Every finding on record at Mission Point Nursing & Physical Rehabilitation Ce

Based on observation, interview, and record review the facility, failed to ensure food stored in the kitchen coolers and a pantry refrigerator were labeled and dated in accordance with the facility food safety policy. Findings include:On 06/7/2026 at 8:20 AM an initial tour of the kitchen was conducted with Dietary Manager (DM) U. During the tour, a review was conducted of the reach-in cooler to the left of the microwave oven. A large, opened container of cottage cheese that was undated when opened was observed. Review of the reach-in cooler to the right of the microwave revealed: a metal container of chopped vegetables that was undated, a bag of shelled raw eggs that was undated, and a 2-quart pitcher, approximately one third full, of a red liquid that was unlabeled or dated. DM U reported the red liquid was a dietary supplement for a resident that had discharged . DM U later reported that the resident was still in the facility but was no longer consuming the supplement.The policy provided by the facility titled Food Safety Requirements last revised 11/1/2025 was reviewed. The policy reflected, .It is the policy of this facility.(that) Food will also be stored.in accordance with professional standards for food safety. The policy further reflected 3.c, iv. Labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by it's used-by date, or frozen/discarded. This indicated that stored food was to be labeled with a known opened date so a discard date could be calculated.On 6/7/2026 at 8:45 AM, a review of the North /South pantry refrigerator revealed a plastic bag of ham dated 6/2 with a first name of a resident on it.The policy provided by the facility titled Use and Storage of Food Brought in by Family or Visitors , implemented 4/1/2026, was reviewed. The policy reflected Policy: It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. The policy further reflected 2.a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator . c. If not consumed within 3 days, food will be thrown away by facility staff. This indicated that facility staff had not monitored the North/South pantry refrigerator for food safety where resident food was stored past the 3 days as directed by policy.

Based on observation, interview, and record review, the facility failed 1) ensure proper usage of enhanced barrier precautions (EBP), 2) ensure proper infection control practice during wound treatment, and 3) ensure proper hygiene during medication administration.Findings include: Enhanced Barrier Precautions R11 Review of a Face Sheet revealed R11 admitted to the facility on [DATE] with pertinent diagnoses which included obstructive uropathy (a blockage in your urinary system that prevents urine from flowing normally) and pressure ulcer of right buttock. Review of a current Care Plan focus for R11, initiated 12/24/2025, revealed .I require enhanced barrier precautions d/t (due to) increased risk of MDRO (multidrug-resistant organism) acquisition due (to) Foley catheter. Further review revealed the following intervention initiated 12/24/2025, .Gown/Gloves should be worn during high-contact resident care activities (Dressing, Bathing, Transferring, Hygiene, Linen changes, Toileting/Brief changes, device or wound care) . In an observation on 6/7/2026 at 11:32 AM in R11's room, R11 had a Foley catheter in place with no signage on his door directing staff that he required the use of EBP. In an observation and interview on 6/8/2026 at 11:30 AM in R11's room, Licensed Practical Nurse (LPN) A donned gloves but no gown prior to pulling down his brief to observe the skin on his buttocks. After she was finished, LPN A reported she should have used a gown as R11 was in EBP and by handling his brief she was providing personal care. Review of facility policy/procedure Enhanced Barrier Precautions, revised in March of 2024, revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Wound Treatment Review of a Face Sheet revealed R7 originally admitted to the facility on [DATE] and currently has a pertinent diagnosis of a stage III pressure ulcer. During an observation and an interview on 6/7/26, Licensed Practical Nurse (LPN) S provided wound care for R7 while the fan was blowing in the room at the resident. LPN S was observed not performing hand hygiene after doffing gloves and donning new gloves a few times during the dressing change. When questioned about the fan and the hand hygiene after the dressing change was completed, LPN S reported she should have had the fan off and performed hand hygiene between glove changes. Medication Administration During a medication administration observation on 6/8/26 at 7:16 AM at the East Hall med cart, Registered Nurse (RN) K was observed pouring R81's morning medication pack into a medication cup. Two of the 3 medications spilled out onto the medication cart. RN K picked up the spilled medications with her fingers and placed them in the medication cup. RN K provided these medications to R81. After RN K provided the medications, she was asked what she should do when she