**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # MI00140255. Based on interview and record review, the facility failed to ensure a resident's change in condition was immediately reported, monitored, and had timely interventions implemented to address these changes for one (R804) of three residents reviewed for change in condition, resulting in delayed follow-up care, and delayed hospitalization for treatment following observations of the resident's right lower extremity being cold to the touch, with two plus pitting edema following a surgical repair two weeks earlier; and a fall with subsequent dislocated metallic prosthesis on the right hip. Findings include: A complaint was filed with the State Agency (SA) that alleged the facility failed to identify and address changes in a resident's clinical condition. According to a facility reported incident (FRI) that was reported to the State Agency on 12/12/23, R804 had been in the room with therapy and complained of right hip pain. Further diagnostic testing revealed a suspected fracture and the resident was sent to the hospital. On 12/13/23, the hospital had notified the Director of Nursing (DON) that the x-ray results showed a transcervical fracture through the right femoral neck with mild superior subluxation of distal fracture fragment. R804 underwent surgery for repair and returned to the facility on [DATE]. It should be noted that prior to the resident's initial admission into the facility on [DATE], they had sustained a fractured left femur from their previous living situation. Review of the clinical record revealed R804 was admitted into the facility on [DATE], discharged to hospital on [DATE], readmitted on [DATE], discharged to hospital on 1/2/24 and had not returned as of 1/31/24. Diagnoses included: encounter for other orthopedic aftercare, fracture of unspecified part of neck of left femur (11/27/23), presence of right artificial hip joint (12/15/23), fracture of unspecified part of neck of right femur (12/12/23), and unspecified dementia. Further review of the clinical record revealed: An entry on 12/30/23 at 12:46 AM by Nurse 'L' read, CNA (Certified Nursing Assistant) on unit alerted writer to the resident's room and stated pointed out to the writer that the resident's hip appeared to be out of place, upon assessment the writer agreed with the CNA, the resident's hip bone appears to be protruding out further than earlier in the shift, the resident shows signs of pain when palpated. The resident denies falling and was in bed when we arrived to her room. The resident's RLE (Right Lower Extremity) feels cold to the touch and she has +2 pitting edema. The doctor has been contacted about the situation and the writer is waiting for a follow up . There was no further documentation as to whether the Physician had returned the call, or that Administration had been notified of the resident's change in condition. The next documented entry was on 12/30/23 at 8:08 PM by Nurse 'F' that read, Acetaminophen Tablet 325 MG (Milligrams) Give 3 tablet by mouth every 8 hours as needed for General Discomfort - pt (patient) c/o (complained of) pain. The next documented entry was on 12/31/23 at 6:43 AM by Nurse 'F' that read, oxyCODONE HCl Oral Tablet 5 MG Give 1 tablet by mouth every 6 hours as needed for Pain related to FRACTURE OF UNSPECIFIED PART OF NECK OF LEFT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING (S72.002D) - pt c/o pain. The next documented entry was not until 12/31/23 at 8:59 AM by Nurse 'F' that read, Upon Cena making her rounds, pt (patient) was observed on the floor, Pt was lying on left side facing the door on the left side of bed and was soiled, bed was in lowest position, call light, hydration, bed control and tv control all within reach of pt while in bed. pts air mattress was inflated properly, pt did not use call light for assistance. Pt assessed for injuries none present at this time. Vitals taken, BP (Blood Pressure)-115/61, P (Pulse)-62, Resp (Respirations)-18, T (Temperature)-97.2, SPo2 (Pulse Oximetry)-96%, pt assisted back to bed by Cena and writer, ROM (Range of Motion) performed on upper and lower extremities with Pain to right hip pain, pain meds given, pt had previous hip surgery, Physician notified, Granddaughter notified, Neurochecks initiated. Frequent monitoring initiated. The next documented entry was a Late Entry Created on 1/2/24 at 1:12 PM for 1/1/24 at 1:11 PM by Physician 'I' which documented .Reason for visit .Status post fracture of the right hip .the patient is status post-ORIF (Open Reduction and Internal Fixation - surgical repair). Continue physical and occupation therapy as planned. Labile and stable . There was no identification, or indication that they had addressed R804's change in condition identified by nursing staff on 12/30/23, or the resident's fall on 12/31/23. The only other physician/extender entry was a late entry on 1/2/24 at 12:52 AM (after resident was discharged to the hospital) for 12/28/23 at 9:51 AM (prior to R804's change in condition) by Nurse Practitioner (NP 'M'). Review of an eINTERACT transfer form dated 1/2/24 by Nurse 'N' included minimal documentation of the resident's status and noted the reason for transfer was an abnormal hip x-ray. There were no radiology results available in the resident's clinical record for review. Further review of the nursing skilled charting assessments revealed no indication of any changes in R804's condition following the change identified on 12/30/23. There was no eINTERACT assessment completed on 12/30/23 with their change in condition. On 1/30/24 at 10:56 AM, a phone interview was conducted with Nurse 'A' who reported they no longer worked at the facility. When asked to recall their documentation and review events in which they assisted in transferring R804 to the hospital on 1/2/24, Nurse 'A' reported they were unable to recall any specific details or provide any additional information. On 1/30/24 at 1:53 PM, a phone interview was conducted with Nurse 'L' who reported they usually worked on the midnight shift. When asked to recall what they could from R804's change in status on 12/30/23 at 12:46 AM, Nurse 'L' reported concerns that they had attempted to contact Physician 'I' and the DON but neither returned their call. Nurse 'L' further reported they had notified the oncoming nurse and didn't know what happened after that. On 1/30/24 at 2:09 PM, Nurse 'F' was attempted to be contacted by phone. There was no return call by the end of the survey. On 1/30/24 at 2:21 PM, an interview was conducted with the DON. When asked about R804's change of condition identified on 12/30/23, and lack of physician response/follow-up, the DON reported the nurse should've completed an eINTERACT' assessment and the physician should've been