**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake 2626738Based on observation, interviews and record review, the facility failed to protect the resident's (R4's) right to be free from physical abuse by another resident (R3), resulting in physical and psychosocial harm to R4. Findings:Resident #3 (R3)Review of an admission Record reflected R3 admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbances, anoxic brain damage, chronic obstructive pulmonary disease, anxiety, insomnia, and a personal history of sudden cardiac arrest. Review of a comprehensive Minimum Data Set (MDS) assessment dated [DATE] reflected R3 was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status score of 8/15. The assessment did NOT indicate whether R3 exhibited wandering behavior or was intruded on the privacy or activities of others. Section F - Preferences for Customary Routine and Activities reflected it was 1 - Very important to have books, newspapers, and magazines to read, listen to music you like, keep up with the news, do things with groups of people, do your favorite activities, go outside and get fresh air when the weather is good and participate in religious services or practices.Review of a Care Plan initiated on 9/5/2025 reflected (R3) am at risk for elopement. I am a wanderer, and exhibit Exit seeking behavior r/t (related to) History of successful attempts (to) leave previous facility unattended. I am independent with mobility without a physical device, I have a diagnosis of dementia/other cognitive problem, I have impaired safety awareness. I wander the unit the majority of the day, lack personal boundaries, and enter other resident's personal space. I wander in-and-out of other resident rooms and have a history of getting into their personal belongings. On 9/09/2025, the facility initiated an intervention Distract me from wandering by offering pleasant diversions; I prefer listening to music, ‘slow jams' and playing cards.Further review of the Care Plan, initiated on 9/5/2025 reflected that R3 has impaired cognitive function or impaired thought process related to dementia diagnosis and anoxic brain injury. I have impaired cognitive function or impaired thought process r/t Dementia diagnosis. I have the potential to demonstrate physical behavioral/verbal frustration related to dementia (impaired personal boundaries, defending my personal space, believing others to be in my home, etc.) I may not be invited to attend my care conference (with family and/or guardian), as my cognition is impaired, and my mood/behavior may escalate r/t talking about placement, behaviors, need for assist, etc. Review of a Nursing Progress Note dated 9/7/2025 at 1:12 PM reflected R3 was Pacing and exit seeking entire shift. Was using his roommate's phone. Attempting to call taxi. Continues to go door to door and checking to open. Repeatedly stated that he is not staying here.Review of Behavior Notes dated 9/7/2025 at 9:13 PM reflects Resident pacing all shift trying to get out of the unit nonstop. Resident using roommates' phone to call for rides and ask for drugs. Resident not allowing staff to take urinated clothes out of room. Resident increased yelling and aggressive behavior we (sic) staff asked for clothes to be cleaned. The Intervention to address the behavior was to explain how laundry works at the facility and was not effective in relieving R3's aggressive behavior. The note included space to document physician notification as well as what interventions were put into place to keep others safe. Both areas in the Behavior Note were left blank. Review of a Nursing Progress Note dated 9/11/2025 at 8:25 PM reflected R3 had exit seeking behaviors from onset of shift until dinner time . (R3) was attempting to open several doors including other resident's rooms. He was easily redirected. The note does not specify how or what R3 was redirected to do. Review of a Nursing Progress Note dated 9/12/2025 at 11:18 PM reflected (R3) with wandering, exit seeking and attempting to take others' items. Redirected easily by staff but increased verbal confrontations with other residents upon entering rooms. The progress note did not specify the residents R3 is having increased verbal confrontations with or what items R3 is trying to take. Review of a Incident Note dated 9/13/2025 at 8:13 PM reflected This resident was involved in a physical altercation with another resident @ (at) 1525 (3:25 PM) on 09/13. This resident (R3) entered another resident's room, made physical contact with the other resident's left cheek with a closed fist. Immediately separated, placed on 15-minute checks. Appropriate parties notified. Immediate intervention implemented: 15-minute checks.Resident #4 (R4)Review of an admission Record reflected R4 admitted to the facility on [DATE] with diagnoses that included bipolar disorder, frontotemporal neurocognitive disorder, schizoaffective disorder, psychoactive substance-induced persisting dementia, muscle weakness, primary open angle glaucoma, bilateral and chronic pain. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R4 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 12/15. Review of a Care Plan Focus identified on 5/8/2023 indicated (R4) have the potential to demonstrate behaviors verbally i.e., to talk to myself and have the potential to use inappropriate language and potential for verbal frustration/agitation r/t dementia and mental illness. Profanity is often a part of my everyday vocabulary. I have the potential to become behavioral when I am not having my wants met immediately, I have the potential to become behavioral r/t guardianship and desire to discharge. I appear to be talking to or seeing things/people that are not there. I have potential to make false accusations. An intervention initiated 2/6/2023 included Analyze key times, places, circumstances, trigger, and what de-escalates behavior and document. Behavior management review per policy. Further review of the Care Plan initiated on 2/6/2023 indicates (R4) Have the potential to demonstrate physical behaviors (my guardian reports I have a history of being physically aggressive with other men in my AFC (adult foster care) r/t cognition and mental illness. My guardian reports that if I begin pacing or I put my coat/leather jacket this is a sign I am increasing in agitation. An intervention initiated 2/6/2023 included Analyze key times, places, circumstances, trigger, and what de-escalates behavior and document. Behavior management review per policy. Review of a Facility Reported Incident (FRI) reported to the State Agency (SA) on 9/13/2025 reflected the Nursing Home Administrator (NHA) was notified at approximately 3:30 PM of an alleged resident to resident incident between R3 and R4. Licensed Practical