**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00149991 and MI00150073. Based on interview, and record review, the facility failed to assess the integrity of a mechanical transfer sling for one resident (R901) reviewed of three for accidents resulting in an avoidable fall requiring emergent transfer to a higher level of care and surgery for fractures sustained to the left and right lower extremities and pain. Findings include: A review of complaint reported to the State Agency included an allegation R901 was dropped from a mechanical (Hoyer) lift and sustained a fracture because the sling was not safe for use. On 2/11/25, a clinical record reviewed revealed R901 was readmitted to the facility on [DATE] with a medical history of atrial fibrillation (abnormal heart rhythm) and required Eliquis (blood thinning medication), chronic osteomyelitis, and diabetes. R901 had an ADL (Activity of Daily Living) self-care deficit related to muscle weakness, reduced mobility, and morbid obesity. R901 required two persons assist and use of a mechanical lift for all transfers from bed to chair. Brief Interview of Mental Status (BIMS) assessed on 11/21/24 scored 15/15 indicating R901 is cognitively intact. On 2/11/25 at 9:42 AM, an interview with the Nursing Home Administrator (NHA) acknowledged on 1/30/25 after their shower, R901 was hanging from a bariatric sling and the strongest part of the sling ripped resulting in R901 falling from the lift and required to be transferred to the hospital. The NHA said no other areas of the sling appeared compromised and was weird because it ripped from its strongest support strap when asked if the manufacturer was contacted, the NHA replied they were not, and the sling was thrown in the garbage (and not available). On 2/11/25 at 10:04 AM, a telephone interview was conducted with R901. When asked about the 1/30/25 accident, R901 commented that they knew how the fall happened, stating I was in a sling that should not have been used. When asked for further clarification, R901 said the sling had a worn-out appearance and the fabric sewn to the strap look old and worn out. R901 said the two Certified Nurse Assistants (CNA) transferring them remarked that soon as they placed them (R901) back into bed, We need to throw this one out. R901 said they were about three-four feet up from the ground, the left strap supporting their left side gave out ,was ripped, tearing the loop strap from the lift and fell injuring their left leg and right ankle. During the interview, R901 said they are still hospitalized , had required surgery for a fractured left femur and broken right ankle because of the fall and had pain as a result. On 2/11/25 at 10:33 AM, a telephone interview with CNA A identified as one of the two CNA's providing the transfer to R901 confirmed they were assisting the lower portion of the sling guarding R901's position as to not hit the walls and the sling just snapped and R901 fell to the ground. CNA A was unable to verify who had the last responsibility of checking the integrity of the slings and confirmed R901 had the sling under them and could not confirm the integrity. On 2/11/25 at 12:15 PM, a telephone interview with Licensed Practical Nurse (LPN) F who authored the Progress Note dated 1/30/25 at 6:04 PM confirmed they heard a loud sound from R901's room, observed them on the ground stating they fell from the lift and had pain in their left leg. LPN F revealed that the upper left loop had ripped from the stitching, was dangling from the hook and the rest of the sling had ripped apart. When asked who is responsible for checking the integrity of the slings, LPN F was unable to answer. An interview on 2/11/25 at 12:30 PM with Laundry Services C clarified when slings are brought to be laundered, they are inspected pre and post washing. If a sling is compromised in any way, the NHA and or Maintenance Manager is notified, and the sling should be disposed of. The last recall of a sling being removed was over two months ago. When asked who has the final inspection of the slings, Laundry Services C remarked they were not sure but it should be the Nurses because they are the ones who retrieve the slings and put them on the residents. On 2/11/25 at 1:33 PM, the Director of Nursing (DON) confirmed that it is the responsibility of the CNA's or whomever is placing a resident into a sling who had the final responsibility of verifying the integrity of the sling. The DON and NHA were informed of the remarks made during the above interviews and confirmed they will reinforce the final check of integrity of the sling is done by the staff placing residents into the sling. During the review of a Past Non-Compliance Binder revealed on 1/31/25 an audit of the slings was conducted and identified a green sling labeled #809A was thrown away and not placed back into circulation (an additional sling was identified as not safe and thrown away). On 2/11/25 at 2:17 PM, LPN G returned a phone call and acknowledged the sling R901 was in was torn from the sling and strap loop and witnessed the Resident laying on the floor complaining of pain. When asked the overall condition of the sling, LPN G stated, it was not a newer sling and it had been in rotation for a while. Review of the facility's policy titled; Safe Lifting and Movement of Residents, dated 1/2022 Documented: .Mechanical lift equipment shall undergo routine checks and maintenance by the nursing and maintenance staff, respectively, to ensure that equipment remains in good working order . