**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Complaint #1337621.Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for one (R801) of three residents reviewed for accidents and supervision, resulting in the resident being hospitalized for alcoholic ketosis due to alcohol ingestion and lactic acidosis due to walking in 94 degree Fahrenheit (F) temperatures after staff allowed him to go on a leave of absence (LOA) with an unknown individual without consent from the legal guardian and did not identify he had not returned for approximately 30 hours. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that noted the following, .two days ago a male resident left the facility and no one knew where he was at for 1.5 days .Someone signed him out but they can't read who it was. The police were contacted. The resident was found at (hospital name) and is still there at this time .On 9/9/25 to 9/10/25, an unannounced onsite investigation was conducted.A review of R801's clinical record revealed R801 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: hemiplegia and hemiparesis following a stroke, alcohol dependence with withdrawal (as of 6/30/25), type 2 diabetes mellitus, and schizoaffective disorder bipolar type. It was indicated on R801's face sheet that he had a legal guardian. A review of R801's Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had intact cognition. A review of a Letters of Guardianship form revealed R801 was appointed a legal guardian with an expiration date of 11/10/25. The letter noted, Having filed an acceptance of appointment, you have the care, custody, and control of that individual .as to the following powers and responsibilities only: MEDICAL, PHYSICAL & PLACEMENT .A review of a Physician's Statement Attesting to Decision making Capacity revealed two physicians signed the form on 10/25/24 and 11/4/24 and indicated Resident does not have the capacity to make informed medical decisions and had a legal guardian.A review of R801's hospital records revealed the following:A review of an Emergency Documentation note revealed R801 was admitted to the emergency room (ER) on 6/23/25 at 1:57 PM (21.5 hours after R801 was signed out of the facility by an unknown person saying he was going to a restaurant). The following was documented in the note, .presents to (hospital) Emergency Department (ED) via EMS (Emergency Medical Services) due to chest pain, pain all over his body, heat exposure (It was a high of 94 degrees F on 6/23/25). EMS reports they were called for chest pain and when they got to the scene the patient seemed to have been drinking and was complaining of pain all over his body. Patient does have a significant cardiac history with CABG (coronary artery bypass surgery) and MI (myocardial infarction - heart attack) .Patient reassessed numerous time throughout his ED stay. he continued to complain of chest pain and pain all over his body .troponin only mildly elevated, likely type II MI due to acidosis and dehydration. Patient was given Versed push for alcohol withdrawal and copious IV (intravenous) fluids .Lab derangements likely due to dehydration and alcohol use disorder .Due to significant lactic acidosis and need for CIWA (Clinical Institute Withdrawal Assessment of Alcohol Scale) protocol patient will be admitted to the stepdown unit for further evaluation and treatment .A History and Physical Report dated 6/23/25 that read, .presents with chest pain, generalized pain, heat exposure .He endorses prolonged heat exposure while being outside and walking as well as feeling dehydrated from multiple episodes of vomiting. Patient is concerned for alcohol withdrawal symptoms as well .admitted to stepdown unit for alcoholic ketosis (A condition that can occur when a person consumes alcohol and does not consume enough food or water to compensate for the alcohol intake and lactic acidosis/a buildup of lactic acid in your bloodstream when your body produces too much lactic acid and/or cannot metabolize the lactic acid it produces) .2/2 (secondary to) starvation and heat exposure .A review of a Consultation Note from the hospital dated 6/24/25 at 2:16 AM revealed, .complaining of chest pain, pain all over his body, heat exposure. He is having difficulty answering questions. Endorses having multiple episodes of emesis (vomiting) today after being outside and walking. He indicates he had 3 beers today. He is requesting medication for alcohol withdrawal .On 9/9/25 at 12:01 PM, an interview was conducted with Unit Clerk 'A'. When queried about the procedures when a resident went on a LOA, Unit Clerk 'A' reported there was a log book that the resident signed out in. If the residents sign themselves out, a contact number was requested. If someone else signed the resident out and they were not recognized, they ask who they are and request a contact number. When queried about the process when a resident had a legal guardian, Unit Clerk 'A' reported residents with legal guardians were permitted to leave with the guardian or others approved by the guardian. Unit Clerk 'A' reported any restrictions on who a resident was permitted to leave with would be indicated on the face sheet.On 9/9/25 at 12:50 PM, R801 was observed seated on the side of the bed. R801 was pleasant and able to participate in an interview. When queried about his hospitalization in June 2025, R801 said a buddy named (R801's friend's name) came to the facility to pick him up, he went to the person's house in (a local city approximately 10 to 12 miles away from the facility). R801 explained he was left with no ride back to the facility, walked to a store, realized it was very hot outside, tried walking back to his friend's house to see if he could get a ride, but got overheated and passed out on the street. According to R801, a bystander saw him and called an ambulance, and he was taken to the hospital. When queried about whether the staff knew that he left the facility, R801 reported his friend arrived at the facility and said he got me a ride so I went with him. We had to go back upstairs, and the nurse told him to sign me out. R801 reported he had a legal guardian and a brother that he was in contact with. R801 did not reveal any additional information. A review of a Release of Responsibility for Leave of Absence form that noted, Authorization must be signed by the patient or by the nearest relative when a patient is physically or mentally incompetent. An entry dated 6/22/25 at 4:30 PM revealed R801 was signed out by an unknown person (signature was illegible). The address and phone number of the destination was only the name of a restaurant with no address or phone number.A review of a progress note dated 6/23/25 at 9:19 PM, written by Registered Nurse (RN) 'B', noted, 2 North nurse assigned to work the 2nd shift informed the other supervisor part that resident (R801) hasn't returned from going on LOA yesterday .preceded to start trying to get in contact with residents family and guardian .the DON (Director of Nursing) and another arrived and preceded to contact the police and gave report regarding the resident being missing since yesterday .Further review of R801's progress notes revealed the following Nursing notes entered as late entries:On 6/22/25 at 7:30 PM (Recorded as a late entry on 6/23/25 at 9:11 PM), Licensed Practical Nurse (LPN) 'C' wrote a note that read, Oncoming nurse was notified about resident going out to (restaurant name).On 6/22/25 at 9:05 PM (Recorded as a late entry on 6/23/25 at 9:09 PM), LPN 'C' wrote a note that read, Resident left to go out to (restaurant name). Resident was signed out in sign out book at the nurses station.On 6/23/25 at 6:35 AM (Recorded as a late entry on 6/23/25 at 8:37 PM), LPN 'D' wrote a note that read, Received report from dayshift Nurse that resident was on LOA with family. Resident did not return to facility during shift. It should be noted that nurses worked 12 hour shifts at the facility. A review of nursing staff assignment sheets for 6/22/25 and 6/23/25 revealed LPN 'E' was R801's assigned nurse on the first shift (7:00 AM to 7:00 PM) on 6/23/25. There were no progress notes regarding R801 not yet returning to the facility during that shift. A review of a progress note dated 6/24/25 at 2:14 AM revealed a police officer returned to the facility and reported R801 was admitted into the hospital.A review of a progress note dated 6/24/25 at 11:18 AM revealed a note written by LPN 'E' that