Nurse (LPN) A was called to R4's room and found R3 in R4's room with coffee spilled on the floor. Both residents claimed to be hit by the other resident. Residents were immediately separated. Bruising and a small skin tear noted to R4's left side of face. Neurological assessments started and every 15-minute checks implemented. Provider called for medication review. Mental health provider to see both residents and social work to follow up. NHA, Director of Nursing (DON), On-Call Provider, and local law enforcement notified. During an interview on 9/24/25 at 10:51 AM, R3 was seated in the dining room of the South 2 (S2) unit at the facility. When asked, he denied knowing anything about an altercation with another resident at the home. R3 said he had never been hit or confronted by another resident on the unit and denied having to defend himself from another resident or striking another resident.During an observation and interview on 9/24/2025 at 11:23 AM, R4 was in his room, seated in a recliner chair, drinking coffee and watching TV. A green and dark purple bruise was observed on R4's cheek bone under his left eye, a small scab was noted in the same area. R4 reported that R3 would come into and out of his room [ROOM NUMBER]-4 times a day over several days and that he kept telling him he couldn't be in his room. R4 said Nobody did anything about it! Then one day he was in my bathroom, and I said, ‘You can't be in there' and he punched me! It made me miserable! R4 was asked if R3 has tried to enter his room since then and he said he had, and it made him feel not safe. R4 said that he is content in his room, I am more content in here than I am out there I will tell you that. I have a stop sign outside my room and it helps sometimes. I told staff he was coming into my room; he kept coming in anyway. My face hurts, of course it hurts, it hurt when he hit me! R4 rated his pain at 8-9/10 and said, Staff need to keep that guy out of my room, keep that guy up on the other side. During an interview on 9/25/25 at 1:12 PM, Certified Nursing Assistant (CNA) J reported that she was working on the unit where R3 and R4 lived at the time of the event on 9/13/25. CNA J said R3 was in and out of rooms taking freshly poured water cups that had just been passed out to residents which wasn't good. CNA J said she was struggling to find something for R3 to do and so she got him a large basket of washcloths to fold, but that only kept him occupied for a few minutes and nothing was working. CNA J said she was talking to LPN A who was at her medication cart, CNA D was in the nurse station and had just logged onto the computer to chart, R3 was in the dining room of the S2 unit and R4 was in his room with the door closed. CNA J reported that moments later she heard R4 yell loudly and ran into his room to see R4 on the floor, one arm on the recliner, saw his face and cheek bleeding, blood running down his cheek, coffee everywhere in his room, R3 was trying to exit and shut the door. R4 said R3 hit him two times and asked them to call the cops. CNA J said the R4's face was instantly swollen and purple in color, blood running down his face, as it went on it got way worse. CNA J said there was no indication R3 was physically aggressive before this incident but perhaps he worked himself into a physical altercation because they simply could not keep him occupied and out of other resident's rooms. During an interview on 9/25/25 at 1:43 PM, CNA B reported she worked the day shift on 9/13/25 the day of the incident between R3 and R4. CNA B said that on that day there were no planned activities, and they tried to keep residents busy but believes R4 may sundown (a change in cognitive status that occurs in the afternoon and evening). According to CNA B, 15-minute checks are routine on the unit due to most residents are at risk for falls and do not really amount to a significant new intervention. CNA B said that a lot can happen in 15 minutes due to the fact that many of the residents on the S2 unit are independently ambulatory. During an interview on 9/25/25 at 2:35 PM, LPN A reported that on 9/13/25 R3 was exit seeking at the start of the shift and going into other resident's rooms, Everyone was pretty tense and there were other residents that were not taking too kindly to it (R3 going in and out of resident rooms). When asked, LPN A indicated three residents specifically were at risk of a negative outcome of some kind due to R3's behavior. LPN A named R4, a resident that lived in room [ROOM NUMBER] and a resident that lived in room [ROOM NUMBER] yelled at R3 very loudly to Hey! Get out of here! (R4) was pacing the unit, pushing all the exit doors, asking where the elevator was and trying to enter other people's rooms. We were doing our best, we tried to have him fold laundry, gave him magnetic blocks, (R3) would not sit still. He was taking water cups out of resident rooms. I had redirected R3 just 2 minutes prior to the incident. R4's door had been shut, then I heard yelling and when I entered the room I see R4 in the recliner chair with blood on his cheek and a bruise turning purple. R3 seemed frustrated because he had been being redirected since the beginning of the shift. I got an order for Ativan (an anti-anxiety medication) but R3 did not calm down for a good six and a half hours, he continued pacing and exit seeking. During an interview on 9/26/25 at 9:00 AM, CNA D reported that she was working on the S2 unit on 9/13/25 at the time of the incident between R3 and R4. CNA D said that R4 and 2 other residents really do not like other residents getting into their space. CNA D reported that she did not see R3 enter R4's room and thinks R3 entered R4's room through the adjoining bathroom. CNA D said the coffee was spilled on the floor in front of the bathroom and heard the cup hit the floor and heard R4 yell that R3 had hit him. CNA D said that R4 didn't leave his room after the incident and R3 continued to pace the halls and exit seek. CNA D said that she did not recall what interventions were put into place after the incident and reported staffing in the afternoons and evenings is tough because resident behaviors increase, and many residents need two people to assist with cares and are a high risk for falls, sometimes requiring what amounts to 1:1 supervision. CNA D said there used to be activities on the unit from 8:00 AM - 8:00 PM, but now it's like activities doesn't exist, and we (nursing staff) can't do it all. During an interview on 9/26/25 at 10:45 AM, RN F reported that she worked on the S2 unit the first shift on 9/13/2025 and reported R4 was calm that day. RN F said that R3 was going into and out of other resident rooms trying to get resident water cups. RN F reported there were no activities