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included education, training, reviewing current slings and removing worn slings to correct the past noncompliance. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00131841. Based on interviews and record review, the facility failed to protect the resident's right to be free from neglect for one R332 of one resident reviewed for neglect, resulting in a pattern of multiple failures that contributed to the residents change of condition to have been found unresponsive, required CPR (Cardiopulmonary resuscitation) and required a transfer to the hospital for a higher level of care in less than 48 hours of admission. Findings include: Review of the medical record revealed R332 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses that included: acute respiratory failure with hypoxia, Guillain-Barre syndrome (rare disorder which the body's immune system attacks the nerves), type 2 diabetes mellitus, asthma, atherosclerotic heart disease, tracheostomy status, hypertensive heart and gastrostomy status. A MDS (Minimum Data Set) assessment dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 14 which indicated intact cognition and was dependent on staff for all Activities of Daily Living (ADLs). Review of the discharge paperwork titled After Visit Summary that was provided to the facility upon readmission on [DATE], documented the following medications and treatments to be implemented upon admission: The facility failed to implement the following pertinent orders upon admission: - Continuous pulse oximetry monitoring - Suction orders for secretions - Humified Oxygen Orders and Oxygen Liter orders - Ipratropium-albuterol 0.5-2.5 mg/3 ml nebulizer, inhale 3 ml three times a day. - Albuterol 2.5 MG / 3 ML (milliliters) 0.083% nebulizer solution. Take 3 ml (2.5 mg total) by nebulization every 6 hours as needed for wheezing or shortness of breath. - Sodium Chloride 7% nebulizer solution, take 4 ml by nebulization three times a day. - Chest Vest 3 times daily to align with nebulizer treatments - Glycopyrrolate (Robinul- used to reduce excessive drooling) 1 MG, one tablet in the morning. - Apixaban (an anticoagulant- blood thinner) 5 MG (milligram), one tablet in the morning and one tablet before bedtime. - Tracheostomy Care - PEG Care And other additional medications that were not implemented such as: - Acetaminophen 650 MG every six hours as needed for pain or Temperature over or equal to 101 F. - Buspar 5 MG, one table in the morning, one tablet at noon and one tablet at bedtime. - Atorvastatin 10 MG, take one tablet nightly. - Dextrose 40% gel, take 15 g (grams) by mouth as needed in the morning for blood sugar less than 70. - Lidocaine 4% patch, place on the skin in the morning. - Seroquel 25 MG, one tablet nightly. - Sertraline 100 MG, one tablet nightly. Further review of the After Visit Summary documentation provided to the facility upon readmission documented the following in part: - . You are being discharged on Oxygen using a trach collar at 28-35% oxygen with humidity . Device Trach Mask . Fi02(%) 28 . Keep 02 Sat between 92%-96% . Routine Tracheostomy/Stoma Care 2 times daily . Chest Vest 3 times daily . Changed frequency to align with nebs . copious sputum production . RT (Respiratory Therapist) Eval (evaluation) and Treat . 02 Flow Rate (L- liters/min- minute) 8 - 10 L/min . - . Assessment and Plan . Patient with copious secretions, these were generally described as thin and watery; secretions were an issue apparently even prior to admission . initiated Robinul at reduced dose (1 mg daily) . this has clearly been of benefit . secretions ultimately did become somewhat thicker, and he was changed to trach mask for humidification purposes; will now plan for trach mask nocturnally to provide additional humidification; Continue to monitor for worsening of secretions, Continue DuoNeb . every 6 hours . Continue as needed use of Cough Assist device . Bilateral lower extremity DVTs (Deep Vein Thrombosis), acute. Continue apixaban 5 mg twice daily; continue to monitor . Patient appears stable, and ready to transfer to skilled nursing facility . peer to peer review with physician . per that physician he was approved to return to his previous long-term care facility . - Review of additional documentation provided to the facility from the transferring facility of a physician Internal Medicine note dated [DATE], documented in part . still requiring suctioning every 3-4 hours, and has episodic desaturations, which are not long-lasting . This statement was bolded and underlined in the report provided to the facility. The facility staff failed to administer the necessary oxygen orders/care, medications, treatments, ensure the continuous monitoring of the pulse oximetry which was required for this resident to closely monitor the episodic desaturations of the resident to ensure the resident maintained a 92 to 96 % pulse oximetry and implement the suction orders that was needed being that the resident was documented to still