spills medication on the cart and she responded she should have picked them up with a spoon. When asked if the papers and part of cart the pills landed on were a clean surface, she responded no, I should have wasted them and provided new medications. During an interview with the facility Infection Preventionist (IP) R on 6/9/26 at 10:30 AM, the surveyor reported the infection control concern with the medication pass on 6/8/26. The IP R confirmed it is an infection control issue, and she is working on a root cause and will be doing staff education. In a medication observation on 6/8/2026 at 7:29 AM in room [ROOM NUMBER]-2, Registered Nurse (RN) T was observed removing a fluticasone nasal spray (prescribed to relieve allergy symptoms) and a Flonase inhaler (used to prevent asthma) from the medication cart. RN T proceeded to enter the R67's room and place both medication boxes onto the overbed stand. RN T did not sanitize the overbed stand or use a barrier prior to placing the medication boxes. RN T administered R67's medications and proceeded to place both boxes of medications back into the medication cart. In an interview on 6/8/2026 at 7:34 AM, RN T stated he does not normally use a barrier when administering those medications. In an interview on 6/8/2026 at 12:07 PM, the Director of Nursing (DON) was informed of the medication observation regarding RN T not utilizing a barrier for the two boxes of medications in a R67's room. The DON reported a barrier should have been used. Review of facility policy/procedure Medication Administration, reviewed 1/17/2023, revealed . Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on interviews and record review, the facility failed to document rationale for two residents (R4 and R9) of five residents reviewed for unnecessary medications to extend as needed (PRN) psychotropic medication beyond 14 days. Findings include: R4 Review of R4's Face Sheet dated 6/9/26 revealed he was admitted to the facility on [DATE] and had diagnoses that included: schizoaffective disorder, major depressive disorder, and generalized anxiety disorder. R4 was not his own responsible party. Review of R4's, Note to Attending Physician/Prescriber dated 1/13/26 revealed, PRN Lorazepam, Per federal LTC (Long Term Care) regulations, if the above PRN anxiolytic order is to continue for longer than 14 days, intended duration and rationale to support use should be documented. The physician/prescriber Response was marked Agree and noted, note placed on 1/20/26. Review of R4's current medication orders dated 6/9/26 revealed, Lorazepam Oral Tablet 0.5 mg *Controlled Drug* Give 1 tablet by mouth every 8 hours as needed for agitation, anxiety, restlessness. Start date 11/14/25 and no stop date. Review of R4's Practitioner Progress Notes dated 1/20/26 at 13:33 (1:33 PM) revealed, Patient follows with (name of psychiatric services) who is helping with psychiatric medication management. He continues on Buspar TID (3 times a day) and has PRN (as needed) Ativan (brand name for Lorazepam) available without end date. (No medical documentation of duration of use or necessity for ongoing use was provided). Review of R4's Order Audit Report dated 6/9/26 revealed, Lorazepam Oral Tablet 0.5 MG was last ordered on 11/14/25. (Requires reordering every 14 days or assessment of ongoing need every 14 days). During an interview with the Director of Nursing (DON) on 6/9/26 at 12:14 PM, she was made aware of the documentation that revealed R4's Practitioner was ordering Lorazepam ongoing past 14 days. The DON confirmed the documentation and provided no additional documentation. R9 Review of a Face Sheet revealed R9 admitted to the facility on [DATE] with pertinent diagnoses which included alcoholic cirrhosis of the liver, dementia, and adult failure to thrive. Review of R9's Physician Orders revealed an active order dated 4/3/2026 for ativan (used to treat anxiety) 0.5 milligrams (mg) one tablet every six hours as needed for anxiety and agitation with no stop date. Upon further review of R9's Physician Orders revealed and active order dated 4/27/26 for a gel that contained Ativan 1 mg, Benadryl (used to treat allergies) 50 mg, and haldol (used to treat acute agitation and behaviors) 2 mg every 6 hours as needed for agitation with no stop date. In an interview and record review on 6/9/2026 at 10:31 AM, the Director of Nursing (DON) was unable to find documentation that the medical provider had documented rationale and risk versus benefit to extend the order beyond 14 days for R9. In an interview on 6/9/2026 at 10:40 AM, the Nurse Practitioner (NP) Q reported that she was unaware that she was required to document rationale and duration for PRN psychotropic medication orders beyond 14 days. Review of facility policy/procedure Behavior Management Program revised 12/20, revealed . PRN (as needed) orders for psychotropic medications are limited to 14 days. If the prescribing practitioner believes it is appropriate for the order to be extended beyond 14 days, then he/she should document their rationale in the medical record and indicate the duration for the order.