happening that day which makes things harder on nursing staff. Review of a facility policy Abuse, Neglect and Exploitation last reviewed/revised 10/2024 reflected It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy includes Employee Training with topics that include 5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect such as: a. Aggressive and/or catastrophic reactions of residents; b. wandering or elopement-type behaviors; c. resistance to care; d. Outbursts or yelling out; and e. Difficulty in adjusting to new routines or staff. Further review of the facility policy pertaining to Abuse, Neglect and Exploitation includes a discussion about Prevention - The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation that achieves: . B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation or resident property is more likely to occur with the deployment of trained and qualified registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms. D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** DPS #2 Based on observation, interview and record review, the facility failed to 1). Ensure coordination of Hospice Services for Resident (#24); 2). Ensure wound treatments were completed as ordered for Resident #48 and 3). Ensure an air mattress was functioning properly for Resident #93, resulting in the potential for unmet care needs for Resident #24 and a decline in condition for Resident's #48 and 93. Findings Include: Resident #24 A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #24 indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: stroke with left sided weakness, dementia, chronic ulcer left foot and left calf, chronic kidney disease, heart failure, diabetes, COPD, history of respiratory failure, epilepsy, arthritis, gout, and peripheral vascular disease. The MDS assessment dated [DATE] revealed Resident #24 had moderate cognitive loss with a Brief Interview for Mental Status (BIMS) score of 9/15 and needed assistance with all care. The resident began hospice services 7/25/2023. During a tour of the facility on 4/02/24 at 8:10 AM, Resident #24 was observed lying in his bed. He was awake and alert and readily engaged in conversation. The resident said he had some lower leg pain and a nurse entered and provided pain medication for him. The resident said he was waiting to get out of bed into his wheelchair. He liked to be up for most of the day. A review of the hospice progress notes in the electronic medical record identified the last hospice note dated 1/31/2024. A review of the document section in the medical record revealed several hospice documents with the last being 3/29/2024, but they were not the notes/assessments from the Hospice nurse. On 4/03/24 at 8:34 AM, during an interview with the Director of Nursing/DON it was reviewed the hospice notes could not be found in the medical record after 1/31/2024. The DON said hospice was supposed to document in the chart and she would check into it. On 4/03/24 at 12:16 PM, Nurse Managers I and J were interviewed related to the missing hospice documents for Resident #24. Nurse Manager J said the resident had previously had a regular hospice nurse, but she left and then the resident didn't have a regular hospice nurse. She said various different hospice nurses saw Resident #24 until recently. Nurse Manager J said the resident now had a new regular hospice nurse. The Nurse Manager said the hospice nurses should have been charting in the medical record. She said she would contact the Hospice company to obtain the Hospice notes. The Nurse Managers said the Hospice nurse usually came in weekly and the nurse aide on Tuesdays. On 4/3/2024 the facility provided hospice documents faxed over from the Hospice company. The documents were not in the resident's medical record to utilize in planning his care. A review of the Care plans for Resident #24 identified the following: I have a terminal prognosis, end of life and am receiving care and comfort only with (Hospice services), r/t (related to) impaired respiratory system, date initiated and revised 7/27/2023 with Interventions including: Work cooperatively with (Hospice services) team to meet my spiritual, emotional, intellectual, physical and social needs, date created 7/27/2023 and revised 8/10/2023. There was no mention of when the Hospice staff were to visit the resident. A review of the facility policy titled, Hospice Services Facility Agreement, date implemented 10/17 and revised 6/23 provided, Policy: It is the policy of this facility to provide and/or arrange hospice services to protect a resident's right to a dignified existence, self- determination and communication with and access to persons and services inside and outside the facility . The facility will collaborate with hospice to ensure that the needs of the resident are addressed . It is the preference of (the facility) that partnered hospice agencies document in the facility electronic health record . Resident #48 A record review of the Face sheet and MDS assessment indicated Resident #48 was admitted to the facility on [DATE] with diagnoses: heart failure, chronic kidney disease, diabetes, osteomyelitis, right leg wound and left great toe wound. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a BIMS score of 15/15 and the resident needed some assistance with care. On 4/02/24 at 9:38 AM, during a tour of the facility, Resident #48 was observed lying in bed. He was observed to have an IV pole/pump near his bedside. He said he was receiving antibiotics for a wound infection. He said he had an infection in his right leg and had previously had surgery there and more recently his foot had rubbed against the foot board of the bed and he got a new sore. He said he was tall and they brought him a longer bed. He said he was comfortable in the longer bed, but his feet were observed rubbing against the footboard. On 4/03/24 at 11:04 AM, upon arriving to Resident #48's room with Nurse G, to observe the nurse providing wound care, the resident said his dressing was not supposed to be changed because the wound care provider changed the order to every other day. On 4/3/2024 at 11:10 AM, during an interview with Nurse J she said the order was not yet updated, but the resident's dressing was to be changed to every other day. She said she was working on it. The Nurse Manager J said the wound team saw the resident the day prior and looked at the wound and the Nurse Manager said she had to review the orders with the physician prior to changing the times. A record review of the physician orders identified the following: Right leg: Cleanse open areas with 0.125% Dakin's solution Pat dry, apply A&D to leg from knee to toes to promote autolytic debridement, then cover with kerlix. Change daily and as needed, start date 