read, Resident's brother called and informed writer that no one besides himself .his brother (name redacted), or his guardian should be able to pick resident up saying 'Anyone else who comes to take him is up to no good'.On 9/9/25 at 1:05 PM, a telephone interview was conducted with LPN 'C', who was assigned to R801 on first shift on 6/22/25. When queried about R801's LOA, LPN 'C' reported R801 was alert and oriented and had been leaving the facility with unknown people in the past. On 6/22/25, LPN 'C' explained R801 asked to leave so she told him to go see the receptionist and sign out before leaving. R801 came back to the unit and LPN 'C' stated, I was really busy so I just told the person to sign him out. LPN 'C' reported it was around 4:30 PM when R801 left the building and the person who picked him up said they were going to a restaurant. LPN 'C' reported she had not recognized the person, but because she knew he had gone out before and she was very busy, she just asked him to sign R801 out before leaving. LPN 'C' further reported she was unaware of any facility policy at that time and did not know she should have also obtained a contact number of the person who picked R801 up and did not ask when he would be expected back. When queried about whether R801's legal guardian permitted R801 to go out with unknown individuals, LPN 'C' said at the time she was not aware of a LOA policy so she did not contact the guardian. LPN 'C' reported R801 did not return before she left from her shift around 7:00 PM so she notified the incoming nurse that R801 was on LOA and had not returned yet. On 9/9/25 at 2:00 PM, a telephone interview was conducted with LPN 'B' who was the second shift (7:00 PM to 7:00 AM) nurse supervisor on 6/23/25. When queried about what happened with R801, LPN 'B' reported a nurse came to them and another nurse supervisor and said she could not find R801. LPN 'B' reported they looked around the whole facility and could not find him. They looked in the LOA logbook and saw that there was something in the log from the previous day at 4:30 PM, but could not read the signature of who signed him out. LPN 'B' explained it was not reported to second shift that R801 was on LOA or that he was not in the building. LPN 'B' further reported it was discovered R801 was admitted to the hospital. When queried about R801 and whether he was safe to be out on LOA with an unknown individual, LPN 'B' stated, All I will say is that he is very lucky! LPN 'B' reported it was known that at least one other time R801 went on LOA with a friend. LPN 'B' reported they felt R801 required more supervision related to going on LOA and did not feel it was in his best interest for unknown friends to pick him up. LPN 'B' said he contacted R801's legal guardian but she did not answer. A review of an investigation conducted by the facility revealed the following:A Quality Improvement Communication and Education Documentation .Staff Education/In-Service Documentation form for LPN 'C' indicated they were in-serviced on LOA Documentation and Assessment. The form noted, It is imperative that nurses document the activity of our residents. In the case of a LOA the documentation must include who the resident is leaving with, where, and when do we expect the residents return. The nurse must also assess if the person can leave with the party. Does the resident have a legal guardian? Does the guardian give their permission for the LOA? The form was signed by LPN 'C' and LPN 'B' (nurse supervisor) on 6/23/25.A copy of an e-mail sent to the DON by LPN 'D' on 6/23/25 documented, Received report from dayshift Nurse that resident (R801) was on LOA with family. Resident did not return to facility during shift.A handwritten statement by LPN 'E' on 6/24/25 documented, I was told that he was not here, family took him out and he hasn't come back yet. The report sheet said LOA. I didn't write a note because I was told he was gone with family. I assumed the nurse whose shift he left on would have reported/made a note about it. I've never wrote a progress note about someone who was already gone with family before I arrived.An In Service document regarding LOA documented, It is imperative that nurses document the activity of our residents. In the case of LOA, the documentation must include: Resident name and room number .Who the resident is leaving with (The name on the log must be legible and with a WORKING phone number) .Where is the resident going and when do we expect them to return .Dose <sic< the resident have a legal guardian? If so, did the guardian give permission? .There must be a doctor's order if the LOA is overnight to leave the facility .Documentation should be in the logbook at the nurses station and a progress note should be written. LOA need to be reported to the oncoming shift and nurses need to notify supervisors if the resident has not returned at the expected time.On 9/9/25 at 3:37 PM, an interview was conducted with the DON, who was the person the Administrator said conducted the investigation into R801's extended LOA. When queried about the facility's protocol for residents going on LOA, the DON reported there should be a doctor's order that says they are allowed to go out. The resident should alert the nurse if they wanted to go on LOA and the nurse should have the resident or the person signing them out sign the log with their name, a contact number for the person taking them out, where they were going, and the time they were expected back. When queried about how the nurses would know who the residents were permitted to leave with if they had a legal guardian who made decisions for them, the DON reported they would not know unless they contacted the guardian or if something was flagged in the medical record. The DON said if a resident had a legal guardian, the nurse needed to obtain consent prior to allowing the resident to leave. When queried about what staff should do if the resident did not return to the facility, the DON reported they should call the resident, the family, the guardian if they were not back by midnight.At that time, the DON was queried about the investigation into R801's LOA. The DON reported she received a call from one of the nurses around 11:00 PM on Monday night (6/23/25) and they said R801 had not returned from LOA since Sunday afternoon, 6/22/25. The DON asked if R801 was signed out on the LOA log and they said he was signed out in the afternoon on 6/22/25, but it was unknown who signed him out. They started calling family and the guardian and neither picked up the phone. They tried to call the resident and he did not answer. The DON explained the police were called to report R801 as a missing person. The DON contacted the nurse who worked on 6/22/25 when R801 left the building on LOA (LPN 'C') and asked her who he left with and when was he expected to return and she did not know and notified the nurse on the second shift that he had not yet returned from LOA. The DON said she called the second shift nurse (LPN 'D') from 6/22/25 and she said LPN 'C' told her he was on LOA, but she did not do anything further on her shift (from 7:00 PM to 7:00 AM) to check to see where the resident was. The DON said she called the first shift nurse from 6/23/25 (LPN 'E') and she told her she did not see R801 during her shift and did not notify anyone. The DON reported both LPN 'D' and LPN 'E' who were contracted through a staffing agency were no longer scheduled to work at the facility because they did not continue to check for R801's return or notify anyone when he had not returned. When queried about whether she interviewed the resident to determine where he had gone and what happened, the DON stated, No. I just left him alone. When queried about what the legal guardian's response was and what additional interventions were put in place for R801 were, the DON said the legal guardian did not call back. When queried about whether any attempts were made other than the night when LPN 'B' realized he had not returned, the DON did not know and said that guardian was difficult to get a hold of. When queried about whether the guardian was unable to be contacted for almost three months, the DON did not offer a response. The DON said no additional interventions were put in place for R801 and there was nothing in place to prevent him from leaving with an unknown person again, other than staff were educated in general on the LOA policy and the form in the