Regency At Jackson

something about the CNA or nurse, would you not make time to talk to her? RN P stated she went into

an issue to put R7 on cares in pairs, no answer was provided.When asked why CNA M stated you (RN

was really struggling to recall the details, then stated if CNA M said she told her that, then she must have said it. RN P stated she didn't speak long enough to R7 to know what the issue was. RN P then stated she was sure the nurse working on the floor knew about the issue, again writer asked why nothing was done about it or followed up on it.

Writer asked RN P how many people knew there was an issue between R7 and CNA M and nobody did anything about it? When RN P was asked why nobody reported or investigated an allegation of abuse when RN P had instructed CNA M not to go in her room because of an issue, revised the care plan to have cares in pairs, had asked to speak to management regarding R7's complaint/concerns, and multiple staff knew about this incident, RN P stated she didn't know.

During an interview on 05/20/2026 at 2:20pm, CNA O was asked when there is an allegation of abuse, what would you do? CNA O stated report it to the floor nurse, nursing manager, DON B, or Administrator A.

During an interview on 05/20/2026 at 2:48pm, midnight shift RN Q, stated she remembered R7, stated R7 wasn't happy here, she had an issue with a CNA, R7 didn't want them to take care of her. RN Q told R7 she was sorry she had that experience with the CNA. RN Q told R7 she would look into this situation and told day shift nurses what was going on.

Writer asked what their abuse policy instructs them to do and RN Q indicated they believed they talked to the people they were supposed to. RN Q stated she told the day shift nurses to follow up on this and the day shift nurses told her management already knew and it was taken care of.

During an interview on 05/20/2026 at 3:00pm, RN P stated she talked to DON B and stated she couldn't get logged into her computer so DON B wrote a progress note regarding R7 leaving AMA. RN P stated she asked R7 if it was urgent or could their concern wait until after the meeting and R7 told her it could wait.

After the meeting, RN P and DON B were told R7 was leaving the facility AMA. RN P stated there were some allegations made by R7.

Writer asked RN P when she found this out and stated she needed to log into PCC to read it. RN P stated nurses that day were LPN J and LPN N, who put the buddy system in place.

During an interview on 05/20/2026 at 3:28pm, Minimal Data Set (MDS) nurse R, looking at R7's care plan, was asked why the cares in pairs was put into place. MDS nurse R stated the care plan was revised by DON B and made R7 cares in pairs on 04/30/26. MDS nurse R stated she added the same interventions on 04/30/26.

Record review revealed no nursing progress note noting behaviors or reason for adding cares in pairs to the care plan.

During an interview on 05/20/2026 at 3:45pm, DON B stated she forgot she wrote up a risk management note, about this resident. DON B stated the business office manager (BOM) D reported to her R7 complained of not getting water and her needs were not getting met.

Writer asked where the progress note was from BOM D with this information.

DON B stated BOM D did not write a note or document in PCC, but gave a verbal report to DON B.Writer asked DON B why nobody investigated or reported R7's allegation of abuse and yet a CNA was instructed not to go in R7's room because of an issue, the care plan was revised to make R7 cares in pairs on 04/30/2026, R7 had asked to speak to management regarding her complaint/concerns, multiple nursing staff and administrative staff knew about the allegation, nobody attempted to talk to her until she was walking out of the facility AMA, and nothing was done to identify and possible resolve her concerns and complaints. DON B stated she didn't know.During an interview on 05/20/2026 at 4:00pm, writer reported abuse allegation to Licensed Nursing Home Administrator (LNHA) A and DON B.

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the CNA or nurse, would you not make time to talk to her? Nursing Administration RN P stated she

pairs.Asked why CNA M said that you, the Nursing Administration RN P told her not to go into R7's

really struggling to recall the details, then stated if CNA M said she told her that, then she must have said it.

Nursing Administration RN P stated she didn't speak long enough to R7 to know what the issue was.

Nursing Administration RN P then stated she was sure the nurse working on the floor knew about the issue, again writer asked why nothing was done about it or followed up on it.

Writer asked Nursing Administration RN P how many people knew there was an issue between R7 and CNA M and nobody did anything about it? Writer asked Nursing Administration RN P how a resident admitted to the facility on [DATE] through 05/01/2026, instructed a CNA M to not go in her room because of an issue, revise the care plan to have cares in pairs, R7 asked to speak to management regarding her complaint/concerns, multiple staff knew about this and nobody reported it or investigated it.

Nursing Administration RN P stated she didn't know.