3/27/2024. Left great toe: Cleanse toe with wound cleaner, pat dry, apply gentamicin ointment directly to wound base, cover with non adherent and secure with kerlix. Change twice a day and as needed (don't forget to skin prep tip of toe, start date 3/27/2024. A record review of Resident #48's Treatment Administration Record/TAR for March 2024 revealed the following: The resident's treatment orders to the Left great toe, were changed on several occasions, but there were many instances when the treatments were not completed as ordered: 3/3/2024, 3/6/2024, 3/9/2024, 3/12/2024, 3/13/2024, 3/20/2024 x2 (twice a day treatment), 3/22/2024, 3/26/2024, 3/28/2024. The resident's treatment order to the Right leg, was changed on several occasions, and there were many instances when the treatment was not completed as ordered: 3/1/2024, 3/3/2024, 3/6/2024 x2, 3/9/2024, 3/12/2024, 3/13/2024, 3/20/2024, 3/28/2024. In addition to the left great toe and right leg treatments, the resident had treatments to his heels, bilateral lower extremities and buttocks. There were a total of 27 missed treatments. The nurses were supposed to monitor the resident's IV antibiotic treatment for the wound/bone infection, but the monitoring was not completed 16 times from March 1, 2024-March 31, 2024. A record review of laboratory results for Resident #48 indicated a critically high Vancomycin antibiotic level on 2/27/24. On 3/7/2024 the antibiotic was changed to Ceftriaxone IV daily for osteomyelitis of the left great toe and heel. A review of the laboratory results also identified a wound culture on 7/23 for the left great toe with the organisms proteus mirabilis and pseudomonas aeruginosa. On 4/03/24 at 12:01 PM, during an interview with Nurse Managers I and J it was noted that the last Wound note from the provider was dated 3/17/2024. Both nurses said they rounded with the wound care provider weekly and the provider charted in a different system and printed out the documentation for the facility. It was then reviewed with the facility physician and scanned into the resident's chart. After that the orders and Care Plans were updated. Reviewed with the nurses that there were many missing instances of documentation for Resident #48's wound treatments for March 2024. The resident was not receiving necessary treatments to aid in infection and wound healing. They said the nurses should have documented and if the resident refused the treatment, they should have documented the refusal. A review of the facility policy titled, Wound Treatment Management and Documentation, date implemented 8/11/06 and revised 2/24 provided, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders . Treatments will be documented on the Treatment Administration Record . Resident #93 A record review of the Face sheet and MDS assessment indicated Resident #93 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Quadriplegia, chronic pain, chronic obstructive pyelonephritis, acute respiratory failure, pressure induced deep tissue damage of right ankle, chronic ulcer left foot, history of traumatic brain injury, polyneuropathy and anxiety. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed assistance with all care. On 4/01/24 at 2:19 PM, Resident #93 was observed lying in bed. His head was above the top of the mattress and his feet were almost touching the foot board. The resident said he was 6'3 tall. He said his bed was not long enough and someone brought a bolster to place across the end of the mattress between the footboard. He said sometimes the bolster fell under the bed. It was observed hanging partially below the mattress. He was observed to have an alternating air mattress, but there were no settings on. There were no lights on the mattress pump. It was not on. There was air in the mattress, but it was not alternating. The resident said it didn't always alternate and had been unplugged at times and he was unsure why it was not on. A review of the physician orders identified the following: Skin, Pressure Ulcer & Wound Treatment Protocol- May follow facility protocol, dated 1/5/2024. There was no mention of the alternating pressure mattress/APM on the physician orders. A review of the Care Plans for Resident #93 revealed the following: I am at risk for impaired skin integrity r/t (related to) risk for immobility, nutritionally at risk, risk for shear & friction, history of pressure injuries, require assistance with my ADL's (activities of daily living . increased risk for reopening healed pressure injury located on posterior head (stage 3) and coccyx (stage 2), date initiated and revised 2/1/2024 with Goal: Minimize my risk for further breakdown through the review date, revised 10/18/2023. Interventions included: APM support surface on bed, dated 10/18/2023. There were no instructions for the APM settings. I have actual impairment to skin integrity that were present on admission . Right medial ankle (DTI/deep tissue injury); Right anterior thigh: Shear (healed); Left Distal left foot: DTI; Left distal, Medial great toe: Trauma (healed) . Date initiated 12/11/2023 and revised 12/12/2023 with Interventions including: Continue to follow the Skin at risk interventions, dated 10/18/2023. A review of the [NAME] and Treatment Administration Record/TAR dated March and April 2024 for Resident #93, did not identify what settings the alternating pressure mattress pump should be set at. On 4/03/24 at 10:00 AM, during an observation of the mattress in Resident #93's room with Nurse Manager I, the air mattress had air in it but there were no lights on the mattress pump; no settings were showing. The Nurse Manager said she didn't know why it wasn't on but there was air in the mattress. It was not alternating. The Nurse Manager said she didn't know what the settings should be. Resident #93 had quadriplegia, was unable to reposition self, had a history of pressure ulcers and continued to be high risk for pressure ulcers. A review of the facility policy titled, Skin and Pressure Injury Risk Assessment and Prevention, date implemented 8/11/2006 and revised 2/24, . Residents determined as at risk for developing pressure injuries will have interventions documented in plan of care based on specific factors identified in the risk assessment . Interventions for Prevention and to Promote Healing . Evidence-based interventions for prevention will be implemented for residents who are assessed at risk and/or who have a pressure injury present .Provide appropriate, pressure-redistributing, support surfaces . This Citation has two Deficient Practice Statements (DPS) DPS #1 This Citation Refers to Intake Number MI00142983 Based on observation, interview, and record review the facility failed to identify, assess, properly monitor, and treat mental and/or