**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00134966 and MI00141309. This citation has two deficient practices. Deficient Practice #1 Based on interviews and record reviews the facility failed to implement an order to obtain daily blood sugar (BS) levels upon admission, failed to identify and report to the physician abnormal lab results, and failed to timely report to the physician a change of condition for one (R104) of one resident reviewed for an expired closed record sample, resulting in a delay of care and services and the prompt intervention to transfer the resident to a higher level of care. Findings include: Review of the medical record revealed R104 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] and expired fifteen days later. R104 was admitted with diagnoses that included: dementia, type 2 diabetes mellitus, long term use of insulin, and hypertension. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 1 (which indicated severely impaired cognition) and required staff assistance for all Activities of Daily Living (ADLs). Review of the hospital documentation provided to the facility upon R104's admission documented the following in part . Problem List . Colitis, Fecal impaction . Medication List . BD SINGLE USE SWABS REGULAR Pads USE ONCE daily . Embrace Lancets Ultra Thin 30G . USE ONCE daily . The swabs are alcohol pads, and the lancets are used to test blood sugar levels daily as documented in the hospital discharge paperwork. Review of the physician orders revealed the resident was receiving Insulin Glargine daily for diabetes mellitus. Further review of the hospital discharge papers documented in part . Additional Insulin Admin (administration) Instructions . Insulin glargine (LANTUS) . Do not mix with other insulins . Notify physician if Blood Glucose less than 70 mg/dl or greater than 349 mg/dl (milligrams per deciliter) . Review of the medical record revealed the facility did not implement the order to utilize the lancets daily to obtain R104's blood sugars until [DATE], two weeks after admitting into the facility. Further review of the medical record revealed no documentation on why the order was not implemented upon admission and implemented two weeks later. Review of the medical record revealed R104 had an unwitnessed fall at the facility on [DATE], that resulted in a transfer to the hospital and documented injury on around his right eye . Area around the right eye cleansed and steri-stripped and revealed a R (right) proximal humerus fracture. Review of the physician orders revealed a Basic Metabolic Profile (BMP) and Complete Blood Count (CBC) ordered on [DATE]. Review of a CMP (Complete Metabolic Profile) and CBC reported to the facility on [DATE] at 1:46 PM, documented multiple abnormal labs as follows: Glucose 352 H (High) - (74-109 normal range) BUN 41 H (7-25 normal range) Creatinine 1.35 H (0.60 -1.30 normal range) B/C Ration 30.37 H (8.0 - 25.0 normal range) AST (SGOT) 11 L (Low) (13-39 normal range) Alkaline Phosphatase 134 H (34 - 104 normal range) GFR Caucasian 51 L (> 60 normal range) RBC 3.75 L (4.10 - 6.20 normal range) Hemoglobin 11.7 L (13.5 - 17.5 normal range) Hematocrit 34.8 L (41.0-53.0 normal range) Neutrophil 78.6 H (40.0 - 74.0 normal range) Lymphocyte 13.1 L (19.0 - 48.0 normal range) Review of the medical record and physician consultations revealed no identification of the review and/or reporting to the physician the abnormal labs. Review of a facility policy titled Lab and Diagnostic Test Results . (Reviewed 10/2023) documented in part . When test results are reported to the facility, a nurse will first review the results . The nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality . Review of two Orders- Administration Note dated [DATE], both at 5:48 AM documented pt (patient) can not swallow for their morning Tylenol medication and pt failed to swallow for their morning Omeprazole medication. This note was documented by Licensed Practical Nurse (LPN) M. Review of the Medication Administration Record (MAR) and medical record revealed the resident had no documented issues with swallowing noted and had taken all previous medications with no swallowing concerns identified. Review of a Nursing note dated [DATE] (more than an hour later at 6:58 AM) documented in part . pt is lethargic, cannot [NAME] (swallow) and nonverbal through out night shift. Blood sugar went up, call np (nurse practitioner) and ordered 2 unit of lispo. This note was documented by LPN M. Review of the medical record revealed multiple nursing and physician notes that documented the resident to have been alert and able to communicate their basic needs to staff (resident primary language was Russian) until the date of [DATE] at 6:58 AM, when the nurse documented the resident was lethargic and nonverbal through out night shift. This indicated a change of condition from the resident's baseline. Review of the medical record revealed no documentation of the physician or np to have been notified of the identified change of condition with R104 at that time. Further review of the record revealed no documented vitals or assessments throughout the night shift, after the change of condition was identified, with the exception of the 7 AM vitals obtained. Review of a Nursing note dated [DATE] at 8:14 AM, documented in part . pt. observed lethargic at 7:00 am during change of shift report, vital signs Bp (blood pressure) 57/61, hr (heart rate) 103, resp (respirations) 22 . md (medical doctor) notified . Md order to transfer pt to (hospital name) via 911 . This note was also documented by LPN M. This indicated a delay with informing the physician of the change of condition with R104. The nurse documented on [DATE] at 6:58 AM, of the resident to have been lethargic, unable to swallow and nonverbal throughout night shift. At 5:48 AM, it was documented that the resident could not swallow their morning medications, However the physician was not notified until 7:00 per the nurses note on [DATE] at 8:14 AM. Review of a Nursing note dated [DATE] at 9:23 AM, documented in part . family states patient passed away at 11 am on 10.23.23 . On [DATE] at 3:18 PM, a telephone interview was conducted with LPN M and LPN M was asked if R104 was observed lethargic throughout their shift on [DATE] nightshift (going into the morning of [DATE]) and LPN M confirmed R104 was lethargic throughout the night and when asked why they did not inform the change of condition to the physician, LPN M stated they were informed by the off going nurse that they took report from that R104 was a hospice resident. LPN M stated they were to monitor R104 until they passed and then inform the hospice group. LPN M stated in part . it was not my normal unit. It was the first day I worked with the resident and she (previous nurse) told me he was hospice and my mistake is I didn't look into his chart to see if he was hospice or not . LPN M was asked if they informed the NP of R104's change of condition when they reported the elevated BS level and LPN M