Based on interview and record review, the facility failed to pass medications per physician orders for 1 Resident (R4) of 5 residents reviewed for pharmacy review.Findings included: Review of R4's Face Sheet dated 6/9/26 revealed he was admitted to the facility on [DATE] and had diagnoses that included: schizoaffective disorder, major depressive disorder, and generalized anxiety disorder. R4 was not his own responsible party.Review of R4's active order start date 11/14/25 for Midodrine HCL (powerful medication that constricts blood vessels, which rapidly elevates blood pressure) revealed, Midodrine HCL Oral Tablet 5 MG, Give 1 tablet by mouth two times a day for orthostatic hypotension Hold if SBP (systolic blood pressure), (sign for greater than) 130.Review of R4's blood pressure log for the last 90 days, run date 6/9/26 around noon, revealed R4 only had 23 recorded blood pressures taken in the last 90 days. R4 had 4 blood pressures that had a SBP above 130. The blood pressures with SBP above 130 were dated 6/7/26 at 20:12 (9:12 PM), 6/6/26 at 15:10 (3:10 PM), 6/6/26 at 7:01 AM, 6/5/26 at 15:11 (3:11 PM). See June 2026 Medication Administration Record, R4 was provided Midodrine on these dates.Review of R4's, Medication Administration Record (MAR) dated 6/1/26 - 6/30/26 revealed, Midodrine HCL oral Tablet 5 mg give 1 tablet by mouth two times a day for orthostatic hypotension Hold if SBP (sign for greater than) 130. The boxes were completed to show R4 had been given this medication two times a day from June 1 to June 8 and one dose was provided on June 9. The MAR did not indicate the time of day this medication was provided and did not show R4's blood pressure was taken prior to giving this medication.During an interview with the Director of Nursing (DON) on 6/9/26 at 12:14 PM, the DON reviewed R4's physician orders and documentation related Midodrine and confirmed staff were not documenting taking R4's blood pressure prior to administration of Midodrine.

Based on observation, interview, and record review, the facility failed to supply clean oxygen tubing for one resident (R58) of 4 residents reviewed for oxygen therapy. Findings include:Review of a Face Sheet revealed R58 was initially admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disease (progressive lung condition that restricts airflow), chronic respiratory failure, and Alzheimer's disease.During an observation on 6/7/2026 at 8:30 AM in R58's room, R58's oxygen tubing (tubing that connects an oxygen source to a person) was brown in color and appeared dirty. Further review of R58's oxygen tubing revealed white tape wrapped around the tubing dated 3/30/2026. Review of an Order Summary on 6/7/2026 at 8:45 AM for R58 revealed no active order for oxygen tubing to be changed.During an interview and record review on 6/9/2026 at 8:38 AM, Registered Nurse Unit Manager (RN/UM) F reported that R58's oxygen tubing should have been changed every week on Sundays. RN/UM F reported there was not an active order for R58's oxygen tubing to be changed until 6/8/2026. Review of facility policy/procedure Oxygen Administration and Concentrator Policy, reviewed 6/2023, revealed .change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated and document in the electronic health record.