logbook were updated to get a contact number. When queried about whether R801 could leave with the unknown person he left with before, the DON stated, Technically he can.A review of R801's Physician's Orders revealed an order since 4/16/25 that noted, MAY LEAVE ON FACILITY SPONSORED TRIPS IF DEEMED MEDICALLY STABLE. There were no other orders regarding LOA. On 9/9/25 at 4:14 PM, an interview was conducted with Social Worker (SW) 'G'. When queried about R801's legal guardian and whether she was able to get in contact with her, SW 'G' said sometimes, but is not too bad to work with. SW 'G' reported she last talked to her a few weeks ago but never discussed anything regarding LOA with her. On 9/10/25 at 9:36 AM, a telephone interview was attempted with LPN 'D'. LPN 'D' was not available for interview prior to the end of the survey.On 9/10/25 at 9:37 AM, a telephone interview was conducted with R801's legal guardian. When queried about R801's LOA and hospitalization in June 2025, the legal guardian said nobody called her and she was unaware that he went on LOA or was in the hospital. The legal guardian explained that anyone other than his brothers would require getting consent from her before allowing R801 to leave the facility. On 9/10/25 at 9:48 AM, an interview was conducted with R801's brother. R801's brother was aware of R801's hospitalization and when asked if he knew what happened said R801 had a bunch of friends in (city name) and if he was with them they will not be doing anything good. R801's brother said the friends find out R801 has some money and they will pick him up and take him out. He said, Nothing good will ever come of it, if he goes with those friends. R801's brother said he let a nurse at the facility know R801 should only go out with him, his other brother, or the guardian.On 9/10/25 at 1:45 PM, an interview was conducted with the Administrator. The Administrator reported it was her first week working in the facility when the incident with R801's LOA occurred. The Administrator reported the DON was responsible to do the investigation. When queried about why no additional interventions were put in place for R801 after he went on LOA with an unknown person and did not come back to the facility and ended up in the stepdown unit at the hospital, the Administrator reported R801 did not have limitations on who he could go out with. When queried about any discussions with the legal guardian about LOAs since R801 returned to the facility on 6/30/25, the Administrator reported the guardian did not call back. When queried about any monitoring that was put in place to ensure the staff followed the policy they were educated on and what was done to ensure other residents did not experience the same type of incident, the Administrator said the staff were educated and that was it. The Administrator said R801 still goes out all the time. A review of a facility policy titled Signing Out Residents, revised 3/15/14, revealed, in part, the following, Each resident leaving the premises must be signed out .If necessary, medications that must be administered while the resident is out will be given to the resident or the person signing the resident out .Restrictions noted on the resident's chart concerning who may not sign the resident out must be honored. Such restrictions may only be placed on the medical record of each resident declared 'medically incapable' by his or her attending physician, and will be designated by the resident's legal representative .Residents must be signed in by a nurse upon return to the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00153580. Based on interview and record review, the facility failed to provide supervision according to the individualized plan of care for one (R801) of three residents reviewed for falls, resulting in an acute intertrochanteric fracture of the left femur (hip) and an acute subdural hematoma (bleeding between the brain and the skull that ultimately resulted in the resident's death after R801 was left unsupervised on the toilet and sustained a fall. Findings include: A review of R801's hospital records revealed the following: A Discharge summary dated [DATE] documented, Discharge Final Diagnosis: Subdural hematoma .(R801) .presented to hospital on [DATE] s/p (status post) unwitnessed fall at her assisted living facility (nursing home). Pt (patient) unresponsive on arrival and not protecting her airway. Pt intubated in the ED (Emergency Department) and taken for CT (Computed Tomography) imaging. Imaging showed acute subdural hematoma measuring 3.6 cm (centimeters) with mass effect, 2.8 cm midline shift, and subfalcine and uncal herniation (a critical condition where accumulating blood compresses and displaces the brain structure causing herniation). Extensive discussion had with family regarding goals of care and comfort measures elected. Pt compassionately extubated on [DATE]. Patient condition continued to decline after extubation. (R801) died on [DATE] at 9:39 . (It should be noted that R801 died on [DATE] at 9:39 per the discharge summary date). A H&P (history and physical) Trauma note documented R801 had a CT of the chest/abdomen/pelvis on [DATE] which revealed an acute intertrochanteric fracture of the left femur and that R801 was unresponsive on evaluation, absent brainstem reflexes. On [DATE], an unannounced, onsite investigation was conducted. A review of R801's clinical record revealed R801 was admitted into the facility on [DATE] and discharged to the hospital on [DATE] with diagnoses that included: hypovolemic shock (a condition caused by severe loss of blood of fluids), dementia with behavioral disturbances, and psychotic disorder. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had intact cognition, no behaviors, required supervision or touching assistance for toilet transfers, and did not have any falls during the assessment period. A review of R801's progress notes from 3/2025 through 5/2025 revealed the following: On [DATE] R801 was observed on the floor on the right side of her bed. R801 reported she slipped while sitting up on the side of her bed and then reaching for her shoes to put on to prepare for a shower. On [DATE], R801 was observed sitting on the floor mat next to the bed. R801 reported she was trying to reach the wash basin and the wheelchair and slid off the bed. R801 was encouraged to use the call light for assistance. On [DATE], R801 was observed on the floor. R801 reported she leaned forward to reach for the wheelchair that was placed by the window. It was documented R801 attempted to self transfer to wheelchair, was a 1 person assist for transfers, but had poor safety awareness and often attempted to transfer independently. It was documented R801's call light was activated at the time of the fall, but R801 did not wait for assistance. On [DATE] at 5:00 AM, R801 was observed on the floor in her room. R801 said she wanted to get to the bathroom and said she did not fall, but sat on the floor mat to prevent herself from falling. The call light was within reach and activated, but R801 did not wait for help. R801 was encouraged to use the call light for assistance. On [DATE] at 2:50 PM, R801 was observed on the floor a second time and said she was trying to go to the bathroom and fell and hit her head on the floor. R801 had a hematoma on the left side of her forehead and was transferred to the hospital in accordance with the physician's orders. R801 returned to the facility at 10:26 PM the same day. On [DATE] at 11:35 PM, R801 was observed on the floor a third time, approximately one hour after returning to the facility from the hospital. R801 reported she did not know what happened and safety checks every hour were implemented for the next 24 hours. On [DATE] at 1:50 AM, R801 was observed on the floor for the fourth time within less than 24 hours. R801 reported she was trying to get cream to put on herself. However the Certified Nursing Assistant (CNA) had already put the cream on a few minutes ago. On [DATE] at 9:30 AM, R801 was observed on the floor by the nurse's station with her wheelchair in front of her. R801 was referred for physical therapy. On [DATE] at 11:15 AM. R801 was observed attempting to self transfer from bed and was placed on one to one supervision. At 11:22 PM, while at the nurse's station, R801 told the nurse she saw a gorilla in her room who almost hit her in the head. At 4:25 PM, R801 was observed on the toilet in her