stated they had not, they only reported the elevated BS level because they thought R104 was on hospice. LPN M was asked when they realized that R104 was not a hospice resident and LPN M replied, . when I was giving report (to the incoming morning nurse) she said No, he is not hospice (R104's name) is a full code and he has to be monitored and has to go out like a full code . At that time LPN M stated they went to obtain R104's vitals, called the physician and transferred the resident out via 911 was the physician directed. LPN M stated the problem was that they were busy throughout the night and didn't read R104's chart. LPN M stated they know now to check the chart. LPN M denied any of the Administration staff to have followed up with them regarding this incident. On [DATE] at 9:35 AM, the Director of Nursing (DON) was interviewed and asked about the delay in LPN M to have informed a physician of the change of condition identified with R104, which resulted in a delay in transferring the resident to a higher level of care, and the DON stated they reviewed what happened and did not identify any concerns at the time. The DON stated LPN M identified a change of condition at shift change, notified the physician and sent them to the hospital where they died. The DON was asked about LPN M progress note that documented the resident to have been lethargic and nonverbal through out the night shift and unable to swallow their morning medications at 5:48 AM, however the physician to not have been notified until the change of shift when the incoming nurse informed LPN M that R104 was not a hospice resident and had to be monitored and sent to the hospital as a full code resident and the DON stated they were unaware that LPN M thought R104 was a hospice resident and the assessment and notification to the physician regarding R104's change of condition was conducted after the oncoming nurse informed LPN M that R104 was not on hospice. The DON was then asked why the facility failed to implement blood sugar testing upon admission for the resident and the DON stated they reviewed the discharge list from the hospital, but it did not document for the facility to obtain the BS levels. The Lancet order was reviewed with the DON, which documented to be used daily. The DON was asked what lancets are used for and the DON replied to obtain blood sugar levels. The DON was asked why an order to obtain the BS levels was eventually ordered two weeks into R104's stay at the facility and the DON did not have a response. The DON was asked why there was no documentation of the abnormal labs reported to the facility on [DATE] to have been reported to the physician or reviewed by the physician and the DON stated they would look into it and follow back up. No further explanation or documentation was received by the end of the survey. Review of a facility policy titled Change in a Resident's Condition or Status (no date documented on policy) documented in part . Our facility shall promptly notify the . Attending Physician . of changes in the resident's medical/mental condition and/or status . Deficient Practice #2 Based on observations, interviews, and record reviews the facility failed to consistently administer a pain medication (Morphine) timely to manage the pain for one (R64) of one resident reviewed for pain medication administrations, resulting in verbalized frustration and severe pain for the resident. Findings include: On [DATE] at 9:40 AM, R64 was observed lying on their back in bed. When asked if they had concern or issues with their care at the facility, R64 stated sometimes they get their pain medication almost two hours late and it .kills me . R64 explained that they had been diagnosed with Parkinson's disease and when they do not receive their scheduled pain medication on time, their pain is unbearable. R64 stated they have verbalized their concern to multiple facility nurses. Review of the physician orders revealed the following scheduled pain medications: Pregabalin 50 MG (milligram) oral capsule, every eight hours for pain. Tramadol HCl 50 MG tablet by mouth every eight hours for pain. Morphine Sulfate 0.25 ml (milliters) solution by mouth every 4 hours for pain/SOB (shortness of breath). Review of a medication audit documented consistent late administrations of R64's Morphine medication for [DATE] as follows: [DATE] - 9 AM Morphine given at 12:48 PM. [DATE] - 9 AM Morphine given at 10:21 AM. [DATE] - 9 AM Morphine given at 10:44 AM. [DATE] - 5 PM Morphine given at 6:15 PM. [DATE] - 9 AM Morphine given at 2:40 PM. [DATE] - 1 PM Morphine given at 2:41 PM. [DATE] - 1 PM Morphine given at 2:42 PM. [DATE] - 5 PM Morphine given at 6:16 PM. [DATE] - 1 PM Morphine given at 2:29 PM. Review of the medical record revealed no documentation on why the Morphine was administered late. Review of a facility policy titled Medication Administration reviewed 11/23 documented in part . Medications are administered in a safe and timely manner, and as prescribed . Medications are administered, in accordance with prescriber orders, including any required time frame . Medication administration times are determined by resident need and benefit, not staff convenience . Mediations are administered within one (1) hour of their prescribed time . On [DATE] at 9:22 AM, the Director of Nursing (DON) was interviewed and informed of R64's verbalized complaints of their pain medications consistently being given late and causing the resident to have severe pain. The DON stated they were unaware of the pain medications to have been administered late and could not speak on the behalf of the nurse's that administered the multiple late doses of the pain medication. No further explanation or documentation was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #'s MI00138332 and MI00135446. Based on observations, interviews and record reviews the facility failed to implement adequate preventive interventions to prevent the development of pressure ulcers, failed to complete accurate skin assessments, failed to ensure implemented preventive interventions were consistently completed and treatment orders were consistently completed as ordered by the physician for two residents, (R's 44 & 27) of three residents reviewed for pressure ulcers, resulting in the development of a facility acquired unstageable pressure ulcer with slough identified to the right heel of R44 within five weeks after being admitted to the facility. Findings include: On 12/12/23 at 9:31 AM, R44 was observed lying on their back in bed. Oxygen was observed being administered via nasal cannula. The resident was snoring and would not awaken with verbal stimuli. Review of the medical record revealed R44 was admitted to the facility on [DATE] with diagnoses that included: acute and chronic combined systolic and diastolic congestive heart failure, pulmonary edema, cardiomegaly, and gout. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition and required staff assistance for all Activities of Daily Living (ADLs). Review of multiple Skilled Daily: Medically Complex assessments completed by the nursing staff revealed the resident was an Extensive Assist of 1 staff for Level of assistance needed to perform Bed Mobility activities (move about in bed, sit to lying, lying to sitting on side of bed). Review of a Skilled Daily: Medically Complex assessment dated [DATE] at 3:02 PM, documented in part . Ability to understand others - Usually . Level of assistance need to eat/consume meals . Limited Assist of 1 staff . Level of assistance needed to perform Bed Mobility activities . Extensive Assist of 1 staff . Level of assistance needed to perform Transfer activities (to and from bed to chair/wheelchair; sit to stand) . Extensive Assist of 2+ staff . Level of assistance needed to ambulate . Extensive Assist of 2+ staff . Skin . None . Describe skin conditions- intact . Review of a Skilled Daily: Medically Complex assessment dated [DATE] at 2:24 PM, documented in part . Level of assistance needed to perform Bed Mobility activities . Extensive Assist of 1 staff . Level of assistance needed to perform Transfer activities . Extensive Assist of 2+ staff . Level of assistance needed to ambulate . Extensive Assist of 2+ staff . Skin . None . Describe skin conditions- intact . Review of a Skilled Daily: Medically Complex assessment dated [DATE] at 2:11 AM, documented in part . Level of assistance needed to perform Bed Mobility activities . Extensive Assist of 1 staff . Level of assistance needed to perform Transfer activities . Extensive Assist of 2+ staff . Level of assistance needed to ambulate . Extensive Assist of 2+ staff . Skin . None . Describe skin conditions- intact . Review of a Nursing note dated 12/11/12 at 10:11 AM, documented in part . Nurse on duty reported that a skin alteration noted on resident's right heel. Writer observed open wound that measured 4.3cm (centimeters) x 4.7cm unstageable pressure ulcer as coded by NP (Nurse Practitioner), wound bed is 80 eschar, 10% slough, and 10% epithelial, resident c/o (complaints of) pain during wound care only, new order for treatment initiated, resident is notified, UM (unit manager) is aware. Heel float boots applied, resident tolerated. Care plan updated . Review of the care plans revealed a care plan titled At risk for alteration in skin integrity related to: impaired mobility, incontinence inability to change brief and transfer self . Initiated on 10/31/23, documented the following intervention in part . Heel float boots WIB (while in bed) . this intervention was implemented on 12/11/23, the day the right heel wound was identified. Further review of the care plan revealed the following interventions implemented prior to the identification of the right heel wound: Pressure redistributing device on bed/chair, Obtain Labs as ordered and report results to physician, Observe skin condition with ADL care daily; report abnormalities, Encourage to reposition as needed; use assistive devices as needed, and Encourage fluids. These interventions were not adequate to prevent a wound development to the resident heels, being that the resident spent most of the day in bed and required staff assistance for bed mobility. Review of the December 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented the following order: Body audit every day shift every Tue (Tuesday), Fri (Friday) for Skin observation 0- No skin breakdown, 1-Previously identified wound/breakdown 2-Newly identified wound/breakdown-describe in progress note. The order start date was 11/7/23. The order was signed off with a check mark on 12/1/23, 12/5/23 and 12/8/23, neither documentation contained the indicator numbers as identified in the order. The order was discontinued on 12/11/23. Review of a physician order and the December 2023 MAR and TAR documented the following order: For right heel care: 1. Cleanse with NS (normal saline) then pat dry 2. Apply Therahoney to wound bed 3. Cover with calcium alginate 4. Lightly wrap with Kerlix 5. Secure with tape every day shift for wound care The order had a start date of 12/12/23 at 7 AM and a discontinue date of 12/12/23 at 10:29 AM. The order was not signed as completed for the date of 12/12/23. Further review of the physician orders and December 2023 MAR and TAR documented the following order: For right heel care: 1. Cleanse with NS then pat dry 2. Apply Betadine 3. Leave open to air 4. Every day shift for wound care This order has a start date of 12/13/23 at 7 AM. On 12/13/23 at 1:56 PM, R44 was observed lying on their back in bed. Light blue colored inflated heel boots were observed on a chair next to their bed. The Administrator was observed in the hall and was asked to have Unit Manager (UM) F (the unit manager that was assigned to R44's unit) come to the room. At 1:59 PM, UM arrived to R44's room and was shown and asked if the light blue inflated boots next to R44's bed was supposed to be on the resident's feet while they are in bed and UM G stated they absolutely should be on the resident's feet while in bed. UM F was asked to show R44's right heel for an observation. UM F informed the resident of the observation and removed the sheets revealing the right heel to have a blue skid sock on and direct contact with the resident's mattress. UM F started to remove the blue skid sock and paused half way through due to some resistance cause by the sock to have been stuck to the right heel wound bed. UM F then pulled the rest of the sock off without moistening the sock for an easier removal. The wound was observed to be about a half dollar in size, dark maroon/purple in color and the wound bed could not be visualized. The surrounding skin was observed to be opened. This observation revealed the wound boots were not while in bed as documented in the resident's care plan and the wound was not left open to air as ordered by the physician. On 12/13/23 at 2:11 PM, an interview was conducted with the Director of Nursing (DON) and the DON was informed of the 12/13/23 observation with UM F and was asked how the facility staff failed to identify the right heel wound despite the assessments documented as completed and the DON stated they were unsure of why the assessments were not effective. The DON was asked why adequate preventive interventions were not implemented to prevent the wound on R44's right heel, considering the resident did not ambulate on their own and is in bed most of the day. The DON stated the resident did walk, and the DON was asked if they ever observed R44 ambulating and the DON replied . Personally, I haven't seen him walking . The DON then stated the resident is usually up due to R44's wife insisting that the resident get out of bed. The DON was informed R44 was in bed sleeping for all of the observations made of R44 throughout the survey. An additional review of the December 2023 MAR and TAR on 12/14/23 revealed the right heel treatment order was not signed as completed for the start date of 12/13/23. No further explanation or documentation was received by the end of the survey. R27 On 12/12/23 at