Based on interview and record review, the facility failed to ensure timely follow up for the monthly drug regimen review recommendations for 2 residents (R4 and R9) of 5 residents reviewed for unnecessary medication. Findings include: R4 Review of R4's face sheet dated 6/9/26, revealed he was admitted to the facility on [DATE] and had diagnoses that included: schizoaffective disorder, major depressive disorder, and generalized anxiety disorder. R4 was not his own responsible party. Review of R4's monthly pharmacy progress notes revealed that the pharmacy identified potential irregularities on 3/8/26, 1/13/26, 12/2/26, 11/11/25, and 10/8/25. Review of R4's Electronic Medical Record (EMR) reviewed no documentation related to the details of the irregularities, the physician being aware of what the irregularities were or had addressed the pharmacy concerns. During an interview with the Director of Nursing (DON) on 6/9/26 at 12:14 PM, R4's pharmacy progress notes were reviewed with the DON. A request was made for the irregularity notes for 12/2/26, 11/11/25 and 10/8/25. The DON said the facility had identified they had a problem with Pharmacy Irregularity documentation in December 2025 and she would not have any additional information for pharmacy irregularities for those dates. R9 Review of a Face Sheet revealed R9 admitted to the facility on [DATE] with pertinent diagnoses which included alcoholic cirrhosis of the liver, dementia, and adult failure to thrive. Review of R9's Note to Attending Physician/Prescriber dated 3/6/2026 revealed .PRN (as needed) Lorazepam (used to treat anxiety), per federal LTC (Long Term Care) regulations, if the PRN anxiolytic (used to treat anxiety) order is to continue for longer than 14 days, intended duration and rational to support use should be documented. Upon further review a second Note to Attending Physician/Prescriber dated 3/5/2026 revealed if the as needed anxiolytic/antipsychotic (used to treat acute agitation and behaviors) order is to continue for longer than 14 days, intended duration and rationale to support use should be documented. Both recommendations had no response from the physician documented. Review of R9's Physician Orders revealed an active order dated 4/3/2026 for lorazepam 0.5 milligrams (mg) one tablet every six hours as needed for anxiety and agitation with no discontinuation date. Upon further review of R9's Physician Orders revealed and active order dated 4/27/26 for a gel that contained Ativan 1 mg, Benadryl (used to treat allergies) 50 mg, and haldol (used to treat acute agitation and behaviors) 2 mg every 6 hours as needed for agitation with no discontinuation date. In an interview on 6/9/2026 at 10:31 AM, the Director of Nursing (DON) reported R9's two Note to Attending Physician/Prescriber recommendations dated 3/5/2026 had not been reviewed by the physician. The DON reported that the recommendations were not addressed. Review of facility policy/procedure Medication Regimen Review, reviewed 1/24, revealed .Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication.the MRR includes: Review of the medical record in order to prevent, identify, report, and resolve medication- related problems, medication errors, or other irregularities. Collaboration with other members of the interdisciplinary team, including the resident, their family, and/or resident representative. facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

Based on interview and record review, the facility failed to ensure complete and accurate medical record documentation of a change of condition that resulted in a transfer to a hospital for one resident (R1) of two residents reviewed for hospitalization. Findings include:Review of the Electronic Medical Record (EMR) revealed R1 was admitted to the facility 2/25/2025 with pertinent diagnoses that included chronic respiratory failure and dependence on a ventilator.Review of the EMR for R1 reflected a Progress Note entry dated 2/2/2026 at 11:15 PM that Resident was transferred. Sent To: (Name of hospital) 2/2/2026 at 21:37 (9:37 PM) Sent From: (name of facility) Reason(s) for Transfer: Abnormal Pulse Oximetry (low oxygen concentration) . The Progress Notes did not reveal documentation of an assessment or findings that described a change of condition that required an emergency transfer to the hospital. Review of the EMR for R1 reflected a Doctor's Order, Oxygen.maintain SPO2 (pulse oximetry) greater than 92%. This indicated that a pulse oximetry result greater than 92% was considered normal.Review of the EMR historical O2 Sat Summary (oxygen saturation) for R1 revealed: 2/2/2026 at 3:59 PM 99% oxygen saturation. On 2/2/2026 at 6:00 PM 93% oxygen saturation, 2/2/2026 at 7:00 PM 93% oxygen saturation. No further oxygen concentration results were documented until 2/10/2026.Review of the EMR historical Assessment section for R1 did not reveal a nursing assessment has been documented on 2/2/2026. The Assessment section did reflect a Transfer to Hospital form dated 2/2/2026.Review of the EMR Transfer Form-V5.1 for R1 dated 2/2/2026 at 11:15 PM reflected Description: Transfer to Hospital. The Reason for Transfer is documented as Abnormal Pulse Oximetry. No other documentation was identified on this form or elsewhere in the EMR that described the signs, symptoms, findings, or other assessments that indicated a change of condition warranted an acute care evaluation.During an interview on 6/8/2026 at 11:46 AM, Unit Manager Registered Nurse (UM RN) G was informed that documented change-of-condition findings resulting in a transfer to the hospital were not identified in the EMR of R1. UM RN G reported a review of the EMR of R1 and a follow up would be conducted.During an interview on 6/9/2026 at 2:09 PM, the Nursing Home Administrator (NHA) was informed additional information was anticipated from UM RN G regarding the transfer of R1 to the hospital on 2/2/2026. The NHA reported that this had been deferred to the Director of Nursing (DON).During an interview conducted 6/9/2026 at 2:12 PM, the DON reported no additional information was found regarding the reason R1 was sent to the hospital on 2/2/2026. The DON reported she had contacted the transferring nurse, and no additional information had been obtained.