room. R801 reported she transferred herself from the bed to the wheelchair and to the toilet and said she forgot to activate the call light. It was documented that the CNA waited with R801 until she was finished using the toilet and then provided assistance. On [DATE] at 10:13 AM, R801 was observed in her wheelchair. R801 reported she transferred herself and took herself to the bathroom and reported she forgot to use the call light. It was noted R801 refused to wear non-slip socks. On [DATE], R801 took herself to the bathroom and the nurse reminded her to use the call light. R801 said she did not have time to wait. A review of a progress note dated [DATE] at 2:41 PM documented as a late entry (on [DATE] at 8:33 AM) by Licensed Practical Nurse (LPN) 'A' revealed, Writer called in room by 2N (2 North Unit) nurse stating that resident (R801) was on the floor in the bathroom. Writer went in to assess resident and observed resident positioned on laying on her back positioned between wall and toilet. Resident assessed and noted to have left temple with large hematoma and c/o (complained of) pain to her L (left) hip. Resident was assisted back to bed via 2 person manual lift .NP (Nurse Practitioner) present at facility and called to assess. Orders were placed for STAT (right away) X-ray to left hip .Neuro checks initiated . A review of a progress note dated [DATE] at 3:03 PM documented by LPN 'D' revealed, Writer called room for reports of resident on floor in bathroom. Res (resident) positioned on buttocks leaning backwards against toilet seat, positioned between wall and toilet. left temple with large hematoma. Reports pain to left him. Pain with attempts to perform ROM (range of motion). Resident was assisted back to bed via 2 person manual lift .NP present at facility and called to assess .Resident reports that she had been seated on toilet and had 'tried to get my wheelchair' and 'slipped off' toilet. CNA assigned to resident was in 2 [NAME] hallway where a majority of residents are assigned, providing care. Was unaware that resident was on the toilet . A review of a progress note dated [DATE] at 4:35 PM documented by LPN 'D' revealed, Writer called room for reports of res (resident) lethargic. Observed in bed, not responding to verbal or tactile stimuli. Diaphoretic (excessive sweating). BP (blood pressure) 200/88. 911 called and notified need to transfer to (hospital) . A review of an investigation conducted by the facility revealed the following: An Investigation Summary that was also submitted to the State Agency (SA) noted, On the afternoon of [DATE], (R801) was placed on toilet by assigned nurse, (LPN 'A'). Resident was within reach of call light, and able to utilize. (LPN 'A') reported that she had exited room to request that CNA assist with toileting. A short time later it was reported that light was observed to be turned on. Nursing, upon entering room observed (R801) on the floor in the bathroom; nurse proceeded to request assistance of additional nursing staff to assist with assessment and transfer. Three nurses entered room; (LPN 'A'), (LPN 'B') and (LPN 'D'). At that time (R801) was yelling out, in discomfort, holding left hip/sacrum area, reporting pain to area. (NP 'E') was at desk and was notified of concerns with left hip pain and likelihood of fracture, prior to attempting anticipated transfer to bed. Verbal orders obtained to perform STAT X-ray to area .Upon assessment a large hematoma was noted to be developing to left forehead/temple. (R801) reported to have been insisting she 'didn't hit my head'. Nurse Practitioner was then called in to assess the injury .ordered Neuro checks per facility policy for head injuries. Nurses continued neuro checks as ordered, although later in afternoon, during an assessment it was noted that (R801) became unresponsive; pupils dilated. 911 was called and sent to hospital. Later determined that resident had sustained a hip fracture and a subdural hematoma; it was reported by hospital that resident had been vented and then placed on comfort care, and passed away .Written statements of involved parties were taken, cameras were surveyed at time of incident. Residents fall interventions were reviewed. Fall care plan in place and approaches were appropriate. It was noted that (R801) was a Falling Star (a facility program for residents at high risk for falls) due to having sustained a recent increase in impulsive behavior and fall trend in weeks leading up to incident; Part of Falling Star policy involved not leaving a resident unattended on toilet. (LPN 'A') insisted that she had observed (CNA 'C') in hallway and asked her to assist with care of resident. (LPN 'A') reported that she would have remained with resident if she had felt that (CNA 'C') was not going to perform delegated task. Management, during watching the cameras noted that interaction with (CNA 'C'), was not observed to have transpired. Bathroom light was seen for 8 minutes before staff entered room, at which time (R801) has sustained the reported fall .Upon investigation, it was determined involved staff were aware of the facility's star protocol and that (R801) was determined to be a falling star. As a result of this investigation (LPN 'A')'s contract with (facility name) was terminated. (CNA 'C') .was also terminated . A review of R801's care plans revealed the following: A Cognitive Loss/Dementia care plan initiated on [DATE] that read, Resident has a memory/recall problem r/t (related to) dementia. A Falls care plan initiated on [DATE] and edited on [DATE] that read, Resident at risk for falling r/t decreased mobility, keeps door closed for privacy causing staff difficulty visualizing attempts to self transfer; takes medications that can cause falls; falls hx (history); debility from recent hospital stay. The care plan noted multiple interventions initiated on [DATE] (after R801 had five falls within 24 hours between [DATE] and [DATE]) that included: Falling star protocol. A review of the facility's policy and procedure for Falling Star Protocol revealed, in part, the following, Purpose .To identify residents who are at high risk for falls and provide visual awareness to all employees at (facility), so that they can participate as a team in an effort to prevent falls from occurring and reduce the risk for injury. All staff are educated on the falling star program .Procedure .Staff must remain in attendance of resident while toileting, either in the bathroom with the resident or just outside the door . Further review of R801's clinical record revealed Physician's Statement Attesting to Decision Making Capacity forms from [DATE] and [DATE] that indicated R801 does not have the capacity for make informed medical decisions. A review of the camera footage from outside of R801's room on [DATE] between 1:26 PM and 2:32 PM revealed R801's call light was activated at 1:26 PM. At 1:37 PM, LPN 'A' entered R801's room and exited at 1:40 PM. At 1:43 PM, R801's bathroom call light was activated. At 1:48 PM, CNA 'C' walked by R801's room, looked at call light, and did not enter. At 1:50 PM, CNA 'C' walked by R801's room and did not answer the call light or enter the room. R801's call light is no longer lit up at 1:51 PM, but nobody was observed to enter the room. At that time, it was explained by the Director of Nursing (DON) that R801 might have turned the call light off herself. At 1:55 PM, LPN 'B' entered R801's room and exited again. LPN 'B' reentered R801's room at 1:56 PM, followed by LPN 'D' and LPN 'A'. Several other staff members were observed to enter the room, including CNA 'C'. NP 'E' entered R801's room at 2:11 PM. On [DATE] at 11:33 AM, an interview was attempted with LPN 'A' via the telephone. A message was left, but LPN 'A' was not available for interview prior to the end of the survey. On [DATE] at 12:18 PM, an interview was attempted with LPN 'B' via the telephone. LPN 'B' was not available for interview prior to the end of the survey. On [DATE] at 12:22 PM, an interview was conducted with CNA 'C' via the telephone. When queried about what occurred with R801 on [DATE], CNA 'C' reported she was not assigned to R801 that day but was assigned to that hallway. R801's assigned CNA had to work on another hallway as well. CNA 'C' reported she did not witness R801's fall or provide any care to the resident. CNA 'C' recalled seeing R801's call light, but was the only person on the hall at the time and there were other call