approximately 11:27 a.m., R27 was observed in their room, laying in their bed. R27 was observed to have an air mattress with protective boots on both of their feet. On 12/12/23 at approximately 2:42 p.m., R27 was observed in their room, laying in their bed. R27's left lateral foot dressing was observed with Nurse B. R27's foot dressing for their pressure ulcer was dated 12/10/23 and was observed to have a dried fluid that had seeped through the dressing. Nurse B was queried if they could describe the dressing and they indicated that it was on the left foot and was dated for 12/10/23. On 12/12/23 the medical record for R27 was reviewed and revealed the following: R27 was initially admitted to the facility on [DATE] and had diagnoses including Multiple Sclerosis and Pressure Ulcer of Left Heel-Unstageable. A Physician's order with a start date of 10/25/23 revealed the following: Wound care left lateral foot: 1. Cleanse with dakins solution and pat dry. 2. Apply alginate 3. wrap with kerlix every day shift for wound A review of R27's December 2023 Treatment Administration Record (TAR) revealed R27's dressing was not completed as ordered on 12/11/23. A comparison of R27's wound evaluations on 12/6/23 and 12/13/23 revealed the following: 12/6/23-Length-1.36 cm, Width-0.39 cm, Area-0.46 cm(squared) .12-13-23-Length-0.97 cm, Width-1.7 cm, Area-1.03 cm(squared) .Further review of the two wound evaluations revealed the wound had increased in size. On 12/14/23 at approximately 12:44 p.m., during a conversation with Nurse Manager E (NM E), NM E was queried regarding the dressing change not being done on 12/11/23 and they reported that they were made aware of it on 12/12/23 when Nurse B had informed them of the observation that it was not done and was still dated for 12/10/23. NM E reported that they did the wound dressing with Nurse B on 12/12/23 and made a note that they notified the doctor of the missed wound treatment. Further review of the progress notes and the TAR revealed no documentation that R27 had refused their wound care on 12/11/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient Practice #2 Based on observation, interview and record review the facility failed to ensure an environment free from hazards for one resident (R69) of seven residents reviewed for accidents/hazards and multiple other residents residing on the Medbridge 3 hallway. Findings include: On 12/12/23 at approximately 10:06 a.m., R69 observed in their sitting in their wheelchair in therapy room. R69 was observed to have oxygen infusing via their nasal cannula. R69 was observed to have their portable oxygen tank (POT) unsecured in a free standing position next to them without any device preventing it from falling over. On 12/12/13 at approximately 10:11 .am., Physical Therapy Assistant Q (PTA Q) was shown the free standing portable oxygen tank infusing oxygen to R69 and was queried if it should be secured. PTA Q indicated that it should be secured and was observed putting it into an oxygen bag located on the back of R69's wheelchair. On 12/13/23 at approximately 8:35 A.m., Certified Nursing Assistant S (CNA S) was observed coming around the corner in the Medbridge 3 hallway. A free standing portable oxygen tank was observed in the hallway and CNA S then opened a door and put it in a secured room. On 12/13/23 at approximately 8:36 a.m., an used syringe was observed placed on top of an unused medication cart. At that time, Nurse O was shown the unused syringe on top of the cart and queried if it should be left unattended and they indicated that it should not, and was observed throwing it in the sharps box. On 12/14/23 at approximately 10:42 a.m. during a conversation with Nurse Manager E (NM E), NM E was queried if portable oxygen tanks should be secured and not left free standing and they reported they should be secured with a caddie or in a bag. NM E was informed of the syringe observation and they indicated that syringes should be discarded in the sharps box after use and should not be left unattended. This citation has two deficient practices. Deficient Practice #1 This citation pertains to intake #MI00141309 Based on observation, interview, and record review the facility failed to ensure proper amount of staff were utilized for bed mobility for one resident (R75), of one resident reviewed for bed mobility, resulting in a fall with multiple fractures requiring a transfer to the emergency room. Findings include: On 12/12/23 at approximately 10:15 AM, R75 was observed in their bed with a sling on their right arm. They were asked about the sling but refused to answer any questions and said, I am tired of being asked about it, I don't want to talk about that!. A review of R75's clinical record revealed they admitted to the facility on [DATE] and re-admitted on [DATE]. R75's diagnoses included: cerebrovascular disease, hemiplegia, hemiparesis, seizures, falls, displaced humerus fracture (added 11/28/23), and multiple rib fractures (added 11/28/23). A review of R75's care plan and [NAME] (care guide) was conducted and revealed that at the time of the fall, R75 required assistance from two staff members for bed mobility and transferring. On 12/13/23 at 10:51 AM, a review of a progress note dated 11/21/23 was conducted and read, .Aide was giving a patient bed bath when fell. ROM (range of motion) was initiated, patient complained of pain in his right ribs, hoyer lift was used to put the patient back in bed . Continued review of R75's progress notes revealed the following: A note dated 11/24/23 that read, .Resident was went out to hospital .for a CT scan of right side to r/o (rule out) possible fracture . A note dated 11/28/23 that read, Resident arrived back to facility from hospital . A note dated 11/29/23 that read, .readmitted <sic> with primary diagnosis, Fx (fracture) ribs and right humerus fracture . A note dated 11/29/23 from the physician that read, .Re-admit .admission records revealed the patient was admitted to (hospital name) on 11/24/23-11/28/23 .Chest CT showed mildly displace acute fracture of 6th-9th ribs .Xray of the right upper extremity shows minimally displaced supracondylar fracture of the right distal humeruswith <sic> elbow joint effusion . On 12/13/23 at 11:15 AM, a review of a facility provided incident/accident report for R75's fall on 11/21/23 was conducted and revealed R75 was a two person assist for bed mobility and on 11/21/23 Certified Nurse Aide (CNA) 'Z' was giving R75 a bed bath by themselves and R75 rolled out of the bed sustaining several fractures. ON 12/13/23 at 1:13 PM, an interview was conducted with CNA 'Z' and they indicated they did not check R75's [NAME] for his bed mobility status and when they performed a bed bath by themselves R75 fell out of the bed. On 12/14/23 at 8:10 AM, an interview was conducted with the facility's Director of Nursing (DON) and they acknowledged the accidental fall when CNA 'Z' was performed R75's bed bath by themselves. A review of a facility provided policy titled, Falls and Fall risk, Managing was conducted and read, .Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number: MI00131453. Based on interviews and record review, the facility failed to protect one (R256) of five residents reviewed for abuse, from sexual abuse by another resident (R255), resulting in psychosocial harm of R256 using the reasonable person concept due to R256 being unable to consent to being touched sexually by R255. Findings include: Review of a Facility Reported Incident (FRI) submitted to the State Agency revealed R255 groped (R256) between the legs and on breasts and it was witnessed by staff. An unannounced, onsite investigation was conducted on 1/12/23 to investigate the allegation. Review of a facility policy titled, Patient Protection Abuse, Neglect, Mistreatment and Misappropriation Prevention revealed, in part, the following: .Sexual Abuse is non-consensual sexual contact of any type .The resident has the right to be free from abuse . Review of R255's clinical record revealed R255 was admitted into the facility on 6/3/22 and discharged on 9/5/22 with diagnoses that included: hemiplegia (paralysis of one side of the body), sarcopenia (skeletal muscle disorder), and bipolar disorder. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R255 had intact cognition, rejection of care behaviors, and no wandering behaviors. R255 required extensive physical assistance with bed mobility and transfers and was able to independently propel in a wheelchair in the facility. Review of R255's progress notes revealed the following: A Customer Service progress note dated 8/10/22 documented, On 08/09/2022 Administrator with admission coordinator as witness, educated this resident concerning the most recent abuse allegation (R255) was involved in. (R255) has been educated to not enter another patients room without their consent and to not touch another resident in any way without their consent. (R255) has also been educated that they should not discuss their genitalia with other residents as this can be an uncomfortable topic for certain individuals. Resident verbally expressed understanding to all of these points. Resident is aware of the on going investigation and spoke to the police on 08/08/2022 concerning the allegation. That progress note was written by the former Administrator, Administrator 'T'. A Customer Service progress note dated 8/22/22 documented, At approximately 12:30 PM, admin (administrator) spoke with resident to remind them of the previous education they received about not touching another resident without consent, not entering another residents room without consent, and not discussing explicit topics with another resident without their consent. (R255) verbalized understanding again and recalled the first conversation as well. Writer informed them that we will remove the 1:1 (one to one) sitter at this time but if there are any further issues they would be addressed. Social work continues to search for alternative placement. A General Progress Note dated 9/5/22 documented, Resident witnessed touching another resident in an inappropriate manner. Administrator was contacted. On-call manager contacted. Administrator contacted the police authority to investigate. No injuries noted on patient and victim. CNA (certified nursing assistant) statement completed and turned into Administrator. Resident transferred out to (hospital) with police escort for further psychiatric evaluation. Review of incident reports for R255 revealed another resident touched R255 inappropriately while (R255) was sleeping on 7/4/22. On 8/9/22, another resident alleged R255 came into their room, touched their leg and talked about (R255)'s penis. At that time, R255 was placed on one to one supervision. On 9/5/22, a CNA witnessed R255 touching R256 inappropriately in the lounge. It was documented that the CNA reported she saw R255 touching R256's breast and rubbing under their gown and proceeded to rub R256's leg. Review of R256's clinical record revealed R256 was admitted into the facility on 9/2/22 and discharged on 9/23/22 with diagnoses that included: dementia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R256 had a severely impaired cognition. Review of R256's progress notes revealed a progress note dated 9/5/22 that read, CNA staff member witnessed another patient touching resident in an inappropriate manner . Review of an investigation of the incident that occurred between R255 and R256 on 9/5/22 revealed the following: An undated, typed summary of the investigation documented, .On Monday, September 5, 2022 at around 9:45 AM (CNA 'C') witnessed (R255) and (R256) in the Internet Cafe together, (CNA 'C') felt like something was not quite right when she left the room and returned to watch through the door. (R255) reached their hands up between (R256's) legs as well as reach up around their breasts. (CNA 'C') immediately told him to stop and pulled (R256) away from .(Local police department) interviewed (R255) who did not deny the incident .recommended a psychological petition to remove .from the facility .Officers agreed to take the case to the prosecutor for review .Both residents are their own responsible parties (it should be noted that according to the clinical record, R256 had severely impaired cognition) .In conclusion, abuse was substantiated as it was witnessed . Review of a signed Witness Statement given by CNA 'C' on 9/5/22 at 1:30 PM, revealed the following documentation: They (R255 and R256) were both in the Internet Cafe together when I walked in. I asked (R255) what are you doing and I said (R256) isn't going to answer any of your questions as (R256) does not have their mind. So leave (R256) alone. I stepped out to check on a call light. then I went to sit at the nursing station and I looked over and I was like what is (R255) doing. (R255) leaned all the way down and pulled up (R256) gown up from their ankles and took their right hand right up (R256)'s gown along their inner left thigh all the way up to their groin area. (R255) took their hand out and (R256) sat up and (R255) went up from behind their gown and started groping their breasts and was starting to go down to their buttocks. This like happened in less than a minute. I yelled out and said what are you doing. (R255) denied doing anything and told me to (explicit language). I removed (R256) immediately and got another CNA to remove (R255) .(R255) seemed uncomfortable but I tried to soothe them and all they said is I need the bathroom . Review of a signed Witness Statement given by Nurse 'X' on 9/5/22 at 12:30 PM revealed the following documentation: A CNA staff member reported to me that (R255) .had touched another resident (R256) in an inappropriate manner .breast and low back, then (R255) proceeded to touch and rub their leg and .proceeded up their leg to their groin area .When questioned again (R255) admitted guilt and said they did touch (R256) .