physical changes in condition and failed to accurately and timely document changes for two Residents (Resident #85 (R85) and R76) resulting in admission to an Intensive Care Unit in critical condition for R85 and delay in treatment for R76. Findings: R85 Review of the electronic medical record (EMR) reflected R85 originally admitted to the facility 8/26/22 and had diagnoses that included: Pseudobulbar Affect (characterized by uncontrolled outburst of laughter or crying), Manic Depression (Bipolar Disease), Dementia and Anxiety. Review of the Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) dated 11/28/23 reflected a score of 2 out of 15 which indicated the Resident was severely cognitively impaired. Section GG of this MDS revealed R85 was functionally able to ambulate independently, could eat on her own with set- up assistance, and could toilet independently. Review of the EMR Progress Note dated 2/23/24 at 5:30 PM that R85 was to be transported to the hospital for Altered mental status and Functional decline. The entry reflected, At the time of evaluation resident/patient vital signs . were blood pressure (BP) of 132/92, although this result was documented as obtained on 2/18/24. Other vital signs documented as obtained at the time of the evaluation include a pulse of 60 beats per minute (BPM) and a temperature of 98.9 degrees Fahrenheit (F). Review of the Emergency Medical Services (EMS) document titled Prehospital Care Report Summary (also known as a Run Report) reflected EMS arrived on scene at 6:04 PM, 34 minutes after the above vital signs were documented. The vital signs obtained by EMS included a pulse of 135 BPM, respiratory rate of 34 breaths per minute, a BP of 133/106 and a temperature of 103.0 F. Review of hospital emergency room records reflected initial vital signs included a core body temperature of 102.74 F, pulse of 141, and a respiratory rate. of 30. Initial laboratory blood test results included a sodium level of 168 (normal of 134 to 146) which was redrawn to confirm the critically high abnormal value. A white blood count (wbc) lab result of 17.12 (normal range of 4 to 10.8. A high result is indicative of a systemic infection). A urinalysis reflected results that included that the urine specimen of R85 was red and tested positive for blood, white blood cells (infection), and protein. Blood cultures were also obtained and later reflected positive for staphylococcus and gram-positive cocci. Hospital physician documentation included: The facility reported (to the hospital) that R85 had increases in her Zyprexa (an antipsychotic medication) and clonazepam (a benzodiazepine often prescribed for the treatment of panic disorders)) two weeks ago which was thought to be the cause of the (R85) having increased weakness and decrease in mental status over last two weeks. And On arrival, (R85) was febrile (fever), tachycardic (high heart rate), had leukocytosis (high white blood cell count), lactic acidosis (potentially life-threatening build up of lactic acid in the blood), an (Acute Kidney Injury) AKI, severe hypernatremia (high sodium blood level), and was minimally responsive. Her (urine) was positive for leukocytes (white blood cells), nitrites, and blood. On exam, she opens her eyes but does not otherwise respond to staff. And .she did have a drop in her blood pressure and required fluid resuscitation .recheck of sodium (lab level) did confirm hypernatremia (high sodium level) . And Critical Care time (treatment) was required due to the life-threatening nature of this patient's condition . Also On arrival patient appears septic., and She did have strong urine odor . The hospital documentation reflected R85 was admitted to the Intensive Care Unit (ICU) in critical condition with diagnoses that included Severe sepsis, Acute metabolic encephalopathy severe and life-threatening with Hypernatremia secondary to free water loss (dehydration) likely contributing to above, Acute cystitis with hematuria, Acute Kidney injury. Subsequent Hospital Course physician documentation included I am concerned for polypharmacy (taking many prescribed drugs), SS (Serotonin Syndrome (SS) symptoms include high heart rate, high blood pressure, confusion, and high fever as a reaction to medication) or Neuroleptic Malignant Syndrome (NMS) . (NMS is a life-threatening reaction to antipsychotic medications characterized by high fever, altered mental status, high heart rate, rapid breathing and high or low blood pressure). Hold all possible drugs that could contribute (listed are medications R85 had ordered at the facility) And Social work consult to determine if (R85) was left in an minimally responsive state for a week given how dehydrated she was Another physician documented, Social work consult to determine if (R85) was left in a minimally responsive state for a week. If so, concern for neglect . The facility EMR was reviewed for the chronology leading to the admission of R85 to the intensive care unit. Review of the Doctor's Orders for R85 reflected Lorazepam (a controlled substance (benzodiazepine)) was prescribed initially on 8/22/23 which was renewed or had the order changed multiple times until 2/7/24. However, the EMR did not reveal that a Risk versus Benefit had been completed for this Resident to take this medication. Other medications R85 was receiving on 2/7/24 included Zyprexa (prescribed for bipolar disorder), pristique and trazodone (antidepressants), L-methyl folate (for depression or adjunct therapy with antidepressants), and Nuedexa (a central nervous system agent used to treat pseudobulbar affect). Review of the EMR reflected on 2/7/24 Lorazepam was discontinued, and clonazepam was ordered. The EMR did not reflect a Risk versus Benefit was completed for use of the clonazepam for R85. Also, on this date the order for Zyprexa had changed along with the addition of the Clonazepam. During an interview conducted 4/8/24 at 11:01 Social Worker (SW) S she initiates the Risk and Benefit form in the EMR anytime a resident has a Doctor's Order for a hypnotic, antidepressant, antipsychotic, anxiolytic, or mood stabilizer. SW S reported that she missed the Ativan order and did not catch the Doctor's Order for the clonazepam for R85. Therefore, Risk versus Benefit forms were not completed when R85 started on these two medications. SW S reported that there are a lot of pieces when a medication requiring a risk versus benefit is ordered to include Care Plan changes and monitoring. SW S reported that a task is added for monitoring but not until a week after the medication was initiated to give the medication a fair chance to take effect. Review of the Practitioner Progress Note completed by Physician Assistant (PA) T dated 2/7/24 at 8:05 AM included documentation of the