lights going off so she tried to find someone else to help answer it. CNA 'C' reported at some point the call light was no longer activated and she went into another resident's room. When she came out of the other resident's room, someone told her R801 had fallen. When queried about whether anyone asked her to assist R801 in the bathroom, CNA 'C' reported nobody asked her to assist and it was her understanding someone left R801 in the bathroom. CNA 'C' reported she had been assigned to R801 in the past and she was usually mentally aware and often self transferred, but after a recent hospitalization R801's mental status seemed altered and explained the resident became more anxious and fixated on medical issues and other things. On [DATE] at 2:17 PM, an interview with the DON was conducted. When queried about R801's fall and what the conclusion of the facility's investigation was, the DON reported R801 was a frequent faller and that her cognition teeters. The DON reported LPN 'A' explained to her that she entered R801's room to answer the call light and assisted her onto the toilet. LPN 'A' left the room and explained to the DON that CNA 'C' was outside of the room and she told CNA 'C' to look for R801's call light and when it was activated to help her off the toilet. The DON reported when the facility reviewed the camera footage, LPN 'A' was observed leaving the room and CNA 'C' was not outside of the room and LPN 'A' was not observed talking to CNA 'C'. The DON reported LPN 'A' should have stayed in R801's room until she was done using the toilet. The DON further explained that all staff should answer resident's call lights regardless if they were assigned to that resident, especially when it was blinking which indicated they activated the call light in the bathroom.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00150810, MI00150926, MI00151349 Based on interview and record review, the facility failed to ensure one (R801) of three residents reviewed for accidents, was transferred in a safe manner with fully functioning equipment and with the proper level of assistance, resulting in the resident falling out of the mechanical lift sling and sustaining an acute impacted fracture (fracture typically caused by force or trauma) of the right hip, a distal intertrochanteric fracture (fracture between the bony protrusion of the thighbone) of the right hip, an acute intertrochanteric fracture of the left hip, and Focal round hyperdensity (spot brighter than the surrounding brain indicating an abnormality) within the right sylvian fissure (part of the brain) measuring approximately 5 mm (millimeters) .potentially representing aneurysm (bulging blood vessel) or hemorrhage (bleeding). Findings include: A review of a complaint submitted to the State Agency revealed an allegation that on [DATE], R801 was dropped out the (brand name for mechanical lift). There was only one care giver moving the resident. It was noted R801 was transferred to the hospital where it was determined she had broken both femurs (hips), left wrist, had a brain bleed, and heart stress. R801 had surgery on the femurs, was in the intensive care unit (ICU), and signed onto hospice services on [DATE]. On [DATE] at 10:58 AM, the complainant provided additional information. It was reported R801 died on [DATE] and the death was deemed accidental according to the medical examiner. At that time, a copy of the death certificate was requested. A review of a second complaint submitted to the State Agency revealed an allegation that Certified Nursing Assistant (CNA) 'A' transferred R801 with a mechanical lift without the assistance of another CNA, did not have the sling under the resident appropriately, and R801 was dropped from the mechanical lift. It was alleged R801 had broken femur bones, a hematoma, a brain bleed, and remained hospitalized . It was further alleged CNA 'A' reported the mechanical lift was missing clamps. A review of a Facility Reported Incident (FRI) submitted to the State Agency revealed R801 slipped out of the mechanical lift while being transferred and sustained injuries. An unannounced, onsite investigation was conducted on [DATE]. A review of R801's clinical record revealed the following: R801 was admitted into the facility on [DATE], readmitted on [DATE], and discharged to the hospital on [DATE] with diagnoses that included: Multiple Sclerosis (MS). A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R801 had moderately impaired cognition and was dependent on staff for transfers and all activities of daily living. A progress note dated [DATE] at 12:45 PM, written by Licensed Practical Nurse (LPN) 'C', noted, Writer called into room and upon arrival writer observed resident on floor. (CNA) stated that she was getting resident up in chair for lunch and bingo with the lift and a second person. She stated when she went to lift her up and move her she began to slide out of the sling and hit the floor. (CNA) was unable to tell if resident hit her head stating everything happen so fast. Writer assessed resident and noted large hematoma on top of resident L (left) hand, no lumps or bruises were noted to resident head at the time and resident had no c/o (complaints of) pain to her head .Resident communicating at baseline with staff. Due to the extent of resident fall a pillow was placed under resident head for comfort and resident was not moved , writer remained at resident side and sent for supervisor. Supervisor came to room and began the process of sending resident out 911. EMS (Emergency Medical Services) arrived to facility around 11:30 (AM) and resident was sent to (hospital) . A review of R801's care plans revealed care plan initiated on [DATE] that noted the following intervention: TF (transfer) with (brand name mechanical lift - a lift used to transfer residents who are unable to stand or assist with transfers). A review of R801's Imaging results from the hospital revealed the following: A CT (Computed Tomography) CHEST/ABDOMEN/PELVIS . completed [DATE] at 4:15 PM revealed, .REASON FOR EXAM: trauma, dropped from (mechanical lift) .Impression: 1. Acute impacted fracture in the subcapital region of the right hip. Additional distal intertrochanteric right hip fracture. 2. Acute intertrochanteric fracture of the left hip extending into the proximal left femoral shaft, incompletely visualized .4. Suspect mildly impacted acute fracture of the distal left radius (wrist) . A CT HEAD WO (without) CONTRAST completed [DATE] at 4:15 PM revealed, .REASON FOR EXAM: trauma .Impression: Focal round hyperdensity within the right sylvian fissure measuring 5 mm. This appears new from prior study and is nonspecific, potentially representing aneurysm or hemorrhage . A review of an investigation conducted by the facility revealed the following: (R801) was being transferred in a (mechanical lift) by (CNA 'A'). One of the sling's loops in the arm of the lift slipped off and (R801) slid to the floor during a transfer from her bed to her wheelchair. 911 was called after complaints of leg pain. Administrator notified on 2/27 that (R801) has an acute displaced spiral fracture of bilateral femoral metadiaphysis and mild foreshortening of the right femur. She has also a suspected nondisplaced radial styloid fracture. She is currently in the hospital. The lift was immediately pulled from the floor and inspected. It appeared to be in good working order however a safety clip on the arm was not present . .Investigation Summary/Actions Taken .(R801) .has been bed bound for a number of years .The Administrator and Director of Nursing (DON) met with (CNA 'A') and reenacted the incident with the same lift to determine the root cause. (CNA 'A') was using the (mechanical lift) to transfer (R801) from her bed to her wheelchair. She had another staff member present (Housekeeper 'B') .