. The therapy mat was observed to be a padded gray surface and approximately six foot wide by seven foot long. It appeared to be fixed to the floor with hydraulic lifts underneath the table. A movable full length mirror was noted to be in the therapy room. OT 'C' was asked if that was the therapy mat R#603 had the fall from. OT 'C' stated, Yes, I hate using that mat now. On 3/18/19 at 3:55 PM, a call to (name redacted) Hospital confirmed R#603 was still admitted to the hospital.