medication changes. However, this note of 2/7/24 also included documentation of vital signs that were taken after this date to include a BP taken on 2/18/24, a pulse and oxygen saturation taken on 2/23/24 and a pain scale result dated 2/16/24. Further review of this 2/7/24 note by PA T revealed that this entry and two entries dated 2/20/24 by PA T were created and entered as Late entries into the medical record on 2/26/24 which was three days after R85 was admitted to the hospital ICU. Review of the EMR Progress Note dated 2/15/24 at 8:46 PM revealed, (R85) noted to be very tired. Refused supper. Refused popcorn and pop for snack which is very unusual, she has a flat affect and poor eye contact. I could not even get her to look at me . Very hard to get her medications in her. She needed help to get them to her mouth and reminders to swallow them. No documentation of vitals signs or further assessment or monitoring were located regarding this entry. The Late Entry Practitioner Progress Note by PA T dated for 2/20/24 at 8:36 AM but created 2/26/24 reflected Staff are concerned as (R85) is no longer anxious, restless, or crying but has started to have a blank stare to her the past week or so and she is not verbally communicating very well anymore. The documentation reflected PA T did observe that R85 does have a blank stare to her and has been eating less with meals. And Flat affect with blank stare look to her, generalized weakness, confused and disoriented, and Unsteady gait. Medication orders were changed per this entry. The vital signs documented in this note were from 2/18/24 and 2/23/24. The second Practitioner Progress Note by PA T entered as a Late Entry for 2/20/24 at 4:28 PM but created on 2/26/24 at 8:51 AM was reviewed. The entry reflected (R85) was revaluated (sic) later on today to see if there has been any improvement with recent med change, (R85) seems a bit worse. Medication orders again changed in the PM note in addition to the changes documented in the late entry from the AM of this same day Review of the Medication Administration Record (MAR) for February 2024 for R85 reflected four separate sections for monitoring for adverse side effects of medications. One section each was established for an anti-depressant, anti-psychotic, anxiolytic, and one for General Anticholinergic effect. Each section was documented in three times a day. A positive finding required this to be noted in the MAR with a Nursing Progress Note entry. Side effects to be observed for and documented included, altered mental status, excessive sedation, dry mouth, confusion, drowsiness, lethargy, irregular heartbeat/pulse. Review of these four sections of monitoring reflected staff initials of no abnormal findings despite staff reports of concerns alleged by PA T. Review of the EMR vital signs history from 2/7/24 until 2/23/24, when R85 was transported to the hospital, vital signs were only obtained twice (2/11/24 and 2/18/24) despite Progress Note documentation of difficulty taking medication, decreased communication, lethargy, and altered mental status (blank stare for the past week or so). No further Progress Notes regarding the mental or physical status of R85 are documented until the Resident was transported by EMS to the hospital where she was admitted in critical condition. On 4/4/24 at 3:27 PM an interview was conducted in an office with the Director of Nursing (DON). The DON reported she expects timely entry of Progress Notes. The DON reported that increased monitoring of R85 should have been ordered after the 2/7/24 evaluation by PA T. After reviewing the late entries of 2/20/24 by PA T the DON reported that the PA thought it was alarming enough to put in a note that the abnormal observations of R85 should have been acted upon. The DON stated, I have no idea why (PA T) made two notes (on 2/20/24) It just makes no sense to me. The DON reported that PA T is no longer at the facility and that the timeliness of pertinent documentation was part of the reason. The DON reported that nurses should have acted upon the findings that were documented in the EMR on 2/15/24 (lethargy, refusing food, helping R85 get medication into her mouth with reminders to swallow). The DON reported an expectation that vital signs would have been taken and the medical provider contacted. The DON reported she was not in-house during the time period prior to the hospitalization of R85 but that she would have been aware of the Resident's status and would have responded appropriately. The DON reported she had no further documentation or information to provide. No further documentation was provided prior to survey exit. R76 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R76 admitted to the facility on [DATE] with diagnosis of (but not limited to) Stroke with weakness, morbid obesity, and history of blood clots to both lower extremities. Brief Interview for Mental Status (BIMS) reflected a score of 15 out of 15 which represented R76 was cognitively intact. During an interview on 4/1/24 at approximately 2:00 PM, R76 was resting on his bed working on his computer. R76 stated that he had a fever yesterday (3/31/24) and he has a history of cellulitis in his lower legs. According to the progress notes on 3/31/24 at 1:39 PM, the note reflected, patient flush and warm to the touch. Axillary temp 101.4. denies s/s (signs and symptoms) feeling ill. No other s/s noted at this time. Administered Tylenol at 1:15 PM. Passed to next shift to monitor. At 3:01 PM the physician was notified of the fever and recommended, Alternated [NAME] (Tylenol) with Ibuprofen. Dip urine. According to the Temperature Summary reviewed from 3/31/24 - 4/2/24 the following temperatures were recorded for R76: 3/31/24 at 2:30 PM 102.9 (degrees Fahrenheit) 3/31/24 at 3:11 PM 102.6 3/31/24 at 4:15 PM 101.6 3/31/24 at 5:20 PM 101.2 3/31/24 at 5:47 PM 101.2 3/31/24 at 6:14 PM 99.9 3/31/24 at 9:58 PM 98.9 There were no further temperatures recorded from 3/31/24 -4/2/24 to review. A skin assessment documented on 3/31/24 at 10:45 PM was reviewed and reflected red open areas to the back of both thighs, and both buttocks. There was a rash to the right abdominal fold and the right axilla. Both legs were red with indentions. The assessment noted treatments in place for all areas. During a follow-up interview and observation on 4/3/24 at approximately 8:36 AM, R76 was resting in bed. When asked if his fever had come back, R76 stated that he didn't know. R76 stated that his lower leg was reddened and showed this surveyor the right lower leg with redness noted from the just below the knee to the ankle. When asked if the doctor had started him on an antibiotic for it, R76 stated, No, I don't think so. Record review of the medication administration record (MAR) for