During an interview on 05/20/2026 at 2:20pm, CNA O was asked when there is an allegation of abuse, what would you do? CNA O stated report it to the floor nurse, nursing manager, DON B, or Administrator A.

During an interview on 05/20/2026 at 2:48pm, midnight shift RN Q, stated she remembered R7, stated R7 wasn't happy here, she had an issue with a CNA, R7 didn't want her to take care of her.

Midnight shift RN Q told R7 she was sorry that she had that experience with CNA, Midnight shift RN Q told R7 she would look into this situation and told day shift nurses what was going on.

Writer asked what their abuse policy instructs them to do, stated she believed she did that, she talked to the people she was supposed to, Midnight shift RN Q stated she told the day shift nurses to follow up on this and the day shift nurses told her that management already knew and it was taken care of.

During an interview on 05/20/2026 at 3:00pm, Nursing Administration RN P stated she talked to DON B, stated she couldn't get logged into her computer so DON B wrote a progress note regarding R7 leaving AMA, stated she asked R7 if it was urgent or could wait until after the meeting, R7 told her it could wait.

After the meeting, Nursing Administration RN and DON B were told R7 was leaving the facility AMA.

Nursing Administration RN P stated there were some allegations made by R7.

Writer asked Nursing Administration RN P when she found this out, stated she needed to log into PCC to read it.

Writer waiting for her to get into her computer.

Nursing Administration RN P stated nurses that day were LPN J and LPN N, who put the buddy system in place.

During an interview on 05/2026 at 3:28pm, Minimal Data Set (MDS) nurse R, looking at R7's care plan, writer asked why the cares in pairs was put into place. MDS nurse R stated the care plan revised by DON B made R7 cares in pairs on 04/30/26. MDS nurse R stated she added the same interventions on 04/30/26.

Record review revealed no nursing progress note noting behaviors or reason for adding cares in pairs to the care plan.

During an interview on 05/20/2026 at 3:45pm, DON B stated she forgot that she wrote up a risk management note, about this resident. DON B stated the business office manager (BOM) D reported to her that resident complained of not getting water and her needs were not getting met.

Writer asked where the progress note was from the BOM D with this information. DON B stated BOM D did not write a note or documents in PCC, gave a verbal report to DON B.Writer asked DON B how a resident, admitted to the facility on [DATE] through 05/01/2026, instructed a CNA to not go in R7's room because of an issue, revised the care plan to make R7 cares in pairs on 04/30/2026, R7 asked to speak to management regarding her complaint/concerns, multiple nursing staff and administrative staff knew about this and nobody attempted to talk to her until she was walking out of the facility AMA, nothing was done to identify and possible resolve her concerns and complaints, nobody investigated it, nor reported it. DON B stated she didn't know.During an interview on 05/20/2026 at 4:00pm, writer reported abuse allegation to LNHA A and DON B.

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During an interview on [DATE] at 2:20pm, CNA O was asked when there is an allegation of abuse, what would you do? CNA O stated report it to the floor nurse, nursing manager, DON B, or Administrator A.

During an interview on [DATE] at 2:48pm, midnight shift RN Q, stated she remembered R7, stated R7 wasn't happy here, she had an issue with a CNA, R7 didn't want her to take care of her.

Midnight shift RN Q told R7 she was sorry that she had that experience with CNA, Midnight shift RN Q told R7 she would look into this situation and told day shift nurses what was going on.

Writer asked what their abuse policy instructs them to do, stated she believed she did that, she talked to the people she was supposed to, Midnight shift RN Q stated she told the day shift nurses to follow up on this and the day shift nurses told her that management already knew and it was taken care of.

During an interview on [DATE] at 3:00pm, Nursing Administration RN P stated she talked to DON B, stated she couldn't get logged into her computer so DON B wrote a progress note regarding R7 leaving AMA, stated she asked R7 if it was urgent or could wait until after the meeting, R7 told her it could wait.

After the meeting, Nursing Administration RN and DON B were told R7 was leaving the facility AMA.

Nursing Administration RN P stated there were some allegations made by R7.

Writer asked Nursing Administration RN P when she found this out, stated she needed to log into PCC to read it.

Writer waiting for her to get into her computer.

Nursing Administration RN P stated nurses that day were LPN J and LPN N, who put the buddy system in place.

During an interview on 05/2026 at 3:28pm, Minimal Data Set (MDS) nurse R, looking at R7's care plan, writer asked why the cares in pairs was put into place. MDS nurse R stated the care plan revised by DON B made R7 cares in pairs on [DATE]. MDS nurse R stated she added the same interventions on [DATE].