contacted. The DON confirmed this had not been completed for R804. The DON further reported the facility had identified this as a concern a few weeks ago and had begun implementing education/training, monitoring with audits, and discussed in their Quality Assurance meeting. When asked what the facility's process was when staff identified a resident's change of condition, the DON reported they were to call the Physician, then call the Unit Manager and if they couldn't get a hold of them, they could call the nurse on call who can then get into contact with the Medical Director. On 1/30/24 at 2:35 PM, an interview was conducted with Nurse Manager 'B'. They reported that they were the nurse on call on 12/30/23 and denied being contacted by any nursing staff regarding R804's change in condition. They further reported had they known, they would've called the Medical Director if there were any concerns with the attending Physician not returning the call. Nurse Manager 'B' further reported Nurse 'L' should have initiated an eINTERACT assessment at the time of the incident and stated whoever recognizes that change in condition would be the person responsible for completing that documentation, no matter what time it is, even if close to the next shift starting. When asked if for some reason, the Physician and DON were contacted and staff still had not returned the call, what should happen, Nurse Manager 'B' reported anything clinical should be called in to the on-call phone, or use nursing judgment to send out to the hospital. At that time, Nurse Manager 'B' provided an x-ray dated 1/1/24 at 10:08 PM which read, PROCEDURE: RIGHT HIP 2 views .FINDINGS RIGHT HIP .Dislocated metallic prosthesis .FINDINGS PELVIS .Dislocated metallic prosthesis on the right hip. On 1/30/24 at 3:22 PM, a phone interview was conducted with Physician 'I'. When asked about whether they had any other practitioners on call, they reported it was just themselves. When asked since they did not have any other practitioners, how did they make sure they were available to respond timely when nursing staff contacted them, Physician 'I' reported, As long as I'm up, but sometimes at 2:00 AM or 3:00 AM it goes through pager. When asked if they recalled anyone reaching out regarding R804's change in status on 12/30, or 12/31 following the documented change in RLE feeling cold to touch and +2 pitting edema and fall, Physician 'I' No don't remember, usually in these important things, they (Nurse's) have the ok to send to hospital for a change in condition. When asked if they had been notified of R804's change in condition on 12/30 and fall on 12/31, what would they have recommended, Physician 'I' stated, I would've had her sent out 911. When asked about their late entry on 1/2/24 for 1/1/24 (the same date of R804's fall) and why there was no mention of the change of condition, Physician 'I' reported they were not able to offer any further explanation. According to the facility's policy titled, Nursing Administration dated 7/11/2018: .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) .accident or incident involving the resident .discovery of injuries of an unknown source .need to transfer the resident to a hospital/treatment center .specific instruction to notify the Physician of changes in the resident's condition .The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R92 On 10/18/23 a concern submitted to the State Agency was reviewed which alleged R92 had multiple falls with a significant injury during their stay at the facility. On 10/19/23 The medical record for R92 was reviewed and revealed the following: R92 was initially admitted to the facility on [DATE] and had diagnoses including Repeated falls, Weakness and Adult failure to thrive. A review of R92's MDS with an ARD (Assessment reference date) of 3/8/23 revealed R92 needed extensive assistance with most of their activities of daily living. R92's cognition was documented as severely impaired cognition. A review of R92's progress notes revealed the following: 3/7/2023-Received pt (patient) A&Ox 2 (knows self and place), Pt denies any Pain or discomfort at this time, All admission assessments completed, Medication entered into PCC (electronic medical record), Physician notified, Pt educated on the use of call light and other remotes, hydration within reach, bed in low position, pt has history of falls, frequent monitoring initiated .Pt has small bruise to lower left abdomen and left antecubital . [Physician Services Note] 3/7/2023-HISTORY & PHYSICAL EXAMINATION CC (chief complaint): debility and weakness for the past one week HPI (history of presenting illness): yrs old male with history of admitted for nursing support and rehabilitation. Patient presented to acute care facility after he sustained a fall. Patient is very poor historian although information obtained from the medical records apparently the patient presented to [local hospital emergency room] after he sustained a fall he does have expressive aphasia secondary to history of a glioblastoma status post resection. He does have history of recurrent falls he is getting weaker and weaker . 3/13/2023 at 18:49-Writer call to residents room by spouse, resident was sitting on floor in front of wheelchair. Spouse stated that she broke his fall and sat resident on the floor. Resident was trying to sit in wheelchair and didn't lock the wheels . 3/14/2023 at 12:00-Resident was observed on the floor. Resident was assessed while on the floor then put in wheel chair. Resident had a skin tear that was on the back of head .Doctor was notified, doctor ordered for resident to be sent to the hospital for a CT Scan (computed tomography) . 3/14/2023 at 20:39-Resident returned from the hospital on a stretcher .Doctor was notified of return. Nurse placed a wound care consult for resident . 3/14/2023 at 23:00-Resident was observed on the floor. Resident had no complaints of pain or discomfort. Resident was able to to complete full range of motion on all extremities with no limitation due to immobility or pain during assessment. Doctor was notified, no new orders . 