This citation pertains to intake #2645718 and 2619157. Based on interview and record review the facility failed to implement ordered wound treatments for 1 resident (R5) of 3 residents reviewed for wound care. Findings include:Review of an admission Record revealed R5 admitted to the facility on [DATE] with pertinent diagnoses which included diabetes, a pressure ulcer, and muscle weakness. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R5, with a reference date of 10/20/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R5 was cognitively intact. In an interview on 12/10/2025 at 9:35 AM, R5 reported staff do not always complete her dressing changes. Review of R5's Treatment Administration Record (TAR) revealed the following dressings not marked as completed by nursing staff- September 2025-Right Lower Anterior Leg- incomplete on 9/13/2025Wound #1 Right Buttock- incomplete on 9/11/25, 9/12/2025, and 9/13/2025 October 2025-Right Lower Anterior Leg- incomplete on 10/1/2025, 10/11/2025, and 10/19/2025Wound #5 Right Buttock- incomplete on 10/10/2025, 10/11/2025, 10/14/2025, 10/18/2025, 10/19/2025, and 10/20/2025Wound #6 Left Shin- incomplete on 10/18/2025, 10/19/2025, and 10/20/2025 November 2025-Wound #5 Right Buttock- incomplete on 11/7/2025, 11/11/2025, and 11/21/2025 In an interview on 12/10/2025 at 9:59 AM, the Director of Nursing (DON) B reported she could find no documentation that R5's dressings on 9/11/2025, 9/13/2025, 10/10/2025, 10/11/2025, or 10/14/2025 were completed or refused. DON B reported all ordered dressings should be marked on the TAR as either completed or refused. Refused dressing changes should have a corresponding progress note explaining the circumstances of the refusal.

Based on observations, interviews and record review the facility failed to implement care plan interventions, standards of care for safety with transfers, and positioning and wheelchair equipment for 1 Resident (R6) of 3 residents sampled for accident hazards.This citation pertains to intake 2619157Review of R6's admission record dated 12/9/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included dementia, chronic pain syndrome, left hip prosthesis, intracranial injury (brain injury), and muscle weakness. R6 was not his own responsible party.Review of R6's care plan revealed a care plan for alteration in musculoskeletal status r/t (related to) left hip dislocation (most recent 11/29/25, 12/3/25 and 12/6/25) with knee immobilizer brace in place at all times per ER (emergency room) doctor. I see an orthopedic provider on 12/10 who is going to see if I am a candidate for surgery dated revision on 12/09/25. Interventions added 12/9/25 included, L (left) posterior hip precautions (no bending L (left) hip past 90 degrees, no crossing legs, and no inward rotation of the L (left) leg). Place pillow between patient legs in supine position as tolerated. pt (patient) is WBAT (weight bearing as tolerated) to LLE (left lower extremity) with knee immobilizer donned at all times. pt (patient) is limited 1 assist with sit to stand transfer to WC (wheelchair) as pt allows/tolerates.Review of R6's ADL (Activities of Daily Living) care plan dated revision on 12/9/25 revealed, Transfer - limited assist X 1 with sit to stand transfer to WC (wheelchair) as pt (patient) allows/tolerates. Ensure knee immobilizer is in place and left hip is supported during transfer.Review of R6's fall care plan dated revision on 12/09/25 revealed interventions that included: ensure I go to dining room for all meals (initiated on 8/13/25).R6 was observed in bed on 12/9/25 at 8:45 AM. R6 was struggling to cut his pancakes with a spoon, he had 3 sausage links on his plate that were not cut. He had not eaten any of the pancakes or sausage and he had a full bowl of cereal. There were no staff in the area to assist him. R6 was asked if he had any falls in the facility and he said, yes. R6 could not recall when he fell or what had happened. R6 pointed to his left leg and said it was not right. R6's toes on the left foot were turned inward, he tried to push his left foot with his right foot but couldn't make his left foot turn. (see care plan above, he was care planned to eat in the dining room due to fall risk and required cueing for eating).R6 was observed in bed on 12/9/25 at 3:08 PM. R6 had a 4 wheeled walker with a seat next to his bed. The seat had 2 standard wheelchair footrests on the seat. Physical Therapist (PT) H was in the room and was asked about R6's care and mobility. PT H said R6 fell on Thanksgiving when he was home with his family, he had a history of left hip dislocations and dislocated it again