(CNA 'A') lifted her off the bed and then moved the lift away from the bed. She began to turn it towards her wheelchair, which was placed at the foot of her bed. As she was turning the lift, (R801's) body weight shifted, and the sling swung out. The legs of the lift were extended but the motion moved one of the slings loops off the arm of the lift and (R801) slid out of the sling and onto the floor. She began to complain of pain in her left hip and had a large hematoma on top of her left hand .She was immediately sent to (hospital) for evaluation . .It was determined the next day, while reviewed hospital paperwork, that she was diagnosed with Bilateral femur fractures and suspected left radial styloid fracture .Her initial CT of her head was negative. Repeat imaging was completed and neurosurgery stated that she likely sustained a mild traumatic brain injury with the development of a very small acute subarachnoid hemorrhage (brain bleed). (R801) is set to have surgery on 3/3 to repair her fractures .The family has decided to pursue palliative care and will not be returning to (facility) . .Investigation showed that preventative maintenance was completed quarterly on the lift and was just serviced on [DATE] .A post incident evaluation of the lift was completed and found that the only concern was a safety clip missing from one arm .It appears that the sling loop slipped out of the arm due to the safety clip not being present .At this time, it appears the missing safety clip played a pivotal role in (R801's) fall. A full nursing staff education is being completed .This education will be focused on the proper assessment of lift equipment prior to use, how to determine what type of transfer status a resident has been approved for . On [DATE] at 11:19 AM, an interview was conducted with Housekeeper 'B' via the telephone. When queried about what happened to R801 on [DATE], Housekeeper 'B' explained she went into R801's room and CNA 'A' was getting R801 ready for lunch. The sling for the mechanical lift was underneath R801 and R801 was lying in bed. When CNA 'A' lifted R801 up using the lift, R801 fell out of the sling and onto the floor. Housekeeper 'B' reported there were no other staff members in the room during the transfer. When queried about whether they were cleaning R801's room at the time, Housekeeper 'B' stated, I guess I was just in there. Housekeeper 'B' reported CNA 'A' asked her to come into the room to spot her with (R801). Housekeeper 'B' explained she was just in the room and did not provide any assistance to CNA 'A' during the mechanical lift transfer of R801. Housekeeper 'B' went to get the nurse after R801 fell. On [DATE] at 11:25 AM, an interview was conducted with CNA 'A'. CNA 'A' reported she began working in the facility in [DATE] and had been a CNA for 22 years. When queried about how R801 fell on [DATE], CNA 'A' explained she was getting R801 up for lunch and bingo afterwards. She got R801 dressed and did her hair and placed the sling (for the mechanical lift) underneath the resident who was on the bed. CNA 'A' reported she checked the battery for the lift and that the feet of the lift were fully expanded. CNA 'A' said she had a spotter in the room with her. CNA 'A' explained she got the sling hooked up to the lift, raised the resident up in the sling, turned the resident to position her over the wheelchair, and when she did that, R801's weight shifted and she fell out of the sling from the lift and onto the floor. When queried about who was assisting her with the transfer, CNA 'A' reported Housekeeper 'B' came in to spot. When queried about why she asked a housekeeper to spot and did not get a nurse or a CNA to assist with the transfer, CNA 'A' reported the other CNA assigned to the hall was in with another resident, the CNA orientee was showering a resident, she did not know where the other CNA was, and the nurse was busy passing medications. According to CNA 'A', the paper she received during orientation regarding mechanical lift transfers only mentioned having a second person in the room as a spotter and she understood that to mean another set of eyes and not actually assisting with the transfer. CNA 'A' further reported one of the clips on the hanger bar to the lift (the part where the sling is clipped too) was missing. CNA 'A' explained that the sling is hooked onto the bar and a clip locks the sling in place. CNA 'A' reported she noticed it was missing on the hook located by R801's right leg and stated, It is what we had available and explained she continued to transfer the resident with the missing clip. CNA 'A' explained she did not think the sling would come off the hook with or without the clip because everyone had been using the mechanical lifts with missing clips, but she could see how that may have contributed to her fall because it was the side R801 fell from. On [DATE] at 12:58 PM, an interview was conducted with the Administrator. When queried about what was discovered through the facility's investigation into R801's fall, the Administrator reported CNA 'A' walked her through what happened and explained after examining the sling and the lift, the side R801 slipped out of was the side with the missing safety clip so they determined that to be the likely cause of R801's fall from the lift. The Administrator further reported after reviewing the facility policy regarding mechanical lift transfers at the time of R801's fall, it was discovered it said two people were required, but did not specify what that meant. It was further reported that the manufacturer's manual for the mechanical lift did not mention the safety clips so it was unclear if it was important. When queried about the purpose of the clips, the Administrator reported the clip locked the sling into place on the hook but that the importance of them was likely not clearly communicated to nursing staff. When queried about CNA 'A' asking a Housekeeper to spot during a mechanical lift transfer requiring two people to assist, the Administrator reported CNA 'A' made a bad decision and should have waited for a member of the nursing staff team to assist. On [DATE] at approximately 3:30 PM, an observation of the type of mechanical lift used on [DATE] with R801 was conducted. On each end of the hanger bars were hooks that secured with a metal clip. At that time, CNA 'D' was interviewed regarding the safety clips on the mechanical lifts. CNA 'D' explained before a month ago, there were times where they would be missing from the lift. CNA 'D' further said they were easy to remove and demonstrated how to remove them and stated, I have never done it, but could see someone taking the clip off because it would be easier to get the sling off the hook after the transfer. On [DATE] at 4:45 PM, an interview was conducted with LPN 'C'. When queried about what happened to R801, LPN 'C' reported she was notified by Housekeeper 'B' that R801 fell from the mechanical lift. LPN 'C' was not in the room when in happened, but assessed R801 after the fall. When queried about whether CNA 'A' requested assistance with transferring R801, LPN 'C' reported she did ask for assistance, but she was in the middle of administering medication. LPN 'C' reported CNA 'A' said she needed assistance, but after LPN 'C' passed the medication, CNA 'A' was in the resident's room and did not return to ask for help. A review of a .Discipline Employee Counseling Report dated [DATE] revealed CNA 'A' received counseling regarding not following the policy regarding lift safety and have a second person during a mechanical lift that was a trained caregiver. A review of a form titled, Orientation - CNA Expectations signed by CNA 'A' upon hire on [DATE] revealed, .Lifts demonstrated first time as 'spotter'/second person . A review of an undated facility policy titled, Resident Transfers revealed, in part, the following, .Prior to transferring the resident, refer to the Care Card for the appropriate transfer status .Safety is our primary concern with transfers . During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included inspection of all mechanical lifts to ensure they were in working order and updated the policy to include ensuring safety clips were part of the safety check process, education was provided to all licensed nursing staff to include proper safety checks of the mechanical lifts and to ensure appropriate assistance is provided according to the resident's plan of care. The facility conducted audits of staff who provide transfers using a mechanical lift to ensure they were used in a safe manner and audits of the mechanical lifts to ensure they were inspected and in proper working order. 