3/15/2023 at 17:49-Medical Practitioner Progress Note (Physician/PA/NP)-Reason for the visit E/M (evaluation/management) for s/p (status/post) fall .EXAMINATION Awake, aware x1 .HEENT (Head, eyes, ears, nose, and throat) traumatic posterior scalp hematoma and abrasion .A/P (Assessment/Plan): 1. s/p fall: patient sent to hospital for evaluation and returned same day .continue fall protocol, vital signs, and neuro checks. utilize fall precautions 3/15/2023 at 20:28-Patient was found laying on matt <sic>, vital signs and physical assessment were done, no new bruising noticed, pain assessment was done, Wife was called and Physician called. Neurological evaluation is being done. 3/18/2023 at 18:20-At 5pm resident wife walked into his room and observed him on the floor laying on his back on the floor mat and bed was in the lowest position. Wife called writer into room and I called the aide to help assist resident back into bed. A review of R92's comprehensive plan of care revealed the following: Focus-Resident at risk for falls r/t (related to) Debility .Further review of R92's care plan did not reveal any frequent monitoring intervention as indicated on the 3/7/23 Nursing progress note. A review of R92's incident and accident forms (I&A) for their falls during their time in the facility revealed the following: 3/13 at 9:06-Incident Description-Writer called to residents room by spouse. Resident was sitting on floor in front of wheelchair. Spouse stated that she broke his fall and sat resident on the floor. Resident was trying to sit in wheelchair and didn't lock the wheels . 3/14 at 1300-Incident Description-Resident was observed on the floor. Resident was assessed before putting him in his wheelchair .Immediate Action Taken-Resident was assessed and doctor was notified immediately. Doctor ordered for resident to be sent out to the hospital . 3/15 at 2015-Incident Description-While doing rounds with another nurse, opened door and noticed patient laying on floor on top of mat . 3/18 at 1700-Incident Description-Wife walked in and then came out ad <sic> states her husband was on the floor. Writer walked in and he was laying on his back on the side of the bed on the floor mat. Bed was in lowest position and both floor mats was on the floor . 3/23 at 0700-Incident Description-Writer was making rounds and observed patient on floor mats . On 10/19/23 at approximately 9:25 a.m., during a conversation with the DON, a review of R92's falls was conducted and the DON was queried regarding the implementation of the interventionfrequent monitoring indicated per the Nursing progress note on 3/7 due to residents previous noted history of falls and they indicated it should have been added to the careplan and a system set up to document what frequent monitoring had meant. The DON was also queried regarding the post fall analysis (Incident and accident form) form for the second fall on 3/14 after R92's return from the hospital and what the immediate interventions were to prevent another fall once R92 had returned from the hospital after their first fall that day at 1300. The DON reported they would look for additional documentation and follow up. On 10/19/23 at 12:38 p.m., during a follow up conversation with the DON, the DON reported frequent monitoring was never added to the plan of care to notify staff of the need to increase supervision for R92. The DON also reported there was no post fall analysis for the second fall on 3/14 nor was an incident/accident form done for it to address the root cause. No documentation that frequent monitoring initiated indicated on 3/7/23 had been completed or that an incident/accident-post fall analysis for R92's second fall on 3/14/23 at 2300 had been done was provided by the end of the survey. This citation pertains to Intake Number(s): MI00136540, MI00138044, MI00135715, and MI00140171. Based on observation, interview, and record review, the facility failed to conduct an accurate fall risk assessment and implement effective interventions to prevent falls for three (R100, R16, and R92) of five residents reviewed for falls, resulting in R100 being transferred to the hospital two times on the same day after falls that resulted in a rib fracture, skin tear, and a laceration to the left side of the head that required sutures; R16 falling out of bed and being transferred to the hospital with a hematoma to the forehead; and R92 sustaining a traumatic posterior scalp hematoma and abrasion which required an emergency transfer to the hospital. Findings include: R100 Review of a Facility Reported Incident (FRI) submitted to the State Agency revealed a report that R100 sustained a fracture after an unwitnessed fall. Review of R100's clinical record revealed R100 was admitted into the facility on 8/15/23 for a five day respite stay (temporary relief of care from the primary caregiver), readmitted on [DATE] for a five day respite stay, and discharged on 9/17/23 with diagnoses: senile degeneration of brain and a fracture of one rib on the right side on 9/13/23. R100 received hospice services (supportive care that promotes comfort and quality of life for those approaching end of life). There was no comprehensive Minimum Data Set (MDS) assessment completed due to the resident's (short) length of stay. Review of a Nursing admission Screening/History dated 9/12/23 at 1:10 PM revealed the reason for admission according to the resident/POA (power of attorney) was utd and the reason for admission from paperwork was respite. It was documented that R100 was admitted from home and was alert and oriented to person and time. The section that documented the assessment of R100's Motor Control was left blank and did not indicate a history of falling or recent fall. It was documented R100's cognition was intact. In the ADL's (activities of daily living)/Functional Devicessection, the nurse documented R100 was Totally Dependent for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing and was not assessed for walking or locomotion. No assistive devices were checked on the assessment. Review of a hand written document that was explained to be the orders and instructions provided to the facility by the hospice agency revealed R100 was admitted for a five day respite and required fall precautions. Review of the hospice referral revealed hospice documentation from when R100 was signed onto hospice, previous hospice visit notes, and plan of care. Review of a hospice Visit Note Report dated 7/21/23 revealed R100's Terminal diagnosis was Senile degeneration of the brain. The following was documented, .Reason for hospice - including history .Pt was intact verbally and could hold full conversations 3 months ago, but now speaks in small sentences ,mostly asking confused questions or talking to loved ones who've passed .3 months ago pt was up independent and steady with walker, now she is up with walker and SB (stand by) assist but has history of multiple falls, one last week and one two days ago. Pt is WC (wheelchair) appropriate and family will be attempting to transition pt to wc . The Fallssection documented R100 had history of falls, was at risk for falling, and ambulated with assistive device. R100's Mental/Cognitive Assessment findings revealed R100 was Alert .oriented to person .disoriented .forgetful .confused .agitated .hallucination .abnormal cognitive functioning . with abnormal attention, remote memory, recent memory, and new learning ability. R100 had abnormal thought process, thought