on Thanksgiving and at least one time since Thanksgiving. PT H said while they are waiting for a custom leg brace R6 is to use the knee immobilizer at all times, and he is currently not walking. PT H said the wheelchair in the hall belonged to R6 and the leg rests on the walker were for his chair. The left leg rest would not be able to support R6's leg properly in the wheelchair as it did not extend or have calf pad. PT H was not aware R6's did not have a proper leg rest for his left leg when he was up in his wheelchair. Unit Manager (UM) I was asked about resident safety needs like being in the dining room for meals and a supportive wheelchair footrest. UM I said R6 went to lunch but was not sure who took him or why he did not have the proper leg rest. She confirmed R6's walker was not to be left at his bedside, and she did not know why he did not go to breakfast.R6 was observed sitting on the edge of his bed on 12/10/25 at 7:20 am. R6's breakfast tray was on his bedside table. Certified Nurse Aide (CNA) F was getting ready to put R6 in his wheelchair. CNA F instructed R6 to stand and turn into his wheelchair. CNA F held onto R6's pants. R6 used his left hand on his bedside table (table on wheels) to support himself as he turned. CNA F struggled to get R6's left leg rest adjusted on his wheelchair. She placed the leg rest in the longest position, and it was still about 8 inches short. The only way his leg could fit on it was to turn the foot plate out of the way. R6 foot did not have support, and his left leg was turned inward. (R6 was care planned to use a sit to stand lift for transfers).During an interview was with CNA F on 12/10/25 at 7:35 AM, CNA F was asked for the reason she did not use a gait belt with R6 when she transferred him to his wheelchair, and she said she did not see one. She looked back into R6's room and found one on the wall. CNA F was asked why R6 ate his breakfast in bed, and she said he was on bedrest most of the time now. CNA F was asked if bedrest was care planned and if he was care planned to eat in the dining room and CNA F said she did not read his care plan today. Review of R6's progress note dated 12/9/25 at 17:06 (5:06 PM) revealed, RN (Registered Nurse) provider and therapy reviewed resident's plan for his recent left hip dislocations. Therapy has updated the recommendations for the residents. Staff is aware and there was a teach and sign performed so that all staff are aware on how resident is to transfer, toilet, and limitations.During an interview with CNA F and Unit Manager (UM) I on 12/10/25 at 8:55 AM, CNA F said she did not know anything about the updates in R6 care plan, and she did not know anything about a stop and sign. UM I went to the white board in the hall and pointed to a folded piece of paper. UM I said during shift report staff were to share the stop and sign. All staff were to read it and sign it. CNA F took the paper down and signed it.A review of the article Guidelines for Pushing Wheelchairs, dated 3/28/23, revealed, When pushing a wheelchair, safety should always be the top priority. Here are some safety guidelines to keep in mind: Always lock the wheelchair brakes before helping the user in or out of the chair. Use a firm grip on the wheelchair handles and keep your back straight and shoulders relaxed. Be aware of your surroundings and avoid obstacles and uneven surfaces. Always use the footrests when the user is sitting in the chair, and make sure they are properly adjusted. When going down ramps or inclines, always walk backward and use your body weight to control the wheelchair's speed . (https://alzheimerslab.com/guidelines-for-pushing-wheelchairs)

This citation pertains to intake 2576436Based on interview and record review, the facility failed to ensure the safety and well-being of one Resident (R101) of three residents reviewed for supervision.Findings include: Review of the admission Record reflected R101 originally admitted to the facility 8/5/2019. The Electronic Medical Record (EMR) reflected pertinent diagnoses that included severe morbid obesity, dependance on wheelchair, heart failure, cardiomyopathy, and diabetes mellitus. The medical record reflected the Resident was his own responsible party.On 8/21/2025 at 10:01 AM an interview was conducted with R101 in his room. R101 reported that on the night of 7/28/2025 at about 11:00 PM Licensed Practical Nurse (LPN) H let him outside to the facility interior courtyard in his power wheelchair so he could water his tomatoes. R101 reported LPN H was to come out shortly to help him but never came outside. R101 reported he attempted to turn off the water