**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Citation related to intake #2575541Based on interview and record review, the facility failed to prevent physical abuse and neglect for two residents (R4, R6) of three residents reviewed for abuse, resulting in emergency hospitalization, injury and fearfulness. Findings include: Resident #4 (R4)Review of an admission Record revealed R4 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses of dementia, Parkinson's disease, and type 2 diabetes. Review of a Brief Interview for Mental Status (BIMS) dated 7-25-25, reflected a score of 0 out of 15 which indicated severe cognitive impairment. Review of a VA (veteran's administration) admission report, faxed to the facility and stamped as received on 7-09-25, revealed the following information regarding R4: (a) veteran (R4) with recent noted appetite and oral intake decrease, (b) wife/caregiver had been offering and feeding R4 with nutritional supplements but there had been a 10-15 pound weight loss in past 6 months, (c) type 2 diabetes assessment-blood sugars are well controlled .VA pharmacy discontinued his insulin in March 2025 and will continue on Metformin 1000 mg (milligrams) twice daily .if blood sugars are consistently elevated above 200, pharmacy has recommended restarting insulin.Review of a Blood Sugar Summary for R4 revealed that blood sugars were not checked by the facility from time of admission on [DATE] to the time of hospitalization on 7-27-25.Review of a Nursing Note for R4 dated 7-18-25 revealed .(R4) arrived at facility via car from home accompanied by wife, walked onto unit using a walker, unsteady gait, no skin concerns noted, and able to handle hot liquids.Review of a Nursing Note for R4 dated 7-19-25 at 8:34 AM reflected .(R4) alert to self, accepts meds crushed, respirations even/unlabored, breath sounds diminished, no edema noted, vital signs stable, ambulates with one person assist and four wheeled-walker, allows staff to assist him.Review of a 'Nursing Note for R4 dated 7-19-25 at 10:23 AM reflected .alert and oriented to self, has difficulty making needs known, no signs or symptoms of pain, lung sounds clear on room air, ambulates with one assist and four wheeled-walker with shuffling gait, able to feed self finger foods.Review of a Nursing Note for R4 dated 7-19-25 at 7:00 PM reflected .alert and oriented to self with confusion, lung sounds clear, no edema (swelling) noted, skin warm and dry, maximum assist needed with ADL's (activities of daily living), requires assist with meals, ambulates with walker and assist, requires assist with meal, is pocketing food and not swallowing well.Review of a Nursing Note for R4 dated 7-19-25 at midnight revealed .alert and oriented to self, respirations even and unlabored, no edema, ambulates with walker and assist.Review of a Nursing Note for R4 dated 7-20-25 at 9:50 AM reflected .alert and oriented to self, confusion, lung sounds clear on room air, no edema, transfers and ambulates with four-wheel walker and one assist, pocketing food and putting too much in his mouth. During an interview on 8-11-25 at 2:00 PM, Family Member W stated that she spoke to R4 on the phone the evening of 7-20-25 and he sounded pretty good and like himself.Review of a Nursing Note for R4 dated 7-21-25 at 6:04 PM revealed .resident noted to be pocketing food, cognition is poor and not following simple directions, Speech Therapy screen placed. This was the only nursing progress note documented on 7-21-25. Review of a Physician Note for R4 dated 7-22-25 revealed the following: (a) required long term care due to dementia, Parkinson's disease, heart disease, and diabetes, (b) currently ambulatory with assist, (c) exam is positive for trouble swallowing, weakness, and confusion.Review of the EHR (electronic health record) for R4 reflected that no Nursing Note (s) were documented for a face-to-face nursing assessment on 7-22-25. Review of the EHR for R4 reflected that no Nursing Note (s) were documented for a face-to-face nursing assessment on 7-23-25. Review of a Nursing Note for R4 dated 7-24-25 at 3:04 AM reflected .resident is alert to self, accepts meds crushed in pudding, poor appetite, resting in bed at this time. This was the only nursing progress note documented on 7-24-25 regarding the overall well-being and assessment of R4. Review of the EHR for R4 reflected that no Nursing Note (s) were documented for a face-to-face nursing assessment on 7-25-25.Review of an Occupational Therapy (OT) Evaluation for R4 dated 7-25-25 indicated the reason for the referral was staff reported that on 7-23-25 and 7-24-25 the resident had difficulty holding up his head and/or was bent over in half forward or leaning position. During an interview on 8-11-25 at 2:25 PM, Family Member V stated that the Wednesday before (R4) went to the hospital (7-23-25) something was wrong, and I told staff that he wasn't himself and that something was different. FM V indicated that nursing staff told her that he (R4) is giving up and this is how the end of life looks. FM wife stated that this was very upsetting to her and that it felt like staff were making excuses, so they didn't have to figure out what happened and why he (R4) was so much worse. Review of a Nursing Note for R4 dated 7-26-25 at 12:30 AM noted .family