(R256) did not recall incident. On 1/12/23 at 2:35 PM, an interview was conducted with CNA 'C'. When queried about what she witnessed between R255 and R256 on 9/5/22, CNA 'C' reported she was not assigned to either resident that day, but was using the computer in the facility's Internet Cafe. CNA 'C explained R256 was seated in a wheelchair in the cafe and R255 self propelled in a wheelchair into the cafe and tried talking with R255. CNA 'C' reported she told R255 that R256 could not understand them and suggested that they leave (R256) alone. CNA 'C' then left the Internet cafe to answer a call light and sat at the nurses' station where they could see into the Internet Cafe. CNA 'C' explained they saw R255 going up (R256's) leg under their gown, then back and around to their breast. CNA 'C' explained R255's hands were underneath R256's clothing. CNA 'C' entered the cafe, told R255 to stop, and moved R256 away from R255. When queried about how R256 presented at that time, CNA 'C' stated, (R256) was really quiet and appeared shocked, but (R256) is so confused so (R256) did not express anything to me. When queried about whether R255 had ever exhibited any sexual behaviors in the past, CNA 'C reported (R255) would make sexual comments to her (CNA 'C') during care, particularly showers and brief changes. CNA 'C' reported she was unaware of previous sexual behaviors with other residents. On 1/12/23 at 2:45 PM, an interview was conducted with the Administrator, who was the facility's Abuse Coordinator. When queried about the sexual abuse that was witnessed between R255 and R256, the Administrator confirmed the abuse was substantiated. The Administrator reported, R256 did not have any family or legal representative on file (R256 had only been in the facility for three days at the time of the incident) and the Administrator requested to press charges on R256's behalf. The Administrator further reported R255 had since been arrested for criminal sexual conduct.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R355 Review of a Facility Reported Incident (FRI) dated 11/24/22 read in part, Apparently after therapy Friday afternoon until sometime on Saturday morning at 10:00am, the resident had something happen to her arm . On the morning 11/19 around 10:00 a.m. (R355) nurse noticed significant rectal bleeding, While preparing (R355) to send to the hospital . (R355) was having arm pain . On Friday 11/18 from 12:50-2:00 p.,. (R355) participated fully in physical therapy . On Thursday 11/24 . referral from hospital indicating an x-ray which showed a left proximal humerus fracture . Review of the closed record revealed R355 was admitted into the facility on [DATE] with diagnoses that included: congestive heart failure, encephalopathy and depression. According to the MDS assessment dated [DATE], R355 had moderately impaired cognition and required the extensive assistance of staff for ADL's, including bed mobility. Review of R355's ADL care plan initiated 10/26/22 revealed an intervention that read, Transfer with ext (extensive) x2 (two people) assist with mechanical lift, Ext x2 assist with bed mobility. Further review of the FRI revealed hospital records that read in part, .(R355) was brought to the ED (Emergency Department) for eval (evaluation) of 'GI (gastrointestinal) bleed and left shoulder pain'. She apparently woke up yesterday am with left shoulder, humeral pain with significant bruising. Unsure of mechanism of injury to shoulder . Work up in the ED revealed multiple findings that include left proximal humerus fracture . Acute comminuted and displaced fracture of the proximal humerus, predominantly through the surgical neck. No suspicious osseous lesion to suggest pathologic fracture . Review of CNA documentation for R355 revealed on 11/18/22 at 3:25 PM and on 1/19/22 at 2:20 AM bed mobility was marked as 3 - EXTENSIVE ASSISTANCE and 2 - One person physical assist. On 1/11/23 at 11:03 AM, Registered Nurse (RN) H, R355's day shift nurse on 11/18/22 and 11/19/22, was interviewed by phone and asked about R355's arm. RN H explained R355 had not complained of pain before her shift ended on 11/18/22, 7:00 PM, but R355 did had some rectal bleeding . when she came back on 11/19/22, 7:00 AM, R355 was complaining about left arm pain . R355's was still having rectal bleeding so she called the doctor about the bleeding and the left arm pain . she put that R355 needed an x-ray of her left arm on the hospital transfer form and told EMS (emergency medical services) when they came to take R355 to the hospital. RN H was asked if R355 had told her what happened to her arm RN H explained R355 was confused and saying things that did not make sense. On 1/11/23 at 11:26 AM, Licensed Practical Nurse (LPN) L, R355's night shift nurse, was called and a message was left. On 1/11/23 at 1:42 PM, CNA I was interviewed by phone and asked about R355. CNA I explained he had worked the afternoon shift (2:00 PM-10:00 PM) and the midnight shift (10:00 PM-7:00 AM) . he was changing R355 around 7:00 PM when he noticed a little blood so he called for the nurse. CNA I was asked if he was by himself, and how he turned R355 in the bed to position or change her. CNA I explained he was by himself and used a draw sheet to turn her towards him because she was so small and frail. When asked if he knew R355's bed mobility status, CNA I explained she was an extensive two person. On 1/11/22 at 2:13 PM, the DON was interviewed and asked if a resident's [NAME] said they were a 2 person extensive assist, could one CNA use a draw sheet to turn the resident. The DON explained if the [NAME] said two person, then there needed to be two people to turn the resident. When asked if it was possible R355's arm could have been broken while being turned by one CNA using a draw sheet, the DON had no answer. On 1/12/23 at 9:46 AM, LPN L was interviewed by phone and asked about R355's arm. LPN L explained he was just walking down the hall to get report when CNA I called to him that he was in the middle of changing R355 and she was bleeding from the rectum . he and RN H went into R355's room . R355 did not complain of any pain . told CNA I to notify him immediately if R355 was bleeding during the night . in the morning, while passing medications, R355 said she was having pain, so he gave her some Tylenol. Review of a facility policy titled, Bed Positioning, undated, read in part, .1. Verify transfer assist needed per [NAME]. Obtain additional assistance as indicated . R71 On 1/10/23 at approximately 10:22 AM, R71 was observed seated in their wheelchair outside of their room with a bedside table in front of them. The resident was alert, but not able to answer most questions asked. A review of R71's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included the following: dementia, adjustment disorder and psychotic disorder. A review of the residents MDS (10/6/22) noted the resident had a BIMS score of 5/15 (severely cognitively impaired) and required extensive one person assist for toileting. Continued review of the resident's clinical record documented, in part, the following: 11/10/2022 General Progress note (1:40PM): .at approximately 