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: MI00133899. Based on interview and record review the facility failed to timely assess, identify and notify the physician of the worsening of the sacrum wound and consistently implement and apply adequate treatment and interventions for one (R69) of three residents reviewed for pressure ulcers, resulting in the development of an infected stage IV pressure ulcer (Stage 4 Pressure Ulcer- Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer). Findings include: Review of the medical record revealed R69 was admitted to the facility on [DATE] with a readmission date of 9/7/22 and diagnoses that included: dementia, chronic kidney disease, difficulty walking and muscle weakness. A Minimum Data Set (MDS) assessment dated [DATE] documented Moderately impaired cognitive skills for daily decision making and required staff assistance for all Activities of Daily Living (ADLs). Review of the progress notes documented on 9/2/22 revealed the resident fell, complained of pain, and an x-ray revealed an intermediate central left inferior pubic ramus and lateral left superior pubic ramus/acetabular fractures. The resident was transferred to the hospital for a higher level of care. Review of a Social Worker note dated 9/7/22 at 1:31 PM, documented the resident was readmitted with a diagnosis of a left inferior pubic ramus fracture after a fall. Review of the medical record revealed a Braden Scale for Predicting Pressure Sore Risk was not completed upon readmission back to the facility on 9/7/22. Further review of the medical record documented the last Braden assessment completed was on 6/29/22 at 1:47 PM, which indicated the resident was At Risk with a score of 16.00. This was not an accurate score to reflect R69's status and change of condition upon readmission into the facility on 9/7/22 after their fall. Review of the September 2022 Medication and Treatment Administration Record (MAR/TAR) documented the following order in part, . Remedy Phytoplex Z-Guard . zinc oxide-white petrolatum . OTC (Over The Counter) paste; 15-57 % . apply liberal amount to excoriation to anus every shift until healed . This order started on 9/7/22, the day R69 was readmitted back to the facility. Review of a Shower Sheet dated 9/8/22 at 5:57 PM, documented in part . Discolored/bruised skin area on buttocks. Excoriated area noted on buttocks . Review of a Nurse Practitioner (NP) note dated 9/8/22 at 6:37 PM, documented in part . complaints of left hip pain and inability to ambulate s/p (status post) fall 9/2/22 . Therapy reports significant decline from prior level of function. Was ambulating . with 2WW (two-wheel walker) and now a lift (hoyer). Therapy reports uncontrolled pain with any LE (lower extremity) movement as does nursing . This reflected the decline identified with R69 after readmitting back to the facility. Review of a Shower Sheet dated 9/10/22 at 5:41 PM, documented in part . Discolored/bruised skin area on buttocks. Excoriated area noted on buttocks . Review of a NP note dated 9/13/22 at 4:42 PM, documented in part . left hip pain and inability to ambulate s/p fall 9/2/22 . Therapy reports need for pressure relieving mattress - starting to get skin breakdown at coccyx per staff . breakdown to coccyx - not assessed . Further review of the medical record revealed no documentation of any assessment, measurements, or characteristics to the skin breakdown on the coccyx. Review of a NP note dated 9/15/22 at 11:07 AM, documented in part . Nursing reports patient not eating . Down 8 pounds in the last week . breakdown to coccyx - not assessed . Decline in function / gait impairment 2/2 (secondary to) fall . Review of a Shower Sheet dated 9/15/22 at 3:26 PM, documented in part . Buttocks area excoriated. Cream applied as ordered . Review of a NP note dated 9/20/22 at 6:15 PM, documented in part . Skin changes to BLE (Bilateral Lower Extremities); breakdown to coccyx - not assessed . Review of a Registered Nurse RN note dated 9/21/22 at 6:10 AM, documented in part . 10x3.8 cm (centimeters) wound to sacrum with 6x3cm slough (slough- non-viable yellow, tan, gray, green or brown tissue; usually moist can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) to wound center. Surrounding skin is pink and intact. Initiated treatment: Santyl, NS (Normal Saline) damp gauze, Foam dressing-change Q (every day) . Alternating airflow mattress in place. Roho cushion to wc (wheelchair) . repositioned frequently/side to side only. Will continue to monitor and adjust care plan as appropriate. Further review of the medical record revealed no documentation of identification of worsening to the sacrum wound prior to 9/21/22 or that appropriate treatment was implemented timely to prevent worsening of the coccyx/sacrum area. Review of R69's care plans documented the following interventions implemented prior to 9/21/22, . BLE (bilateral lower extremity) tubigrips; on in am, off at hs (hour of sleep) . A&D to heels q (every) HS . Adequate fluid and food intake . Assist bar to bed for bed mobility . Assist with toileting and repositioning . Body/skin audit at least weekly . Braden scale quarterly and PRN (as needed) . give incontinence care after each episode . Hydraguard protectant cream to buttocks and peri area after each incontinent episode . keep call light within easy reach . keep closet stocked with briefs . maintain good body alignment w/ weight distributed evenly . Nystatin powder under B (both) breast prn . Report any red or open areas . ROHO cushion to wc, check inflation qs (every shift) . Further review of the care plans revealed on 9/21/22 the facility implemented the following intervention- Santyl, NS damp gauze, Foam dressing- change Q day, No further interventions were implemented. Review of the September 2022 MAR and TAR documented an order to Reposition side to side Q 2 hours - keep pressure off of coccyx area . every shift with a start date of 9/21/22. Review of the medical record revealed the initial physician assessment of the sacral ulcer was on 10/10/22, more than two weeks after the identification of the wound worsening. Review of a physician consult dated 10/10/22, documented in part . sacral ulcer . Continue Santyl daily . see (physician name) . for deep debridement . follow up with me in 2 weeks . Review of a RN note dated 10/10/22 at 9:37 AM, documented in part . Sacrum, unstageable (unstageable- Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) - 3.0x8.0cm - Dry wound bed with 70% thick, spongey, yellow-green slough/ 5% necrosis to center of slough/ 25% pearly pink bed. Santyl appears to be effectively debriding wound, irregularly shaped . mild pungent odor . Review of a RN note dated 10/18/22 at 3:59 AM, documented in part . Sacrum, unstageable- 7.5x3.0cm - Dry wound bed with 30% thick, spongey yellow-green slough to center of wound/ 70% pearly pink bed surrounding slough, Santyl appears to be effectively debriding wound . Scant exudate. Moderately pungent odor . Painful with dressing change . Review of the October 2022 MAR and TAR documented staff continued to apply the Zinc oxide-white petrolatum paste liberally to the excoriation to anus every shift with the Santyl ointment that was applied to the sacrum daily. Review of a physician consult dated 10/26/22, documented in part . significant stage IV pressure ulcer (Stage 4 Pressure Ulcer- Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed .) sacrum with exposed bone with extensive necrotic tissue. Unable to debride at bedside. Will require O.R. (operating room) debridement. Discussed palliative vs active care with daughter . Santyl to ulcer daily . Turn Q2 (every two) side to side . Palliative/hospice consult . If active treatment, will require . ostomy, OR debridement, PEG with tube feeding . Doxycycline 100 mg (milligram) BID (twice a day) x 14 days . Cipro 500 mg BID x 14 days . Review of the medical record revealed no documentation of the staff to identify the worsening of the sacrum wound prior to the physician assessment on 10/26/22. Review of a Licensed Practical Nurse (LPN) note dated 10/26/22 at 7:03 PM, documented in part . Treatment in place <sic> coccyx wound. Oral ABT (antibiotics) ordered for wound infection . Review of the October 2022 MAR and TAR documented the Santyl ointment was discontinued on 10/31/22. Review of the medical record revealed no documentation on why the Santyl ointment was discontinued on 10/31/22, despite the physician ordering the Santyl treatment to continue on 10/26/22. Review of the November 2022 MAR and TAR documented the following order . mild soap and water, pat dry, cover wound cover <sic> with foam dressing. Change Q day and PRN this order started on 10/31/22 and was discontinued on 11/1/22. This is not an appropriate treatment for a stage IV pressure ulcer. Review of the medical record revealed