require every 3-4 hours suctioning. On [DATE] at 12:39 PM, the Assistant Director of Nursing (ADON) A and Regional Clinical Director (RCD) M who was present to help cover the facility in the absence of the Director of Nursing (DON) were both interviewed and asked the facility protocol for admission/readmission and medication reconciliation and the ADON A stated the facility will implement the orders from the transferring facility and the resident, orders and plan of care are then discussed at the next morning meeting with the interdisciplinary team (weekday). The ADON A then stated any changes or concerns would be discussed at that meeting with the disciplinary team and then discussed with the doctor to review. If any changes are made to the medications, treatments or plan of care it would be documented in the resident's medical chart. At this time the ADON A and RCD M was asked to review and look into the chart of R332 and explain why the resident oxygen orders, medications, and treatments were not implemented as documented by the transferring facility. The ADON A and RCD M stated they would look into it and follow back up. Review of the medical record revealed R332 admitted to the facility on [DATE] which is a Friday at 7 PM (per the nursing admission assessment) and their admission and orders was not reviewed by the interdisciplinary team at the next morning meeting due to the resident having been found unresponsive early Sunday morning on [DATE]. Further review of the medical record revealed no documentation of a physician directive to change the course of treatment for this resident. The facility staff failed to accurately reconcile and implement the resident medications and treatments upon admission. On [DATE] at 12:26 PM, the Respiratory Therapist Director (RTD) N was interviewed and asked the facility's protocol on the respiratory therapist team evaluating the admission/readmission of a resident that requires a Trach mask with humidified oxygen and RTD N stated a Respiratory Therapist would see the resident the day of admission and review the admission packet as well as the Nursing staff. RTD N then stated the Respiratory Therapist are in the building 24 hours a day and are required to complete two daily respiratory assessments however they constantly monitor the residents throughout the day, which would be documented in the residents' chart. The RTD N stated the respiratory therapists has the ability to implement any orders needed for respiratory care, but usually the nurses would implement the orders upon admission. RTD N was then asked to look into R332's chart and explain why the resident was not seen on the day of admission on [DATE] by the respiratory department and why the resident oxygen, nebulizers, suction orders and tracheostomy orders were not clarified by the respiratory therapist when the resident was first seen by the respiratory department on [DATE]. The facility Respiratory Therapist failed to assess and provide care on the day of admission and review the resident admission documents to ensure all oxygen and tracheostomy orders were implemented and administered accurately, timely and consistently as required. On [DATE] at 12:39 PM, ADON A and RTD N returned for a follow up interview. The ADON A stated they reviewed the record and could not provide an explanation on why R332 orders were not implemented correctly upon admission. RTD N stated they identified only one RT on that night and did not find any documentation of R332 to have been seen by RT on the day of admission. RTD N stated as far as the orders the nurse usually puts all of the orders in. At 3:29 PM, the ADON A returned and stated they talked to the nurse that admitted R332 on [DATE] and they could not recall what happened. No further explanation or documentation was provided by the end of survey. Review of the medical record revealed the resident pulse oximetry was not obtained continuously and was last obtained on [DATE] at 6:24 PM, which at that time was 96% via for a resident with a Tracheostomy mask who was supposed to be receiving humidified oxygen via the Tracheostomy mask. Further review of the medical record revealed the staff did not obtain any further pulse oximetry reading, ensured monitoring of the resident's pulse oximetry levels throughout the night or that suctioning was completed throughout the night being that the resident was documented to require every 3 to 4 hours of suctioning. The resident was found unresponsive on [DATE] at approximately 12:35 AM. The facility staff failed to assess and monitor the resident from [DATE] at 6:24 PM, until the resident was found unresponsive on [DATE] at approximately 12:35 AM. Review of a Nursing note dated [DATE] at 1:18 AM, documented in part . At approximately 0035 hours CNA (Certified Nursing Assistant) was making routine rounds found resident unresponsive. Nurse notified. Nurse checked for pulse and respirations. Resident was absent of both pulse and respirations. Help was called for and CPR was initiated immediately. Respiratory began bagging resident via [NAME] collar. 911 notified for emergent transfer. Upon EMS (Emergency Medical Services) arrival <sic> was placed and first round of Epi was administered. Resident was found to have a pulse at approximately 0053 hours. Resident loaded and transferred care to EMS . Review of a facility policy tilted Abuse, Neglect and Exploitation revised [DATE], documented in part . Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00131841. Based on interview and record review the facility failed to ensure respiratory orders were implemented accurately, ensure tracheostomy care was implemented, ensure timely and thorough respiratory therapist assessment and evaluation and ensure continuous pulse oximetry monitoring for a resident who required continuous monitoring of 02 levels for one (R332) of three residents reviewed for respiratory care. Findings include: Review of the medical record revealed R332 was initially admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses that included: acute respiratory failure with hypoxia, Guillain-Barre syndrome (rare disorder which the body's immune system attacks the nerves), type 2 diabetes mellitus, asthma, atherosclerotic heart disease, tracheostomy status, hypertensive heart and gastrostomy status. A MDS (Minimum Data Set) assessment dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 14 which indicated intact cognition and was dependent on staff for all Activities of Daily Living (ADLs). Review of an After Visit Summary documentation provided to the facility upon readmission on [DATE], documented in part the following medications and treatments to be implemented upon admission: Ipratropium-albuterol 0.5-2.5 mg/3 ml nebulizer, inhale 3 ml three times a day. Sodium Chloride 7% nebulizer solution, take 4 ml by nebulization three times a day. Pulse Oximetry . Continuous pulse oximetry monitoring should be in place at all times . Suction orders for secretions Humified Oxygen Orders and Oxygen Liter orders Albuterol 2.5 MG / 3 ML (milliliters) 0.083% nebulizer solution. Take 3 ml (2.5 mg total) by nebulization every 6 hours as needed for wheezing or shortness of breath. Chest Vest 3 times daily to align with nebulizer treatments Glycopyrrolate (Robinul- used to reduce excessive drooling) 1 MG, one tablet in the morning. Tracheostomy Care Review of the medical record revealed none of the above orders implemented upon admission and throughout the duration of the resident's inpatient care at the facility with the exception of the Ipratropium-albuterol 0.5-2.5 mg/3 ml nebulizer to be inhale 3 ml three times a day (nebulizer treatment), which was only implemented after the family asked the facility staff why the order was not implemented. Review of a Nursing note dated [DATE] at 2:02 PM, documented in part . Residents brother and sister at bedside. Resident's brother came up to desk and stated, My brother is supposed to be on continuous pulse ox. Latest pulse ox was 98%. (Respiratory Therapist name) from RT speaking with brother regarding the above . At this time the facility staff implemented the Ipratropium-Albuterol to start three times a day. Further review of the After Visit Summary documentation provided to the facility upon readmission documented the following in part: . You are being discharged on Oxygen using a trach collar at 28-35% oxygen with humidity . Keep 02 Sat between 92%-96% . Routine Tracheostomy/Stoma Care 2 times daily . Chest Vest 3 times daily . Changed frequency to align with nebs . copious sputum production . RT (Respiratory Therapist) Eval (evaluation) and Treat . 02 Flow Rate (L- liters/min- minute) 8 - 10 L/min . . Assessment and Plan . Patient with copious secretions, these were generally described as thin and watery; secretions were an issue apparently even prior to admission . initiated Robinul at reduced dose (1 mg daily) . this has clearly been of benefit . secretions ultimately did become somewhat thicker, and he was changed to trach mask for humidification purposes; will now plan for trach mask nocturnally to provide additional humidification; Continue to monitor for worsening of secretions, Continue DuoNeb . every 6 hours . Continue as needed use of Cough Assist device . continue to monitor . Patient appears stable, and ready to transfer to skilled nursing facility . peer to peer review with physician . per that physician he was approved to return to his previous long-term care facility . Review of additional documentation provided to the facility from the transferring facility of a physician Internal Medicine note dated [DATE], documented in part . still requiring suctioning every 3-4 hours, and has episodic desaturations, which are not long-lasting . This statement was bolded and underlined in the report provided to the facility upon admission. Review of the medical record revealed the initial Respiratory Therapist assessment to have been completed the day after admission ([DATE]) for R332. Review of the medical record revealed the resident pulse oximetry was not obtained continuously and was last obtained on [DATE] at 6:24 PM, which at that time was 96% via for a resident with a Tracheostomy mask who was supposed to be receiving humidified oxygen via the Tracheostomy mask. Further review of the medical record revealed the staff did not obtain any further pulse oximetry reading, ensured monitoring of the resident's pulse oximetry levels throughout the night or that suctioning was completed throughout the night being that the resident was documented to require every 3 to 4 hours of suctioning. The resident was found unresponsive on [DATE] at approximately 12:35 AM. Review of a Nursing note dated [DATE] at 1:18 AM, documented in part . At approximately 0035 hours CNA (Certified Nursing Assistant) was making routine rounds found resident unresponsive. Nurse notified. Nurse checked for pulse and respirations. Resident was absent of both pulse and respirations. Help was called for and CPR was initiated immediately. Respiratory began bagging resident via [NAME] collar. 