content, perceptions, insight, and judgement with incoherence, delirium, obsessions, compulsions, hallucinations, and anxiety . Review of a Fall Risk Assessment dated 9/12/23 revealed R100 was low risk for falling and had never fallen before. Review of R100's progress notes revealed the following: A General Progress Note dated 8/19/23 that read, Writer was standing at the med (medication) cart and heard a thump and heard the walker fall to the floor. Writer ran into resident rom <sic> and asked what happen she stated, 'I don't know' .skin assessment revealed: A lump located in the back of the head and a dark purplish lump on the left arm new order to send resident to he hospital . This event occurred during the first respite stay in the facility which was from 8/15/23 to 8/20/23. A General Progress Note dated 9/12/23 revealed R100 was a new admission to the facility with multiple discolorations noted to BLE (bilateral lower extremities) .a hematoma to RLE (right lower extremity) . A General Progress Note with an effective date of 9/13/23 at 5:08 PM noted, While writer was sitting at the nursing station, writer heard a loud bang coming from (R100's room number). Writer immediately ran into resident's room and observed resident sitting at 90 degree with her back parallel to the bathroom doorframe. Writer asked resident what happened and resident stated that she fell and hit her head. Writer inspected resident's head and noticed slight erythema (redness) on occipital region of head (back of head) with no bleeding present .Resident is not complaining of dizziness or trouble breathing .no change in ROM (range in motion) in any of resident's extremities. Resident has small dime sized skin tear on LLE (left lower extremity). Resident states that she has pain in her head. Writer contacted NP (Nurse Practitioner) and ordered resident to be sent to (hospital) for evaluation. EMS (Emergency Medical Services) arrived at 1640 (4:40 PM) to transport resident . A General Progress Note with an effective date of 9/13/23 at 10:36 PM, written by LPN 'E' noted, Pt (patient) returned from .hospital around 10:35 pm via EMS, with no new orders, diagnosis from the hospital was a closed fracture to one rib of the right side . A General Progress Note with an effective date of 9/14/23 at 2:26 AM noted, Pt came back to facility around 10:35pm (on 9/13/23) from hospital, Around 10:55pm (on 9/13/23), while writer was assisting another pt, cena (Certified Nursing Assistant) came to get writer and stated that the pt was sitting on the floor bleeding, pt was sitting on the floor on the side of the bed near the door, pt stated she wanted to get up to use the bathroom, Pt assessed for injuries, pt has laceration on the left side of head, no other skin alterations noted at this time .Pt assisted back to bed, Bed in low position, call light and hydration within reach, NP notified and ordered to send pt to hospital, 911 was called . A General Progress Note with an effective date of 9/14/23 at 8:25 AM noted, Resident returned from (hospital) at 8:25am with no new orders .Resident had a fall and has a laceration over left eyebrow with 2 sutures placed at the hospital . Review of R100's care plans revealed a plan of care created on 8/17/23 and initiated on 9/13/23 that indicated R100 was at risk for falls. The interventions were to ensure R100 wore appropriate footwear when ambulating or mobilizing in wheelchair, to ensure the call light was within reach, and to follow facility fall protocol. Review of a General Progress Note dated 9/14/23, written by the Director of Nursing (DON), revealed, Daughters .at resident's bedside. Spoke with them regarding incident and resident being transferred to the hospital. Daughters stated that this is the resident's behavior at home and that she needs constant supervision, resident constantly gets up to go to the bathroom. One time resident got up 87 times stating she needed to go to the bathroom per daughter .Daughters stated that they were constantly looking for ways to try and keep her safe . On 10/18/23 at 2:43 PM, an interview was conducted with Admissions Director 'C'. When queried about the process for admission for respite care, Admissions Director 'C' reported the admission process was the same as any other admission, but hospice typically came within an hour of admission to see the resident and coordinate care with the facility nurse. On 10/18/23 at 3:15 PM, an interview was conducted with LPN 'G' via the telephone. When queried about R100, LPN 'G' reported they were familiar with the resident. LPN 'G reported R100 had dementia and was a fall risk. LPN 'G' explained R100's daughter said they had to constantly monitor the resident at home because she would get up to go to the bathroom. When queried about the first fall that occurred on 9/13/23, LPN 'G' reported they were near R100's room and heard a loud bang. They ran into R100's room and the resident was leaning against the frame of the bathroom door. R100 reported they were trying to get to the bathroom. When queried about whether it was known that R100 was a fall risk prior to the fall, LPN 'G' reported they were aware which is why they were trying to keep an eye on them. On 10/18/23 at 3:54 PM, an interview was conducted with LPN 'E' via the telephone. LPN 'E' reported they did not remember R100, their readmission to the facility with a fractured rib from a fall on 9/13/23, or the second fall and hospital transfer that occurred on 9/13/23. On 10/19/23 at 9:27 AM, an interview was conducted with the DON. When queried about how the facility ensured interventions were implemented for the immediate needs of residents admitted for respite care, the DON reported they were admitted like any other resident admitted into the facility. The referral from hospice was reviewed that included orders for care, and a hospice nurse typically came to the facility the same day the resident was admitted to coordinate care with the nurse. At that time, the DON was asked to provide any information provided by hospice on 9/12/23. The DON explained that any fall risk would be considered based on information from hospice. When queried about R100 and the fall risk assessment that documented R100 did not have any previous falls and was at low risk for falls even though the resident fell in the facility during the previous respite stay the previous month, the DON reported the assessment was not accurate and should have taken into consideration previous falls. When queried about any interventions put into place upon admission on [DATE] to prevent falls and what was put into place after R100 was readmitted on [DATE] after a fall with a rib fracture, the DON reported she would look into it. When queried about when a resident should be assessed after being readmitted