Record review revealed no nursing progress note noting behaviors or reason for adding cares in pairs to the care plan.

During an interview on [DATE] at 3:45pm, DON B stated she forgot that she wrote up a risk management note, about this resident. DON B stated the business office manager (BOM) D reported to her that resident complained of not getting water and her needs were not getting met.

Writer asked where the progress note was from the BOM D with this information. DON B stated BOM D did not write a note or documents in PCC, gave a verbal report to DON B.

Writer asked DON B how a resident, admitted to the facility on [DATE] through [DATE], instructed a CNA to not go in R7's room because of an issue, revised the care plan to make R7 cares in pairs on [DATE], R7 asked to speak to management regarding her complaint/concerns, multiple nursing staff and administrative staff knew about this and nobody attempted to talk to her until she was walking out of the facility AMA, nothing was done to identify and possible resolve her concerns and complaints, nobody investigated it, nor reported it. DON B stated she didn't know.

During an interview on [DATE] at 4:00pm, writer reported abuse allegation to LNHA A and DON B.

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Regency at Jackson 434 W North Street Jackson, MI 49202

be managed in house.

Specifically, he reported that R10's wound to his sacrum had been pretty stable

Wound NP S reported that there are times when wound care had not been performed or not performed

on occasion and that his concern was when he would observe a date on the dressing and it wasn't the date that he expected it to be (indicating the dressing had not been changed as often as ordered).

Wound NP S reported that both R10 and R13 should have wound care completed daily.

When asked about R13, Wound NP S reported that he had been treating a wound to his left heel for a couple of months and healing is going slow.

When asked if there are any concerns with wound care being performed in house, Wound NP S reported there had been a few times when wound care had not been done and that the resident is able to report when it's completed and when it is not.

Wound NP S reported that his documentation in the electronic medical record reflected his observations of wound care not being completed by in house staff and that sometimes the dressing he observes is the same dressing that he had applied the week prior (indicating it had not been changed by floor staff for an entire week).

Wound NP S reported that he will typically report that to whoever he is rounding with, which is typically Nursing Administration P.

Wound NP S further reported that staff had mentioned running out of dressings, specifically blue foam. On 5/28/26 at 12:54 PM, during an interview with Nursing Administration P, it was confirmed that she rounds weekly with Wound NP S, she takes the photos and Wound NP S performs the assessments.

When asked if any audits are done to confirm completion of daily wound care, Nursing Administration P reported that none were completed outside of the weekly rounds that she completes with the Wound NP and no ongoing or widespread education on wound care had been done upon being notified of wound care not being completed for an entire week.

When asked what the expectation is for dating the wound care dressings, Nursing Administration P reported she would like to see the date, time and nurses initials.

When asked what she was aware of regarding wound care not being completed, she reported that once or twice in the past Wound NP S had reported wound care not being completed and that one on one education was done with the nurse identified as not completing it.

When asked about the facility not having necessary wound care supplies, Nursing Administration P reported she felt the issue was the treatment cart needed to be organized.

When asked specifically about the blue foam, she reported that it's at the bottom of the cart and the staff don't really dig for it.

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Regency at Jackson 434 W North Street Jackson, MI 49202

According to the Minimum Data Set (MDS) assessment dated [DATE], R2 scored 8/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition).A review of an incident report for R2 dated 1/19/26, revealed the following: Pt (patient) was observed laying on her right side. Pt complaining of pain of the head and her right arm.

Ambulance notified and pt was sent to ER (Emergency Room) for evaluation. In the Notes section dated 1/20/26 it was documented IDT (Interdisciplinary Team) team met to review residents fall, root cause analysis residents' bed was not extended to proper size, resident rolled out of bed due to mattress hanging over edge, ongoing investigation, intervention placed to check that resident's bed is properly positioned when in bed, education provided to staff, care plan updated on expandable bed.On 5/27/26 at 1:25 PM, during an interview with RN K, when asked if she recalled the details of R2's fall in January 2026, she reported R2 had rolled out of bed, which was observed by CNA (certified nursing assistant) L who was on the other side of the room at the time. RN K reported it was determined that the mattress was too wide for the bed frame and she believed the mattress/bed frame had been placed in the room the day before the fall but was unsure who was responsible for placing the mattress/bed frame in the room without it being properly fitted.On 5/27/26 at 1:51 PM, during an interview with CNA L, when asked what details he recalled from R2's January fall, he reported, he and another CNA had started the process of getting R2 out of bed with the Hoyer lift when her roommate required assistance. R2 was laying flat on her back with the Hoyer sling under her and from the other side of the room, approximately 30 seconds after leaving R2's bedside, he heard R2 screaming and she had fallen out of bed. CNA L reported it was later discovered someone had come in to clean the floors while R2 was out of her room, made the bed frame smaller (less wide) to fit out of the door and when it was placed back in R2's room it was not extended properly to support the mattress which led to R2 rolling out of bed. On 5/28/26 at 1:25 PM, during an interview with NHA (Nursing Home Administrator), when asked what she could tell me about R2's January 2026 fall, she reported it was witnessed, she was sent to the emergency room because she was having pain, they did a head CT (cat scan) and x-rays were negative. NHA further reported, upon investigation of the root cause it was determined a housekeeper had closed her bed (reduced the width) to take it out of the room and when it was brought back into the room it wasn't expanded properly and the mattress extended past the frame.