here at beginning of shift and assisted resident with fluids and supplements, resident did take medications with much encouragement, resident is non-verbal. Review of a Nursing Note for R4 dated 7-26-25 at 2:53 PM reflected .resident is not responding appropriately with staff and is difficult to arouse, declined meals this day. Further review of the EHR revealed that vital signs were not assessed and documented for R4 on 7-26-25, nor did the documentation reflect that the physician was made aware of the change in condition. During an interview on 8-11-25 at 2:25 PM, Family Member V stated that she was at the facility and spoke with nursing the evening of 7-26-25 and asked if they were able to provide IV therapy (intravenous fluids). Nursing told her that because R4 is at the end of life and is not doing well, it would be very difficult on his body to have him sent to the Emergency Room. I was disgusted with them about this.Review of a Nursing Note for R4 dated 7-27-25 at 12:10 AM reflected .resident received night-time care and repositioned by staff, no signs or symptoms of respiratory distress noted at that time, resting comfortably. The note did not include any assessment of R4's alertness, orientation, ability to open his eyes or respond to staff. Review of a Nursing Note for R4 dated 7-27-25 at 1:47 AM reflected .resident is not opening his eyes or responding to staff interactions. No additional assessment information was documentedReview of a Nursing Note for R4 dated 7-27-25 at 2:39 AM indicated .at 2:10 AM nursing went into resident's room after bed check as staff stated resident felt warm. Vital signs taken: blood pressure 82/47, pulse 113, respirations 24, oxygen saturation 90%, and temperature 99.3. Phoned (responsible party) and advised that we would be sending R4 to the Emergency Department. Review of an Emergency Medical Response (EMR) run report revealed the following: (a) EMS was dispatched priority 1 with lights and sirens and was at R4's bedside at 2:27 AM, (b) primary symptom-altered mental status, provider's secondary impression-sepsis, (c) initial blood pressure 60/34, heart rate 115, oxygen saturation 81% with a non-rebreather mask placed by the facility, temperature 103.1, and respirations 30 and labored, (d) R4 was unresponsive, (e) EMS switched R4 to oxygen via nasal cannula and oxygen saturation immediately improved to 98%, (f) (R4) was not conscious, did not respond to sternal rub or follow commands, was very hot to the touch, and (g) staff indicated that (R4) has been declining over the past day or two. Review of the complaint #2575541 received by the State Agency and submitted by paramedic U for R4 reiterated the findings noted above in the EMR run report and added .patient was placed on a NRB (non-rebreather) oxygen mask which was improperly being used and was causing harm to the patient. Key findings of sepsis were noted, and this was not a sudden medical issue. Review of emergency room Provider Notes dated 7-27-25 at 2:46 AM reflected the following regarding R4: (a) per nursing facility report (R4) had been less responsive for the past two days, (b) patient was emergently intubated (a tube was placed to breath for him), (c) was ill-appearing, diaphoretic (sweating), had very dry oral mucosa, (d) blood sugar was 1,165 (one thousand one hundred and sixty five), (e) was in renal (kidney) failure, (e) had severe dehydration, and (g) was admitted to the ICU (intensive care unit) in critical condition. Resident #6 (R6) and Resident #1 (R1)Review of an admission Record revealed R6 was an [AGE] year-old-female, last re-admitted to the facility on [DATE]. Review of a BIMS dated 7-22-25 revealed a score of 11 out of 15 which indicated some cognitive impairment. Review of an admission Record revealed R1 was an [AGE] year-old-female, originally admitted to the facility on [DATE] with pertinent diagnoses of severe dementia with behavioral disturbances, anxiety, and history of a stroke. Review of a Nursing Note for R1 dated 7-17-25 indicated the resident wandered the unit and was exit seeking. Review of a Nursing Note for R1 dated 7-18-25 reflected that the resident appeared restless and anxious, wandered on the unit going into other resident's room, not easily redirected, argumentative with staff, began to follow another female resident around the unit.Review of Nursing Notes for R1 dated 7-21-25 reflected that the resident was actively exit seeking, going into other resident's room, going through their belongings in closet and dresser drawers, difficult to redirect, argumentative with staff, yelling profanity at staff and roommate, difficult to redirect the majority of the day, slapped the nurse when R1 was noted to be wearing her roommates pants. Review of a Nursing Note for R1 dated 7-22-25 reflected that the resident appeared restless and anxious, going into other resident's rooms, exit seeking, followed another female resident around the unit and when nursing intervened, R1 attempted to hit the nurse, and continued to wander into other resident's rooms as they were receiving bedtime care and yelled at staff when asked to leave the room. Review of a Nursing Note for R1 dated 7-23-25 revealed that the resident was arguing with her roommate, yelling, and tried to slap staff.Review of a Nursing Note for