into the facility, the DON reported it should occur right away unless there was something else important happening. On 10/19/23 at 11:20 AM, the DON followed up and reported R100 was ambulatory and the intervention that was in place for her was to ensure she had appropriate footwear. The DON was unable to explain where R100's ambulation status was assessed prior to the first fall on 9/13/23. When queried about what should have been done to prevent a second fall upon readmission to the facility on 9/13/23, the DON reported the resident fell before anything could be implemented. The DON reported the facility was not aware of R100's fall risk and after talking to family on 9/14/23 they learned about it. It should be noted that it was known that R100 fell in the facility on 8/19/23 and it was documented in R100's hospice paperwork that was provided to the facility that they were at risk for falls. R16 On 10/17/23 at 10:42 AM, R16 was observed lying in bed. R16 made slight eye contact but did not speak. R16 received oxygen via a tracheostomy (a tube surgically placed into the windpipe in order to provide assistance with breathing). R16's hand appeared contracted and they were propped up with a foam wedge. It did not appear that R16 was able to reposition in bed without assistance. Review of a complaint submitted to the State Agency alleged R16 fell out of bed on 6/30/23 and was hospitalized with a golf ball sized contusion on her forehead, her face was swollen and she had bruising on the side of her face. It was alleged the facility staff were not able to explain how the resident fell out of bed but the nurse blamed the CNA (Certified Nursing Assistant) and the CNA blamed the nurse. Review of R16's clinical record revealed R16 was admitted into the facility on 3/28/22 and readmitted on [DATE] with diagnoses that included: cerebral infarction, anoxic brain damage, asthma, chronic respiratory failure, seizures, epilepsy, and contractures. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R16's cognition was not assessed and they were totally dependent on at least two staff members for bed mobility, toilet use, and bathing; they were not transferred from bed during the assessment period; and and was totally dependent on one staff member for dressing, eating, and hygiene. R16 received all nutrition via a Percutaneous Endoscopic Gastostomy (PEG) tube (a tube surgically placed into the stomach to deliver nutrition). Review of R16's progress notes revealed the following: A Skilled Nursing progress note dated 6/30/23 at 11:59 PM, written by Registered Nurse (RN) 'A', noted, Nurse was in (another resident's room number) .when I heard the CNA calling for help. When I went into patients' room she was hanging out of bed. 2 CNAS present. We assisted pt back to bed. Nurse assessed. Hematoma noted to forehead .Nurse was in patients' room about 5 min (minutes) prior to fall. Pt (patient) was in bed comfortable. Pt can't state what happened. On call NP (Nurse Practitioner) notified. Neuro checks ordered. Mother notified and requested a hospital transfer . Review of an incident report for R16 dated 6/30/23 and completed by RN 'A' revealed there were no predisposing environmental, physiological, or situational factors that contributed to the fall. No witnesses were included on the report. It was documented on 7/6/23 that, IDT (interdisciplinary team) team met to discuss resident/incident. After thorough investigation it was determined that the incident occurred as a result of resident not being positioned properly in bed. Appears resident may have been placed too close to side/edge of bed. Corrective action for this incident is staff was in services on bed mobility and positioning. Perimeter mattress placed on bed . Review of R16's care plans revealed the following: A care plan initiated on 3/29/22 and revised on 3/24/23 that read, Resident has an ADL (activities of daily living) deficit r/t (related to) debility, quadriplegia, hx (history) CVA (cerebral vascular accident - stroke), anoxic brain injury, limited ROM (range of motion), multiple contractures, aphasic (difficulty speaking), seizures, chronic respiratory failure w/ tracheostomy, non-verbal, unable to follow commands. Review of interventions revealed R16 was dependent for bed mobility initiated on 3/1/23. A care plan initiated on 3/29/23 and revised on 7/3/23 that read, Resident at risk for falls . An intervention was initiated on 3/29/22 that noted, Provide assistance as needed for mobility tasks and assure utilization of appropriate devices . On 10/19/23 at 1:17 PM, an interview was conducted with the Director of Nursing (DON). When queried about any investigation that was done regarding R16's fall from bed on 6/30/23, the DON reported she did not have a written investigation but it was determined the CNA (CNA 'AA') did not position the resident properly and therefore R16 fell out of the bed. The DON reported RN 'A' reported they were in R16's room five minutes prior to the CNA finding them on the floor and RN 'A' should have noticed R16 not being positioned properly and ensured they were repositioned. Review of a facility policy titled, Fall, adopted on 7/11/18, did not include the facility's protocols on how to prevent falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00133791 Based on observation, interview, and record review the facility failed to ensure one resident (R501) was free from sexual abuse, out of three residents reviewed for abuse, resulting in R501's being sexually abused by a staff member, physical trauma, feelings of psychological trauma and fear, and criminal charges filed against the staff member. Findings include: Several complaints were received by the State Agency regarding a resident sexually abused by a staff member. At the time of the original investigation (1/12/23) into the complaints, evidence was requested but unable to be obtained until 1/26/23. A follow-up investigation after review of additional evidence was conducted on 1/27/23. A review of a facility provided policy titled, Abuse and Neglect updated 10/31/22 was conducted and read, POLICY: It is the policy of this facility to provide professional care and services in an environment that is free from any type of abuse .Abuse includes: .4. Sexual . On 1/11/23 at 10:10 AM, a review of a facility provided investigation file that alleged R501 was sexually assaulted by a staff member was conducted. The file contained the following: A typed summary dated 12/12/22 indicated R501 reported to Nurse 'C', Certified Nurse Aide (CNA) 'D' was, .inappropriate with her while administering her bed bath . The summary indicated the allegation was also witnessed by Nurse 'E'. The summary continued to read, .