1330 patient presented position head on floor body over head near toilet unresponsive for 2 mins.Vomiting 3x, mental status change observed .right eye not reactive or responsive to light, patient was having medium sized hard bm .Patient sent to (name redacted) hospital . Care Plan: Focus: Urinary incontinence related to functional incontinence, impaired mobility (revision 4/6/2022) . Interventions: Provide assistance with toileting (date initiated 3/31/2022). Focus: At risk for falls due to unsteady gait, impaired mobility, dementia and behavioral disturbance (date initiated 3/30/2022) . Interventions: when transferring resident to restroom do not leave unattended (11/10/22) . An Incident/Accident report (I/A) dated 11/10/22 was reviewed and documented, in part: Patient's Name: R71 .Date of Incident 11/10/22 1:30 PM .Location of Incident: Patient's Room .Description of Incident: approximately 1330 patient presented position head on floor body over head near toilet, unresponsive for 2 mins Vomiting 3x mental status change .right eye not reactive to light. Patient was having medium sized hard bm at time of observed on floor .Was patient taken to hospital? Yes .Describe cause of incident, if known: Patient escorted to bathroom by therapy. Patient insisted to be in bathroom by herself. Therapy stepped out for privacy as patient frequently self-transfers to bathroom with out assistance .a few moments later therapy observed patient in laying position with head on floor body over head near toilet .unresponsive for 2 minutes .Corrective Action: neck stabilized with neck collar. Staff able to transfer patient to bed. Upon assessment right eye not reactive to light, along with multiple emesis episodes. 911 called . On 1/12/23 at approximately 9:35 AM, the Director of Nursing (DON) was asked if there were any further documents, including statements that would specify names of staff (therapy etc.) involved in the incident. The DON reported that all documents were attached to the IA and suggested talking with the Therapy Department. On 1/12/23 at approximately 11:10 AM, an interview was conducted with Physically Therapy Manager (PTM) W. PTM W was asked if she was familiar with the incident and who was therapy person noted in the I/A. PTM W reported she recalled the incident and that that the therapy person was Physical Therapy Assistant (PTA). PTM Wfurther reported that R71 had been evaluated to start PT again on 11/8/22 due to a decline in mobility. PTM Wprovide documentation pertaining to the assessment completed on 11/8/22 that documented, in part: has patient fallen in the past? Yes .Does patient feel unsteady when standing? Yes .Does patient worry about falling? Yes . On 1/12/23 at approximately 9:40 AM, PTA J was interviewed about the incident. When asked what occurred, PTA J noted that it was the first day R71 was to start PT. She went to the resident's room and the resident was confused and initially did not want to attend therapy. R71 then stated she would go but needed to go to the bathroom and wanted her privacy. PTA J further stated that she physically did not assist her to the toilet but witnessed that she was on the toilet and then left the room to get her some water and when she returned R71 was on the floor, and she contacted a nurse for assistance. On 1/12/23 at approximately 11:11 AM a second interview was conducted with the DON. Nurse Y was also present during the interview. When asked if R71, given her decline in functioning, history of falls and dementia should have been left alone in the bathroom, the DON reported that she might have given the resident privacy, but would not have left the room and would have remained outside of the bathroom door. This citation pertains to Intake Number(s): MI00131690, MI00131961, and MI00131453. Based on observation, interview, and record review, the facility failed to ensure three (R42, R355, and R71) of 10 residents reviewed for accidents, were positioned, transferred, and supervised in a manner consistent with their plan of care, resulting in a fracture to R42's foot, a fracture to R355's left humerus (long bone in the arm that runs from the elbow to the shoulder), and loss of consciousness and vomiting of R71. Findings include: Review of a facility policy titled, Interdisciplinary Care Planning, revised 3/2018, revealed, in part, the following: .Once the care plan is developed, the staff must implement the interventions identified in the care plan . R42 Review of a complaint submitted to the State Agency revealed an allegation that R42 was dropped in the shower which resulted in injury. On 1/12/23 at 8:50 AM, R42 was observed seated in bed with a breakfast tray in front of her. At that time, R42 was interviewed and queried about any concerns regarding her care. R42 reported on 12/21/22, while in the shower room with Certified Nursing Assistant (CNA) 'B' and another CNA, CNA 'B' insisted that she stand. R42 reported she explained to CNA 'B that she could not stand or walk and CNA 'B' dragged me from the shower chair to the bathroom and I have had trouble with my left foot ever since. R42 explained she required a mechanical lift that utilized a body sling and suspended her in the air without standing, in order to transfer but the two aides did not utilize a mechanical lift that day. R42 stated, (CNA 'B') was very rude and did not believe that I could not stand. R42 reported she did not fall, but her left foot hurt since that day. R42 further reported an X-ray was completed which revealed an injury. R42 reported she told the assigned nurse once she was back in her room and discussed her concerns with the Director of Nursing (DON). R42 explained that she had an appointment with a foot doctor that day (1/12/23) and believed it was due to the injury she sustained on 12/21/22. When queried about the level of pain she experienced on a scale of one to 10 with 10 being the worse pain possible, R42 reported her pain was a 10. Review of R42's clinical record revealed R42 was admitted into the facility on 5/10/19, readmitted on [DATE], and had a transfer to the emergency room on [DATE] with diagnoses that included: spondylosis (osteoarthritis of the spine) with myelopathy (spinal cord compression) cervical (neck) region, adjustment disorder, low back pain, and type 2 diabetes. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R42 had intact cognition, no behaviors, was totally physically dependent on staff members for transfers and bathing. Review of R42's care plans revealed a care plan initiated on 5/16/19 and revised on 3/11/22 that documented, ADL (activities of daily living) Self care deficit as evidenced by immobility/balance, generalized weakness/debility. Documented interventions included the following that was initiated on 3/22/22: Transfer with mechanical lift with x 2 assist. Review of R42's progress notes revealed the following: A COVID-19 (Coronavirus Disease 2019) Surveillance progress notes dated 12/21/22 at 3:14 PM and 10:42 PM documented R42 was not experiencing nausea, vomiting, or diarrhea. There were no progress notes documented on 12/21/22 that referred to any injury or fall as reported by R42 and the complaint intake. A Skilled Nursing progress note dated 12/25/22 at 1:06 AM documented, .Pt (patient) C/O (complains of) left ankle painful to touch, MD (physician) notified place an order X-ray 2-view and venous doppler to Left lower extremity to Rule out DVT (deep vein thrombosis) . A General Progress Note dated 12/27/22 documented, Patient states on 12.21.22 patient was receiving a shower from 2 cenas. while patient was in shower she fell ill and began experiencing vomiting along with diarrhea. patient was taken out of shower station. in process of trying to rush patient back to room related to illness, patients left foot was bumped in shower station. Patient did not complain of pain during this time. swelling noted to area a few days later. orders for xray and doppler of foot to rule out dvt (deep vein thrombosis/blood clot). findings show fracture to left ankle. CT (computerized tomography) suggested. patient sent to hospital. resulting in ankle fracture and splint to area . A General Progress Note dated 12/27/22 documented, Resident transferred to hospital for transverse fracture (complete fractures that traverse the bone perpendicular to the axis of the bone) through the distal (away from the point of attachment - joint) tibia (shin bone)/medial malleolus (inner ankle) shown on xray . A NP (Nurse Practitioner) Progress Note dated 12/27/22 documented, Chief Complaint - swelling, weakness .Patient seen today, nurse reports swelling to the left lower extremity over 48 hours . On exam pt complains of pain to the foot area .D/w (discussed with) nurse, no report of any recent fall or trauma .12/25 xray showing 'Severe osteopenia. Acute nondisplaced transverse fracture through the distal tibia/medial malleolus. Possible nondisplaced distal fibular shaft fracture. Mild diffuse soft tissue swelling. Consider CT for further evaluation' . Diagnosis 1-acute left foot swelling with left foot pain .Diagnosis 1 Plan - d/w pt and unit manager, obtain CT scan pt has been mostly on bed past 3 days, continue to immobilize left foot until CT scan done, consider immobilizer consider opiate medication for when pain escalates . On 1/12/23 at 10:24 AM, an interview was conducted with CNA 'A' who was assigned to R42 on 12/21/22 during the day shift. When queried about how a resident's transfer status was determined, CNA 'A' reported staff were required to check the resident's [NAME]. When queried about what happened with R42 on 12/21/22, CNA 'A' reported R42 originally did not want a shower, but eventually agreed to having one. CNA 'A' explained R42 was transferred from the bed to the shower chair with the assistance of CNA 'B'. When queried about how R42 was transferred, CNA 'A' stated, (CNA 'B') picked (R42) up and set her in the chair. I picked up her legs and he had her arms from behind and we picked her up and set her in the chair. CNA 'A' further reported they took R42 to the shower and proceeded to give a shower when R42 began throwing up and had a bowel movement in the shower. CNA 'A' further explained R42 was washed in the shower chair and then brought back to her room where CNA 'A and CNA 'B' picked R42 up by her arms and legs a second time and placed her in the bed. When queried about whether R42 complained of any pain, CNA 'A' reported R42 reported her leg hurt before, during, and after the shower. On 1/12/23 at 9:47 AM, the Administrator and DON were asked to provide any incident reports and associated investigations for R42. Review of an incident report for R42 revealed the following: Date of Incident: 12/27/22 .Location of incident: Shower Room .Description of incident: Patient received left lower foot xray related to pain and swelling. patient was assisted onto shower chair via 2 people. As aides held upper and lower extremities and placed onto shower chair. Resident began vomiting and diarrhea in shower. upon resident feeling sick, resident was being escorted by cena out of shower when her left foot was bumped while exiting. Cena attempted to rush patient back in room to give care as patient was actively vomiting. It should be noted that the incident occurred on 12/21/22 and there was no incident report completed on that day and no progress note documented in the electronic medical record until six days later on 12/27/22. Review of the facility's investigation revealed the following witness statements: A signed Witness Statement given by R42 on 12/30/22 documented, It was on Dec. (December) 21, (CNA 'A') was assigned to give me a shower. She asked the guy aide to help me. He went to get me up, I said that I don't stand. So they both tried to lift me up by my arms. I told them not to. So the guy aide stood in front of me. He stood me up and put me in the shower chair. I did not feel a crack at that time. My foot hurt a little when he stood me up. When I was in the shower room, I got sick and nauseous. They put me back in my room. They put me back in my room the same way . A signed Witness Statement given by CNA 'A' on 12/27/22 documented, On December 21 I was assigned to (R42) for a shower. Myself and another Cena picked her up from her bed and put her into the shower chair. I had her legs and the other cena held her arms. Her feed did not bump anything at this time. I then took her to the shower. While in the shower the patient starting vomiting and having diarrhea. The only time her foot got bumped was when I turned around in the shower chair and I was washing her up. This was to her left foot. I asked (CNA 'B') to help me in the shower because she started vomiting. Once we got back to the room, we used (brand name mechanical lift) back in bed . A signed Witness Statement given by CNA 'B' on 12/27/22 documented, On December 21 (CNA 'A') was assigned to give (R42) a shower. It was around 9 AM (CNA 'A') asked me to help her get into the shower chair. I held her arms and (CNA 'A') held her feet. I came back to help (CNA 'A') in the shower room because the patient was having diarrhea and vomiting. I remember only cleaning the shower room. I believe I heard her say 'ow!' when she took her out of the shower room. At that time I was at the nurses station looking up her [NAME] on how to transfer since she was not my patient I wasn't sure when I was first asked to help. I saw that she was a (brand name mechanical lift) and helped (CNA 'A') put her back in bed via (brand name mechanical lift) this time. On 1/12/23 at 10:45 AM, an interview was conducted with the DON. When queried about whether CNA 'A' and CNA 'B' provided care to R42 on 12/21/22 according to her required plan of care, the DON reported they did not. The DON reported the CNAs should have checked the [NAME] before attempting to transfer R42. The DON further reported that residents should never be transferred by their arms and legs. The DON explained that both CNA 'A' and CNA 'B' received education on ensuring residents were properly transferred.