R1 dated 7-26-25 revealed the resident was often found in other resident's rooms, going through closets and drawers and taking items of clothing back to her room and was easily angered when staff attempted to redirect her. R1 was also yelling and confrontational with other residents.Review of a Nursing Note for R1 dated 7-27-25 reflected the resident attempted to push other residents around the unit in their wheelchairs and attempted to remove another resident out of a chair in the common area. Review of a Nursing Note for R1 dated 7-28-25 revealed the resident was taking other resident's belongings and angry when staff attempted to retrieve the items, arguing with other residents that asked her to leave them alone, pushing other resident's in their wheelchairs, fidgeting with other residents, combative and verbally and physically aggressive to staff, punched a nurse in the chest when removed from a male residents' room, and nurse redirected (R1) multiple times, and each time R1 continued to attempt to push the other female residents in wheelchairs. Review of a Nursing Note for R1 dated 7-29-25 reflected that the resident walked by a staff member and hit her in the face for no reason.Review of a Nursing Note for R1 dated 8-01-25 revealed that R1 was trying to push another female resident in a wheelchair, a staff person intervened and R1 attempted to hit the staff person but hit the female resident instead. Review of a Nursing Note for R1 dated 8-02-25 indicated that the resident was physically aggressive when pushing other residents in their wheelchairs, upsetting them. Review of a Nursing Note for R1 dated 8-03-25 revealed that R1 hit multiple staff members, grabbed at staff arms and wrists, pushed a male resident who was sleeping in a chair, and had no boundaries with other residents by getting directly in other residents faces to speak to them or yell at them. Review of a Nursing Note for R1 dated 8-05-25 reflected that R1 hit a staff person in the face causing the staff's glasses to cut their face. Review of a Nursing Note for R1 dated 8-09-25 indicated that R1 was pushing a resident around the unit in a wheelchair and when staff intervened, R1 started swinging at staff, touching other residents when they did not want to be touched, easily angered, slapped a staff person, and was in and out of other residents rooms most of the day. Review of a Nursing Note for R1 dated 8-10-25 at 8:30 PM revealed that R1 attempted to push other residents in their wheelchairs in the common area. R6 told R1 to leave them alone. R1 went over to R6 and punched her in the mouth. Review of a Facility Reported Incident (FRI) dated 8-11-25 reflected .(R1) was witnessed unprovoked making a fist with her right hand and making contact with a closed fist to R6. During an interview on 8-11-25 at 8:30 AM, R6 stated that the night before last (8-10-25) R1 was bothering other residents so I told her to stop. She came over and punched me in the mouth and split her lip. R6 stated that it hurt, it was bleeding, and that she is still afraid of R1. That lady (R1) is so mean and awful, she shouldn't be here. Review of a Behavior Note for R6, dated 8-11-25 at 10:00 AM revealed . (R6) became tearful with nurse and CNA this morning and stated that she was afraid of R1 and that she did not want to come out of her room today. During an interview on 8-11-25 at 12:56 PM, CNA (certified nurse aide) M was standing in R1's room and when asked, stated that he was called in to provide 1:1 for R1. During an interview on 8-11-25 at 2:10 PM, CNA R stated that R1 had not been placed on 1:1 supervision prior to today.On 8-11-25, a review of Care Plans for R1 did not show any interventions put into place by the facility to ensure that other residents are safe from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # MI00142627 and MI00142701 Based on interview and record review, the facility failed to provide safe standards of care for a dependent resident (R2) of 2 Residents reviewed for death, resulting in R2 falling out of bed when she was being provided care and sustaining lacerations and fractures that resulted in her subsequent death. Finding included: Review of R2's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: chronic kidney disease, dementia, adjustment disorder, dysphagia (difficulty swallowing), osteoarthritis and osteoporosis (weak bones). R2 was her own responsible party. Review of R2's incident and accident report dated 2/4/24 at 10:20 AM revealed, R2 was being washed up and was rolled over in bed to change and she shifted her weight in bed and rolled out of the left side of the bed. Resident Description revealed, I fell off the bed. R2 sustained a skin tear to her left lower leg and back of her head. R2 was sent to the emergency room for evaluation. Review of Certified Nurse Aide (CNA) E written statement from the facility investigation for R2's fall out of bed 2/4/24 revealed, I was cleaning up R2 for the day. I just got done cleaning her vaginal area & rolled her away from me so I could clean her bottom & change her brief. I had my hand firmly on her right shoulder when she shifted her weight & rolled off the bed. I tried to grab a hold of her, so she didn't fall. I ran to the side of her bed to check on her. She was awake & alert. I told her I would