(R501) reported to both nurses that the male CNA was wiping her vaginal area for a long time during care .she felt like he was inappropriate with his hands during care .(Nurse 'C') was instructed by the Administrator to notify the police to make a report .The male CNA had left the facility .The police arrived at the facility to speak with the resident and initiated their own investigation. The police instructed the nursing staff not to perform a complete skin assessment on the resident to allow this to be completed by a third party from (name redacted) Nurse 'F' (a forensic nurse) in lieu of ER (Emergency Room) visit .The following morning, the police spoke with the administrator regarding the incident .Administrator and DON (Director of Nursing) visited resident .Upon interview, resident reports incident occurred on 12/12/22 .Resident reports that (CNA 'D') entered her room around 7:30-8pm with bathing supplies .Resident alleges that when he started to clean her private area, that he kept going 'deeper and deeper, while spreading her vaginal area open' and was washing her 'aggressively' .and 'she could feel him penetrate me with his fingers and I no longer could feel the wash cloth on his hand'. She stated that he continued to do this for about 5 minutes. She reports that she did not know what to do but lay there. 'He then flipped me over and washed my buttocks aggressively .after he got me dressed and started to exit he stated that he would be back when the coast is clear'. I told him 'you will absolutely not be coming back into my room ever'. Resident stated that after some time of crying that she reached out to her 'spiritual advisor' on what she should do . A typed, signed statement from CNA 'D' dated 12/19/22 that read, .When I went in there and asked if I could provide a bed bath she said 'yes'. Once I did that she reported she had a bowel movement .I started to set up the bed bath after I cleaned her up. I had a lot of soap and water and put the towels across her chest, and her bottom. She started to make moaning noises after I drapped <sic> the towels. I kept going with cleaning. She started moaning noises when I was cleaning her private area .After continuing she started to thrust her hips towards my hand that was cleaning. She kept doing it .And that's when things got weird .She was making comments that she has a 'young girl (expletive for vagina)' and that 'I haven't had a (expletive for penis) in 30-40 years' to me. When I was exiting the room she was trying to call me back into the room she stated she hasn't (expletive for orgasm) yet .I feel like the lady had her part in this, but I don't feel like I raped her. A written, signed statement from Nurse 'C' dated 12/13/22 that read, .I was informed by CNA the resident (R501) wanted to see me. I went into room and asked her what was wrong and she began to say she felt like her CNA from earlier was inappropriate with her .Resident continued by saying she felt like her CNA was being inappropriate in her private area .She said she felt like the male CNA was being little rough and penetrated her with his fingers . A written, signed statement from Nurse 'E' dated 12/12/22 that read, .It was reported that the male was 'wiping her for a long time', she felt like he 'finger (expletive)' her. Reported that she was crying and visibly shaken up by the incident . On 1/11/23 at 11:00 AM, an interview was conducted with R501 in their room. R501 said on 12/12/22 they were sexually assaulted by CNA 'D'. R501 said CNA 'D' penetrated her vagina with his fingers. R501 continued to say Police Detective 'G' took their statement and had been following up with them on the case. R501 said they received a letter that informed them the County Prosecutor was filing charges against CNA 'D'. R501 said Detective 'G' told her CNA 'D' admitted to penetrating her vagina with his fingers. At that time during the interview, R501 started crying and said they did not like the male psychologist sent to see them after the incident and did not want to speak to the male social worker. R501 said a female social worker, Social Worker 'A' had been following up with them. R501 was visibly upset and continued to cry through the end of the interview. On 1/11/23 at 11:05 AM, R501 granted permission to review the letter they received from the Office of the Prosecuting Attorney. The letter revealed the court process and resources available to R501 as a victim of sexual crime. On 1/11/23 at 12:50 PM, a phone call was placed to CNA 'D', however; the call was unanswered and the voice mailbox had not been set up. On 1/11/23 at 1:30 PM, a review of R501's clinical records revealed they admitted to the facility on [DATE] with diagnoses that included: disc degeneration, low back pain, repeated falls, and morbid obesity. R501's most recent Minimum Data Set assessment dated [DATE] indicated they were cognitively intact, non-ambulatory, and required extensive assistance from one to two staff members for bed mobility, transferring, wheelchair mobility, dressing, toilet use, and personal hygiene. A review of R501's progress notes revealed the following: A physician's note dated 12/13/22 that read, .Pt (patient) is tearful today and states she is upset about an ongoing issues <sic> that has been addressed with staff. She is depressed . A Psychiatric Nurse Practitioner note dated 12/14/22 that read, .Complaint of sexual assault .She recalls the incidents <sic> on Monday, at first in the morning when she had to use the bedpan, when she thought the male aid <sic> was cleaning her down too deep in the genital areas .in the evening, it happened again when he had to do the bed bath .She becomes emotional and she recalls in detail how the male aide was very rough .and inappropriately placing his fingers inside of her vaginal area that lasted about 5 minutes. Her crying becomes intense as she states she just froze while this was happening .Patient has been in contact with the police, and social work .She agrees to increasing her zoloft (anti-depressant medication) from 100 to 150 mg (milligrams) .If crying persists, pt can benefit from temporary xanax (anti-anxiety medication) 0.5 mg . A Psychologist Note dated 12/14/22 that read, .seen following an alleged incident that occurred Monday night. She related a male CENA (CNA) as he was giving her bed bath, sexually molested her. She described how he inappropriately touched her breasts and inside her vaginal area .She related that she felt in shock .She was very upset and cried as she talked about the present incident. She related that she is trying to process what had happened to her. She stated there her 'heart is broken' by what he did to her and later that her 'heart hurts' .Asked if anything like this had ever happened to her she related when she was [AGE] years old, her uncle molested her .she never told anyone what had happened until she was an adult .