March 2024 and April 2024 reflected no order to alternate Tylenol and Ibuprofen for a fever. The Ibuprofen 200 mg, give 400 mg by month every 4 hours as needed for fever was started on 4/2/24 (not on 3/31/24 as the doctor had recommended). There were no antibiotic orders listed on the MAR at the time of this record review on 4/3/24 at approximately 8:45 AM. During an interview and record review on 4/3/24 at approximately 9:00 AM, the Clinical Care Coordinator (CCC) I reviewed R76's progress notes, temperature logs, physician notification and MAR with this Surveyor. There were no temperatures logged from 4/1/24 - through the time of this interview. When asked if the staff monitored R76's temperature after 3/31/24, CCC I stated that there were none recorded. When asked if the order to alternate Tylenol and Ibuprofen was initiated on 3/31/24, the CCC I stated that it did not get onto the MAR until 4/2/24 (2 days after receiving the order from the physician). When asked if the urine was collected for testing, CCC I stated that R76 refused because it is too painful for him. When asked if the physician was made aware, CCC I stated she was unable to find any notification in the record. The facility failed to assess and monitor for fever and potential for infection. The Practitioner wrote a progress note on 4/3/24 at 9:51 AM that reflected, This 57 y/o (year old) WM (white male) complains of increasing warmth, tenderness, and erythema in his RLE (right lower extremity). On exam, he has developed a RLE cellulitis (infection of the skin). I ordered Augmentin 875 mg bid (twice daily) for 10 days .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake number MI00140515. Based on observation, interview, and record review, the facility failed to ensure safe transfers with a mechanical lift (per manufactures guidance) and thorough assessment after a fall for 1 of 3 residents (Resident #51) reviewed for falls. This deficient practice resulted in Resident #51 (R51) falling from a mechanical lift with a delay in assessment and treatment for 3 fractures. Findings include: According to the facility investigation report submitted to the state agency on 10/23/23 at 10:50 PM, the facility reported that on 10/14/23 at 12:55 PM, R51 was being transferred from a wheelchair to the bed by 2 staff members that were operating a full body mechanical lift when the left leg strap of the sling became unattached from the lift causing R51 to slide out of the sling and onto the floor from a height of approximately 3 feet, coming to rest on her bottom with her right lower leg bent at the knee and tucked under her left leg. An onsite x-ray was ordered and confirmed a right leg fracture. On 10/14/23 at 5:48 PM, R51 was sent to the emergency room where it was discovered that R51 had also sustained a left hip and pelvis fracture in addition to the right leg. The facility provided a copy of the Falls Reduction Policy dated 2/24/2002, last revised on 4/2023 for review. The policy reflected, 4. When a resident experiences a fall, the facility will: a. Assess the resident. b. Complete a Post-Fall Assessment. c. Complete a Risk Management Incident Report . According to the Total Mechanical Lift Competency Checklist signed by the DON and the NHA on 10/20/23 reflected, 2. Mechanical Lift Operation .e. Positions resident on the appropriate sling size and style as per resident's Care Plan .g. Attaches the sling straps without pulling or tugging to the desired setting. Considers elevating the head of the bed to facilitate ease in completion. h. Gently raises resident minimally from surface. Unweight resident from bed. Performs a safety check . R51 Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R51 was admitted to the facility on [DATE] with diagnosis of (but not limited to) traumatic brain injury, seizure disorder and dementia. Brief Interview for Mental Status (BIMS) reflected a score of 5 out of 15 which represented R51 had severe cognitive impairment. R51 had a guardian for all medical decision making. R51 required extensive staff assistance of 1-2 with all activities of daily living. According to the Activities of Daily Living care plan dated 7/25/23, reflected the following intervention for transfers, Dependent using the full body mechanical lift and 2 staff. Date initiated: 7/25/23. There was no indication of which style of lift sling (full body or divided leg) nor size indicated on the care plan as the Total Mechanical Lift Competency Checklist for lifts and slings reflected. On 11/1/23 at 10:13 AM the DON provided a copy of the [name of Total Mechanical Lift company] Full Body Slings Size Chart for review. The DON hand wrote on the bottom of the sheet that R51 was using the size large from this sizing chart that the facility labeled B-10. The DON provided a blue lift sling that reflected, B-10 written on it for inspection. The sling shape did not look like the Full Body Sizing Chart that was provided for review. The sling further reflected a tag that indicated the style of sling was a Divided Leg Sling. When asked what is documented on R51's care plan, the DON stated that the facility does not document the sling style and size to use on the care plans. The DON stated she expected the staff to check the current weight and refer to the sling sizing chart posted at the nurses' desk to determine the appropriate sling to use on residents. This direction was different than the instructions that the Total Mechanical Lift Competency Checklist reflected. During an interview on 10/31/23 at 1:00 PM, CNA A stated that she assisted CNA B on 10/14/23 at 12:55 PM with the transfer of R51 from the wheelchair to the bed. CNA A stated R51 was already seated on a sling pad, they positioned her next to the bed, attached the sling to the lift and proceeded to lift. CNA A stated that before R51's weight was completely off the chair they heard a clip noise, the CNA's paused and visually (not physically) rechecked the straps on the lift, then proceed with the transfer. When R51's weight was fully on the lift and before she was positioned over the bed, the left leg strap became unattached and R51 slid out of the sling and onto the floor. CNA A stated that she was able to guide R51's head so it did not hit the floor. When asked if the CNA's lifted R51's weight just off the seat of the wheelchair and did a safety check before proceeding with the transfer, CNA A stated, No, not exactly. We put them (the straps) on and tug down on them. When asked if the lift and sling were immediately taken out of service, CNA A stated that they used the lift and sling to transfer R51 off the floor and back into bed before taking it out of service. According to the Employee Counseling Notice dated 10/14/23, CNA A was given a verbal safety