go get help. I ran & found a CNA & a nurse from another hall. This statement was signed by CNA E and dated 2/4/24. Review of R2's Activity of Daily Living (ADL) care plan dated revision on 9/13/22 revealed an intervention dated 8/19/21, Bed mobility with two assist. Review of R2's emergency room report dated 2/4/24 no time revealed, R2 was a level 2 trauma. She had a large skin tear of the left lower leg and above her eye. The nurses note revealed, Pt (patient) is bed/wheelchair bound and rolled out of bed striking back of her head and left leg. Left leg I painful and has large skin tear. Pt also has laceration to back of head. Pt did not have loc (loss of consciousness) Pt on thinners (blood thinning medications). Patient reported she was pushed out of bed by staff. Review of R2's hospital Details of Hospital Stay dated discharged [DATE] revealed, Presenting Problem/History of Present Illness. R2 is a 100 y.o. (year old) female who presented with bilateral femur fractures after sustaining a fall. Patient was admitted on [DATE]. Orthopedics and Cardiology were consulted and due to patient's age and guarded prognosis, they recommended non-surgical, conservative management. There has been a concern regarding lack of responses of the night of 2/7 with sudden shortness of breath with worsening altered mental status and on 2/8, family discussion was held and was decided to initiate Comfort Care. Patient's pain had been controlled with morphine infusion since then along with other comfort measure including Ativan, Scopolamine, Lasix and Glycopyrrolate (end of life comfort medications). Patient peacefully passed away early on 2/11. Time of death was pronounced at 0415 of 2/11/2024. During an interview with Licensed Practical Nurse (LPN) C on 12/13/24 at 1:15 PM, LPN C said she was working on 2/4/24 when R2 rolled out of bed. LPN C said she was on break and CNA G came to get her reporting R2 was on the floor. LPN C said she did the risk management report and RN D did the assessment. R2 was sent to the hospital. LPN C said CNA E said R2 moved herself during care and fell out of bed. LPN C said she had worked with CNA E prior to this event. She was in a good mood, she volunteered for a 4-hour shift, everything was going smoothly, R2 gave no indication anyone was trying to harm her. LPN C was asked how she would roll a resident in bed if she was providing care independently, and she said for safety she would roll them toward her. LPN C said R2 was care planned for assistance of 2 people and CNA E should not have been providing care for R2 by herself. During an interview with CNA G on 2/13/24 at 1:48 PM, AM, CNA G said she was working on 2/4/24 when R2 rolled out of bed. She recalled she was returning from lunch RN D informed her R2 was on the floor and asked her to get LPN C. CNA G went to R2's room, R2 was on the floor and stated she fell. CNA E was in the room crying, she was a wreck, so I told her to step out of the room. CNA G said LPN C and RN D assessed and treated R2 and R2 was sent to the hospital. CNA G was asked when she assists a resident roll in bed how does she do it. CNA G said I roll them toward me for safety. During an interview with CNA I on 2/13/24, CNA I said she was working on R2's unit on 2/4/24 and had a resident in the shower and came to get CNA E. CNA I said she was the first one there. R2 was on the floor naked, cold and bleeding. R2 just wanted to get back into bed. CNA I said she helped LPN C and RN D get R2 back into bed. R2 did not make any statements of anyone trying to harm her. CNA I was asked how she would roll a resident in bed when she was working independently, and she said she would roll them towards her as it feels safer. During an interview with the Director of Nursing (DON) and Nursing Home Administration (NHA) on 12/13/24 at 12:25 PM they said they received a call from the facility on 2/4/24 about R2 rolling out of bed. They came into the facility and immediately began investigating the fall. They provided CNA E's written statement that indicated she was independently caring for R2 when she rolled out of bed and CNA E wrote she rolled R2 away from her. The DON and NHA denied have any policy for safe bed care and denied doing any education related to bed care safety. They identified that R2's care plan was to have 2 people for assistance and the education they did was to ensure staff follow care plans. CNA E was suspended than terminated. All residents were not assessed for safe care plans to ensure all dependent residents would be care planned to have assistance of 2 people. No documentation of other staff interviews was provided prior to exit. Review of the Michigan Nurse Aide Candidate Handbook effective April1, 2022 revealed, page 46, POSITION A DEPENDENT RESIDENT IN BED ON SIDE, 6. Directs RN (registered nurse) Test Observer to stand on side of the bed opposite working side of the bed to provide safety. 7. From the working side of bed - gently move resident's upper body towards self. 8. From the working side of the bed - gently move resident's hips towards self. 9.From the working side of the bed - gently move resident's legs towards self. 10. Gently assist/turn resident to slowly roll onto correct side that the RN Test Observer read to the candidate in the scenario at the start of the task.