(R501) is found to be alert and oriented x 3 (alert and oriented to person, place, and time), is insight oriented. She feels a sense of violation because of the incident .She feels angry and betrayed by what happened to her . On 1/11/23 at 3:22 PM, an interview was conducted with Nurse 'F', (a forensic nurse specialized in sexual assault assessment) who performed the forensic exam on R501 after the allegation of sexual abuse. Nurse 'F' was not able to share any information, but did provide the process to request R501's assessment. The process was followed and the documents were requested, however; they were never received. On 1/12/23 at 12:00 PM, an interview was conducted with Police Detective 'G'. Detective 'G' said an arrest warrant for CNA 'D' had been filed, the investigation had been closed and a request for the investigation from the police department could be initiated. A request for the police investigation was made on 1/12/23 at 12:31 PM. On 1/12/23 at 1:00 PM, an interview was conducted with the facility's Administrator regarding the incident. They acknowledged the fact the incident was being investigated criminally by the local police department, but were not able to obtain any of the police investigation information to aide in their facility investigation. They further indicated the facility followed their policy, but could not conclusively substantiate the allegation. They said they were afraid, something wasn't good given their follow-up conversations with Detective 'G'. On 1/26/23 at 9:44 AM, a copy of Detective 'G's police report and various investigation documents were provided via e-mail from the (City Name) Township Police Department. A review of documents revealed the following: A narrative from responding Police Officer 'H' that read, .(R501) advised me of the following: Between 1900-2000 (7P-8PM) hours, (CNA 'D) came into her room to give her a bed bath .When (CNA 'D') began cleaning her vaginal area, she advised me that he .began 'probing' her vagina with his fingers. She then stated that (CNA 'D') discarded the rag and began going deeper into her vagina with is <sic> fingers. For approximately five minutes, when she stated that (CNA 'D') 'finger (expletive) me'. (CNA 'D) then flipped (R501) over and began washing her buttocks .While cleaning her he kept rubbing the rear of her vagina .(R501) was extremely emotionally distraught when relaying the above information to me . A narrative from Detective 'G' that read, .Upon arrival, I met with (R501) in her room. (R501) reiterated her version of events that she told (Police Officer 'H'). I then contacted (company name) .I spoke to a support line employee and was able to facilitate a forensic exam that took place .12/14/22 .I interviewed (CNA 'D') in a recorded interview room where he told us the incident was consensual .(CNA 'D') admitted to inserting his fingers into her vagina .Conclusion (R501) is a resident/patient at (facility name) .(R501) is bed bound due to her weight and is unable to wash herself. (R501) alleges that (CNA 'D') forcibly and digitally penetrated her while he was giving her a bed bath .When confronted with these allegations, (CNA 'D') admitted to digitally penetrating (R501), but that (R501) was the instigator in the matter .The case will now be forwarded to (County Name) Prosecutor's Office for a warrant request . The documents reviewed also revealed a warrant for CNA 'D' was obtained on 12/28/22, and on 1/12/23 CNA 'D' was arraigned in District Court for criminal sexual conduct. Continued review of the documents provided from the (City Name) Township Police Department revealed Nurse 'F's medical forensic exam that read, .Brief history of the assault: .He washed my top part like normal .then started to wash my vagina. He was pushing down more and more. I could feel his fingertip, not the wash cloth pushing in and out of my vagina for about 5 minutes .I was so afraid he was in the building still .E. Symptoms since assault .Patient very tearful throughout exam and history. States that she is fearful of the assailant and worried staff may be talking about what happened .notes soreness to vagina . Continued review of the assessment form completed by Nurse 'F' revealed documentation of abrasions, tearing and generalized soreness to the genital area. On 1/27/23 at 9:00 AM, an interview was conducted with the facility's Administrator. They were informed a copy of the police report had been obtained from the (City Name) Township Police Department. They were asked if they had requested a copy of the report and said they had not. On 1/27/23 at 10:06 AM, an interview with Social Worker 'A' was conducted regarding follow-up visits with R501 after the sexual assault allegation. Social Worker 'A' said they were following up routinely, and at R501's request. They said R501 continued to report to them their feelings of trauma since the event.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #s MI00129532, MI00131065, MI00129819, MI00131003, MI00130272 and MI00132173. Based on interview and record review, the facility failed to ensure consistent and comprehensive skin assessments, wound care consultant's treatment orders were entered into the record, wound care treatments were performed, and timely care planning for pressure ulcers for one resident (R103) of five residents reviewed for pressure ulcers, resulting in the development and worsening of pressure ulcers. Findings include: A review of a facility provided policy titled, Policy/Procedure-Nursing Clinical adopted 7/11/2018 was conducted and read, .Subject: Skin Monitoring and Management-Pressure ulcer .It is the policy of this facility that: A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing .1. RESIDENT ASSESSMENT . A. Complete an admission assessment/evaluation and skin risk assessment to identify risk and to identify any alterations in skin integrity noted at that time . D. Develop comprehensive care plan if indicated following the evaluation/assessment. Care plans must be individualized and designed to meet the needs of the resident for whom they are being developed. E. Assessment of wounds on admission, readmission AND discharge: A licensed nurse (which may be the Wound Nurse) must assess/evaluate a resident's skin on admission. All areas of breakdown, excoriation, or discoloration, or other unusual findings, must be documented in the admission Assessment. A licensed nurse (which may be the Wound Nurse) must assess/evaluate each wound that exists on the resident. This assessment/evaluation should include but not be limited to: Measuring the wound Staging the wound Describing the nature of the wound (e.g., pressure, stasis, surgical wound) Describing the location of the wound Describing the characteristics of the wound .I. Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's Order . On 10/31/22 at 3:53 PM and 11/2/22 at 1:41 PM, reviews of R103's closed record revealed they admitted to the facility on [DATE], transferred to the hospital on [DATE], re-admitted on [DATE], discharged again to the hospital on [DATE], and re-admitted on [DATE]. R103's diagnoses included: urinary tract infection, sepsis with septic shock, protein calorie malnutrition, heart disease, and Alzheimer's disease. R103's Minimum Data Set (MDS) assessment dated [DATE] indicated they had severe cognitive impairment, was non-ambulatory, and required extensive total assistance from two staff members for bed mobility, transferring, and wheelchair mobility. MDS section M. for skin conditions indicated R103 admitted to the facility with pressure ulcers. R103's admission Braden Score (a score calculated to determine risk for pressure ulcer development) was noted to be a 16, meaning they were at risk for the development of pressure ulcers. A review of R103's admission nursing assessment dated [DATE] was reviewed and revealed they admitted with a stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough) on their left foot, a stage one pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence) on their right hip, and a stage one pressure ulcer on their right ankle. It was noted the assessment did not include any measurements or descriptions of the wounds, and a box at the bottom of the skin assessment was checked that read, Treatment ordered or required. A review of R103's orders and treatment administration records was conducted and revealed no treatments were ordered for R103's wounds upon admission. It was further noted the first treatment orders on the TAR (treatment administration record) were entered on 10/7/21, when the wound care consultant physician first saw R103. Continued review of R103's closed clinical record revealed a wound care consult dated 10/7/21 that indicated the following: A right hip deep tissue injury (DTI, persistent non-blanchable deep red, purple or maroon areas of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues. It is common for a thin blister to form over the surface of the dark wound bed, and the wound may further evolve to become covered by thin eschar) that measured 6.5 centimeters (cm) x 7.0 cm with a recommended order for a dry dressing every other day beginning on 10/8/21. It was noted the TAR was blank for the treatment on 10/8/21. A right posterior thorax DTI that measured 6.0 cm x 3.0 cm with 50% eschar (black, dead tissue) with a recommended order for medihoney and foam dressing daily. A review of the TAR did not reveal this daily treatment had been ordered and performed. A left posterior thorax DTI that measured 1.0 cm x 4.0 cm with a recommended order for betadine and a foam dressing daily. A review of the TAR did not reveal this daily treatment had been ordered and performed. A left hip DTI that measured 3.0 cm x 5.5 cm with a recommended order for a border foam dressing every other day beginning 10/8/21. An order to clean the sacrum with soap and water and apply calmoseptine every shift and as needed. A left medial ankle DTI that measured 1.0 cm x 1.5 cm with a a recommended order for betadine and cover with a bulky dressing daily. A review of the TAR did not reveal this daily treatment had been ordered and performed. It was noted, R103 discharged to the hospital on [DATE] and re-admitted on [DATE], however; no re-admission assessment was documented in the record and no orders for any type of wound care treatments were implemented upon their re-admission. R103's next wound care consult dated 10/14/21 revealed the following: A right hip UTD (Unstageable ulcer, full thickness skin or tissue loss where the depth cannot be determined) that measured 8.0 cm x 7.0 cm with 100% eschar with a recommended treatment of medihoney and foam dressing daily. A review of the TAR did not reveal this daily treatment had been ordered and performed. It was further noted this wound worsened and increased in size from the 10/7/21 assessment. A left posterior thorax UTD that measured 3.0 cm x 6.0 cm with 90% eschar with a recommended treatment of medihoney and foam dressing daily. A review of the TAR did not reveal this daily treatment had been ordered and performed. It was further noted this wound worsened and increased in size from the 10/7/21 assessment. A left hip UTD that measured 3.0 cm x 5.0 cm with 80% eschar and 10% slough with a recommended treatment of medihoney and foam dressing daily. A review of the TAR did not reveal this daily treatment had been ordered and performed. It was noted R103 transferred to the hospital on [DATE] and re-admitted on [DATE]. R103's admission assessment dated [DATE] was reviewed and the skin assessment section was noted to be blank. R103's next wound care consults dated 10/28/21 revealed the following: A right hip UTD that measured 6.0 cm x 7.7 cm with 100% eschar and a recommended treatment of medihoney and a foam dressing daily. A review of the TAR did not reveal this daily treatment had been ordered and performed. A new right ankle UTD that measured 0.5 cm x 0.5 cm with a recommended treatment of betadine and a bulky dressing daily. A review of the TAR did not reveal this daily treatment had been ordered and performed. Right posterior thorax UTD that measured 8.0 cm x 7.7 cm with 90% eschar and a recommended treatment of medihoney and foam dressing daily. A review of the TAR did not reveal this daily treatment had been ordered and performed. A left posterior thorax UTD that measured 5.7 cm x 6.0 cm with 100% eschar and a recommended treatment of medihoney and foam dressing daily. A review of the TAR did not reveal this daily treatment had been ordered and performed. It was further noted this wound worsened and increased in size from the 10/14/21 assessment. A left hip UTD that measured 4.5 cm x 10.0 cm with 100% eschar and a recommended treatment of medihoney and foam dressing daily. A review of the TAR did not reveal this daily treatment had been ordered and performed. It was further noted this wound worsened and increased in size from the 10/14/21 assessment. A review of R103's care plans was conducted and revealed the first care plan and interventions for R103's pressure ulcers was dated 11/9/21, over a month after R103 admitted to the facility with existing pressure ulcers. On 11/2/22 at 11:28 AM, an interview was conducted with the facility's Director of Nursing regarding the process of the coordination between the wound care consultant and the facility. They explained when the wound care consultant did assessments and made recommendations they were to be scanned into the resident's record, the orders were entered and the treatments were to be performed.