911 notified for emergent transfer. Upon EMS (Emergency Medical Services) arrival <sic> was placed and first round of Epi was administered. Resident was found to have a pulse at approximately 0053 hours. Resident loaded and transferred care to EMS . On [DATE] at 12:26 PM, the Respiratory Therapist Director (RTD) N was interviewed and asked the facility's protocol on the respiratory therapist team evaluating the admission/readmission of a resident that requires a Trach mask with humidified oxygen and RTD N stated a Respiratory Therapist would see the resident the day of admission and review the admission packet as well as the Nursing staff. RTD N then stated the Respiratory Therapist are in the building 24 hours a day and are required to complete two daily respiratory assessments however they constantly monitor the residents throughout the day, which would be documented in the residents' chart. The RTD N stated the respiratory therapists has the ability to implement any orders needed for respiratory care, but usually the nurses would implement the orders upon admission. RTD N was then asked to look into R332's chart and explain why the resident was not seen on the day of admission on [DATE] by the respiratory department and why the resident oxygen, nebulizers, suction orders and tracheostomy orders were not clarified by the respiratory therapist when the resident was first seen by the respiratory department on [DATE]. On [DATE] at 12:39 PM, the Assistant Director of Nursing (ADON) A and Regional Clinical Director (RCD) M who was present to help cover the facility in the absence of the Director of Nursing (DON) were both interviewed and asked the facility protocol for admission/readmission and medication reconciliation and the ADON A stated the facility will implement the orders from the transferring facility and the resident, orders and plan of care are then discussed at the next morning meeting with the interdisciplinary team (weekday). The ADON A then stated any changes or concerns would be discussed at that meeting with the disciplinary team and then discussed with the doctor to review. If any changes are made to the medications, treatments or plan of care it would be documented in the resident's medical chart. At this time the ADON A and RCD M was asked to review and look into the chart of R332 and explain why the resident oxygen orders, medications, and treatments were not implemented as documented by the transferring facility. The ADON A and RCD M stated they would look into it and follow back up. Review of the medical record revealed R332 admitted to the facility on [DATE] which is a Friday at 7 PM (per the nursing admission assessment) and their admission and orders was not reviewed by the interdisciplinary team at the next morning meeting due to the resident having been found unresponsive early Sunday morning on [DATE]. Further review of the medical record revealed no documentation of a physician directive to change the course of treatment for this resident. On [DATE] at 12:39 PM, ADON A and RTD N returned for a follow up interview. The ADON A stated they reviewed the record and could not provide an explanation on why R332 orders were not implemented correctly upon admission. RTD N stated they identified only one RT on that night and did not find any documentation of R332 to have been seen by RT on the day of admission. RTD N stated as far as the orders the nurse usually puts all of the orders in. At 3:29 PM, the ADON A returned and stated they talked to the nurse that admitted R332 on [DATE] and they could not recall what happened. No further explanation or documentation was provided. On [DATE] at 10:17 AM, Licensed Practical Nurse (LPN) O (the nurse that admitted R332 on [DATE] was interviewed and when asked about R332's admission on [DATE], LPN O stated they didn't remember a whole lot, but did remember the resident came at the start of their shift and it was their first time completing an admission by themselves. LPN O stated since it was their first time doing an admission, they told the nurse coming on duty that they believed they put everything in correctly. When asked if the facility has a protocol in place for another nurse to double check the orders of an admission, LPN O stated they were unsure. When asked if they administered any medications to R332, LPN O stated they could not remember. When asked if they remembered if the facility's respiratory therapist seen R332 on the day of admission, LPN O stated they could not recall. On [DATE] at 11:44 AM, a call was made to the physician that was assigned to R332 and who also serves as the facility's Medical Director (MD) P and a message was left for the physician to return the call however MD P failed to return the call.