no documentation on why the Santyl treatment was stopped on 10/31/22 and why the soap and water treatment started on 10/31/22 and was discontinued on 11/1/22. Further review of the November 2022 MAR and TAR revealed no treatment to have been applied to the sacrum wound from 11/1/22 until the date of R69's death on 11/4/22. Review of the medical record revealed no documentation on why the wound treatment to the sacrum was stopped. Review of the medical record revealed R69 was admitted to hospice care on 10/27/22 and was pronounced deceased on [DATE]. On 4/5/23 at 2:31 PM, the Director of Nursing (DON) was interviewed and asked why there was no timely physician assessment of the sacrum wound, no timely identification of the worsening of the wound, no timely and adequate interventions and treatment implemented for the sacrum wound, completion of a readmission Braden assessment, and why the treatment for the sacrum wound was stopped on 10/31/22 and an order for soap and water started and was stopped on 11/1/22 with no further treatment to the wound until the resident's death. The DON stated they would look into it and follow back up. On 4/6/22 at 8:32 AM, the DON returned for a follow up interview and stated the June 2022 Braden assessment was an inaccurate reflection of R69's status upon readmission on [DATE], a new Braden should have been completed. The DON was unsure on why the Santyl treatment was discontinued but believe hospice implemented the soap and water treatment. The DON stated they found orders that was supposed to be implemented for the sacrum wound, however reviewed the MAR's and TAR's, and found the orders was never implemented for staff to apply to R69's sacrum wound once it was discontinued. The DON stated staff should have notified the physician and documented in the progress notes regarding the worsening of the wound. The DON stated they would start education with their staff immediately. No further explanation or documentation was provided by the end of survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00133679 Based on observation, interview and record review, the facility failed to ensure one (R707) of two residents reviewed for accidents was transferred in a manner consistent with their plan of care, resulting in a fracture to R707's left humerus (long bone in the arm that runs from the shoulder to the elbow). Findings include: Review of a Facility Reported Incident (FRI) read in part, .(R707) had an increase in pain after a transfer on 12/12/22 . a follow up x-ray was completed 12/27/22 . left proximal humerus fracture . On 1/18/23 at 10:32 AM, R707 was observed lying in bed. R707 was asked how her left arm was injured. R707 explained it was her shower day and the Certified Nursing Assistant (CNA) came in to give her a shower, she told him she needed a mechanical lift, but he told her he was strong enough to pick her up, he then put the shower chair up close to the bed and lifted her up by putting his arms under her arms and lifted her up and put her in the shower chair . he lifted her left arm higher than her right arm. R707 explained she told the CNA, well, that was uncomfortable, and that she did not want to have a shower, so he picked her up again and put her in the bed and gave her a bed bath. When asked if she told anyone about her arm injury, R707 explained she told the nurse during the night because her arm was hurting so bad she needed a pain pill. In R707's room, a blue binder was observed on the wall in a vertical wall file with R707's bed number on it. Upon opening the binder, a bedside care plan documented R707's transfers as, [NAME] or [NAME] II (mechanical lift), 2 assist. R707 asked what was in the blue binder as she had never seen anyone look at it before. R707 was asked how staff transferred her. R707 explained they used a mechanical lift. When asked how many staff transferred her with the mechanical lift, R707 explained she knew there were supposed to be two staff, but a lot of the time there was only one staff member that would transfer her. Review of the clinical record revealed R707 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: stroke affecting the left side, diabetes and heart failure. According to the Minimum Data Set (MDS) assessment dated [DATE], R707 was cognitively intact and required the extensive to total assistance of staff for all activities of daily living (ADL's). Review of R707's ADL care plan revealed an approach edited 12/10/20 that read, TF (transfer) = vanderlift x 2PA (two person) with sling wrapped as cocoon. Review of R707's progress notes revealed: A nursing note by Licensed Practical Nurse (LPN) D dated 12/13/22 at 1:51 AM that read in part, 1:39 am Resident c/o (complaining of) pain on left shoulder, when asked why her shoulder hurt stated It hurts when I move it, the big black man picked me up today for a shower and told him that he can't do that because it hurt, so he put me down and end up giving a bed bath. Resident was given norco (pain medication) . A physician note dated 12/13/22 at 3:54 PM read in part, .patient complained of pain to left shoulder after attempted transfer for shower . Patient is irritable today and reports pain to shoulder with any movement or touch . A nursing note by LPN E dated 12/13/22 at 7:06 PM read in part, Resident has been complaining of L (left) shoulder pain, prn (as needed) pain medication given, appetite poor during dinner . A physician note dated 12/15/22 at 4:43 PM read in part, Patient seen in follow up of left shoulder pain . Patient reports that her left shoulder continues to hurt . patient remains tender to touch. Patient reports shoulder pain is acute. No prior history of shoulder pain. Pain is worse with movement and increased with log rolling for brief changes. Patient reports difficulty sleeping secondary to pain . A physician note dated 12/20/22 at 4:19 PM read in part, .Patient reports continued left shoulder pain. Reports of increased pain with movement of any part of left arm . A physician note dated 12/27/22 at 2:26 PM read in part, .Patient seen in follow up of left shoulder pain . Repeat left 2 view x-ray done today showing: Acute appearing fracture of the surgical neck as noted . On 1/18/22 at 3:35 PM, CNA B, R707's assigned CNA on 12/12/22, was interviewed and asked what happened with R707 on 12/12/22. CNA B explained he was going to give R707 a shower, he sat her up on the side of the bed, pulled the shower chair up to the bed and did a stand a pivot and put her in the shower chair. CNA B was asked if he knew what R707's transfer status was before he transferred her. CNA B explained she was a mechanical lift, but sometimes R707 would stiffen up when using the lift and he knew he could lift residents up and they would not fall. CNA B was asked what happened after he got R707 into the shower chair. CNA B explained R707 objected and said it was uncomfortable and wanted to be put back in bed, so he put her back into the bed and gave her a bed bath. When asked if R707 ever told him her left arm or shoulder hurt, CNA B explained R707 did not say anything hurt. On 1/18/23 at 4:00 PM and 1/19/23 at 8:00 AM, CNA E, R707's assigned midnight CNA, was called and a message was left. No return phone call was received by the end of the survey. On 1/19/22 at 9:12 AM, LPN D was interviewed by phone and asked about R707's left arm. LPN D explained sometime after 1:00 AM, CNA E came to her and said R707 was complaining of arm pain, so she went in and R707 told her the big black man picked her up and it hurt, so he put her back in bed and gave her a bed bath. LPN D was asked if she knew if R707 had gotten a shower the day before. LPN D explained it was documented that CNA B had given R707 a shower on 12/12/22. On 1/19/23 at 10:50 AM, the Director of Nursing (DON) was interviewed and asked if staff could pick up a resident and do a stand and pivot on someone that was a two person mechanical lift. The DON explained residents should always be transferred per their transfer status. Review of a facility policy titled, Resident Bedside Care Plans dated 1/15/14 read in part, It is the policy of [Facility] to use a Resident Bedside Care Plan Cart to communicate to direct caregiver's the information needed to care for the resident . Information on the Resident Bedside Care Plan will include, but not be limited to, .transfer status . The Resident Bedside Care Plan will be placed in each resident's room for easy access .