The NHA reported, following the fall, they completed a facility wide audit of all beds to ensure proper fitting of the mattress and frame. NHA was unable to produce that audit prior to survey exit.

The NHA was asked if she could provide the care plan update made to R2's care plan following the fall, and the NHA did not provide that information prior to survey exit. A review of the facilities policy titled Fall Management updated 7/8/25, documented in part The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls.

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According to the Minimum Data Set (MDS) assessment dated [DATE], R10 scored 14/15 on the Brief Interview for Mental Status exam (which indicated intact cognition).A review of a Urology Office Visit note, dated 4/21/26, documented in part .presents today at the outpatient Urology office regarding urinary retention.He resides at a nursing facility and the catheter has been previously ordered to be changed every 4 weeks, however patient thinks it is longer between exchanges than that.Today he reports that the catheter seems to not work as well lately. He is noticing more leaking in his brief from the urethra and less urine in the bag.

Him and the aide that is with him confirm he is NOT getting any catheter flushes. He is unsure but believes the catheter was last exchanged around 3 weeks ago.Catheter bag leaking, very minimal concentrated urine in bag.

Brief is wet from leaking through urethra.Assessment/Plan: Resides at a nursing care facility, previously ordered to have catheter exchanged monthly however unsure if this is happening every month.

Patient thinks it is longer between exchanges than that. He is not having any catheter irrigation/flushes.

Today pt reports increased leaking of urine from urethra into brief.

Feels the catheter is not working well.Discussed need for daily irrigation of catheter to prevent sediment build up which is likely what is causing the leaking through his urethra.We exchanged his 20 fr (French-unit of measurement) SPT (suprapubic tube-tube that is surgically placed directly into the urinary bladder) today in the clinic.Order placed for nursing to irrigate SPT daily with 50 ml normal saline and as needed for clogging of catheter.A review of R10's Medication Administration Record for April and May, revealed that staff were documenting completion of a twice daily 60ml flush, however R10 is alert and oriented with a BIMS of 14, reported that it was not being done and was seen by urology and their notes supported R10's claim.On 5/28/26 at 11:51 AM, during an interview with DON (director of nursing) when asked what the expectation was for flushing a suprapubic catheter, she stated that the most recent guidance was that a suprapubic catheter should be done as needed.According to the Cleveland Clinic Website (https://my.clevelandclinic.org/health/treatments/25028-suprapubic-catheter) It's important to rinse (flush) a suprapubic catheter with sterile water to help prevent blood clots from blocking the device and otherwise keep the catheter clean and working properly.

You should flush your suprapubic catheter at least once a day.

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Regency at Jackson 434 W North Street Jackson, MI 49202

observations of wound care not being completed by in house staff and sometimes the dressing he

rounding with, which is typically Nursing Administration P.

Wound NP S further reported staff had

interview with Nursing Administration P, it was confirmed she rounds weekly with Wound NP S, she takes the photos and Wound NP S performs the assessments.

When asked if any audits are done to confirm completion of daily wound care, Nursing Administration P reported none were completed outside of the weekly rounds she completes with the Wound NP and no ongoing or widespread education on wound care had been done upon being notified of wound care not being completed for an entire week.

When asked what the expectation is for dating the wound care dressings, Nursing Administration P reported she would like to see the date, time and nurses initials.

When asked what she was aware of regarding wound care not being completed, she reported, once or twice in the past Wound NP S had reported wound care not being completed and one on one education was done with the nurse identified as not completing it.

When asked about the facility not having necessary wound care supplies, Nursing Administration P reported she felt the issue was the treatment cart needed to be organized.

When asked specifically about the blue foam, she reported, it's at the bottom of the cart and the staff don't really dig for it.