counseling that reflected, Employee was transferring the resident using a mechanical lift when the sling became unattached during the transfer resulting in the resident sliding to the floor. Employee failed to double check sling straps by pulling on them to ensure they were securely attached to the mechanical lift prior to lifting the resident using the mechanical lift. The counseling was signed by the CNA A and the DON. During an interview on 11/1/23 at 8:45 AM, CNA B stated that she assisted with CNA A as they transferred R51 with a mechanical left from the wheelchair to the bed. After they attached the sling to the lift with the straps, they began to lift R51, heard a clip noise and stopped the lift, visually rechecked the straps and proceeded with the transfer when midway R51's left leg strap became unattached from the lift causing her to slide out of the sling and onto the floor. When asked if the CNA's lifted R51 off the wheelchair, stopped and did a safety check before proceeding, CNA B stated, We look at the straps, tug on them, lift and normally keep on [NAME]. I'm not completely sure how it (the strap) popped off. According to the Employee Counseling Notice dated 10/14/23, CNA B was given a verbal safety counseling that reflected, Employee was transferring the resident using a mechanical lift when the sling became unattached during the transfer resulting in the resident sliding to the floor. Employee failed to double check sling straps by pulling on them to ensure they were securely attached to the mechanical lift prior to lifting the resident using the mechanical lift. The counseling was signed by the CNA B and the DON. During a telephone interview on 11/1/23 at 2:37 PM, RN C stated that CNA B came to get her in the hallway (on 10/14/23 at 12:55 PM) and told her that R51 had fallen from the mechanical lift. RN C stated that she was not R51's assigned nurse that day but stepped into the room to help the CNA's with the situation. RN C stated that she did not physically evaluate or perform a range of motion (an assessment used to move each joint to evaluate for function, pain, and changes from their baseline). RN C stated she asked R51 verbal questions about where her pain was. RN C stated that together with CNA A, CNA B and CNA F they rolled R51 back onto the sling and lifted her from the floor to the bed. When asked if the same mechanical lift and sling R51 had fallen from was used, RN C stated, Yes. RN C stated that when she asked R51 about her pain, R51 denied pain but had a shocked look on her face. During an interview on 11/1/23 at approximately 2:00 PM, RN D stated that she was assigned to R51 that day and when she entered the room, she noted R51 already back in her bed. RN D stated CNA A and CNA B were changing her brief. RN D stated she noted a reddened area to R51's right knee, subsequently called the physician, obtained a STAT x-ray order, and attempted to notify the guardian. When asked if she did a full range of motion assessment (ROM) on R51, RN D stated, No, I did not. When asked if she gave R51 anything for pain, RN D stated, No, I did not. RN D stated that at 2:00 PM she gave shift report to RN E. During a telephone interview on 11/1/23 at 3:35 PM, RN E stated she took over care of R51 on 10/14/23 at 2:00 PM approximately an hour after she had fallen from the lift. During the shift-to-shift report with RN D, RN E stated together they entered R51's room and examined her right leg. RN E stated that R51's had light bruising from her knee that had extended to her foot. RN E stated that R51 was not verbal at this time and could not rate or describe her pain. RN E stated that RN D reported that she had not provided pain medication yet. RN E stated she went out to the medication cart and obtained 2 tablets of Tylenol extra strength but R51 had her lips clenched tight and would not take the medication. RN E noted that R51's color was pale. RN E stated that the x-ray tech came about 2:30 PM. At about 3:30 PM, RN E was notified of the nondisplaced fracture of the proximal tibia (right leg fracture) which she reported to the physician and guardian. RN E reported that later in the shift, R51's color was even more pale, her blood pressure was very low, her pulse was high, staff were unable to obtain an oxygen saturation and was not able to palpate a pedal pulse (feel pulse in foot), so she notified the physician and guardian and sent R51 to the ER at approximately 5:48 PM. RN E stated that later that evening was made aware that R51 had also fractured her left hip and pelvis. During an interview on 11/1/23 at 4:30 PM, when asked if ROM was part of the post fall assessment the DON stated, Yes. The DON added if she thought it would further injure a resident she would stop and notify the physician of that as well. The DON stated that she expected this to all be documented in the medical record. There was no ROM assessment documented in the electronic health record. During an observation and record review on 11/1/23 at approximately 1:50 PM, R51 was sleeping in her bed and did not awaken when her name was called. The progress notes reflected that R51 was readmitted to the facility on [DATE]. The record reflected that R51 would not have been a good surgical candidate, therefore upon readmission to the facility R51's guardian elected to admit her to hospice for comfort and pain management of the fractures. Resident #52 (R52) During an interview and observation on 11/1/23 at 1:30 PM, CNA I and CNA J stated they both received mechanical lift education within the last few weeks. The Surveyor observed as they used a full body mechanical lift to transfer R52 from a wheelchair to the bed. The CNA's attached the sling to the lift and pulled down on the strap, lifted the resident and without stopping, transferred R52 from the wheelchair to the bed and unattached the sling. The CNA's failed to follow the Total Lift Mechanical Lift Competency Checklist to stop the lift after the resident's weight was fully supported by the lift (unweight) and perform a safety check before completing the transfer. Resident #53 (R53) During an interview and observation on 11/1/23 at 1:40 PM, CNA G and CNA H stated they both received mechanical lift education within the last few weeks. The Surveyor observed as they used a full body mechanical lift to transfer R53 from a wheelchair to the bed. The CNA's attached the sling to the lift and pulled down on the strap, lifted the resident and without stopping, transferred R52 from the wheelchair to the bed and unattached the sling. The CNA's failed to follow the Total Lift Mechanical Lift Competency Checklist to stop the lift after the resident's weight was fully supported by the lift (unweight) and perform a safety check before completing the transfer.