and return to the building, but his power wheelchair got stuck in mud. R101 reported he cannot walk so he called out repeatedly and attempted to gain attention by spraying water at resident room windows. R101 reported about five hours later, around 4:00 AM he was found by Certified Nurse Aide (CNA) D. R101 reported that a walker was brought out to him so he could stand and support himself while two CNA's freed his powerchair from the mud. On 8/22/2025 at 12:36 PM a telephone interview was conducted with LPN H. LPN H reported on the night of 7/28/2025 R101 let himself out to the facility interior courtyard about 11:45 PM. LPN H reported R101 wanted her to come out, but she had told him she was really busy and may not be out. LPN H reported she had seen the Resident outside alone in the courtyard on previous occasions and that, while residents were not supposed to know the door key code, R101 must have known the code. LPN H reported she was not concerned as it was an interior courtyard. LPN H reported she had checked R101's room several times during the night but that it was not unusual to not see him in his room or during the night. LPN H reported R101 was part of a small group of residents up during the night that would sign out to go smoke or watch television in a common area. LPN 'H' reported about 4:00 AM she still had not seen the Resident and asked staff to look for him. LPN H reported the Resident was found by CNA D in the facility courtyard in his power wheelchair which was mired in the mud. LPN H reported a walker was taken out to the Resident and staff stood with him while the power wheelchair was pushed out of the mud.On 8/22/2025 at 12:16 PM a telephone interview was conducted with CNA D. CNA D reported on the morning of 8/28/2025 she had not seen R101 for a long time which was not unusual for the Resident. CNA D reported R101 didn't usually stay in the facility during the night and would sign himself out to smoke with a couple of other residents. CNA D reported she started looking for R101 sometime after 3:30 AM. CNA D reported the staff near the facility exit reported that R101 had not gone outside and that was when she checked the interior courtyard. CNA D reported she found R101 in his power wheelchair stuck in the mud in the courtyard. CNA ‘D reported that R101 was upset and had complained that he had been in the courtyard for for hours despite yelling out. CNA D reported R101 had a phone with him but that the phone was not functioning. CNA D reported the Resident's walker was retrieved and he stood by while staff pushed his power wheelchair out of the mud. Review of the EMR Progress Notes for R101 reflected an entry dated 7/29/2025 at 4:15 AM by LPN H. The entry reflected, resident (R101) was found in the courtyard stuck in his electric wheelchair in the mud, he had been out watering the garden and tried to shut off the water when he got stuck, no injuries.During an interview conducted 8/22/2025 at 7:30 AM, Unit Manager (UM) J reported if a resident leaves the building, they or their guardian are required to sign out in the books that are on the unit or at the front door. UM J reported staff do hourly rounds on residents and can check the books to see if a resident had left the facility.During an interview conducted 8/22/2025 at 7:21 AM Registered Nurse (RN) B reported that residents are coded out of the building by staff. RN B reported that if a resident cannot be accounted for the Elopement protocol is initiated and a head count is conducted. RN B once all residents are accounted for an all clear is announced overhead.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Health care agencies have instituted purposeful hourly rounds to improve nurse responsiveness and patient satisfaction. Purposeful rounds include the 4 Ps (i.e., pain, potty, positioning, and periphery). Nursing staff usually conduct hourly rounds and ask patients about their pain and whether they need to toilet; then the patients are positioned for comfort, and an environmental check is done. The implementation of purposeful rounding improves patient safety by decreasing the occurrence of patient preventable events and proactively addresses problems before they occur (Zadvinskis et al., 2019). [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1448). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review the facility failed to 1) effectively administer their water management program, 2) ensure appropriate hand hygiene during wound care for 1 resident (R6) of 2 residents reviewed for pressure ulcers, and 3) ensure adequate cleaning of a Continuous Positive Airway Pressure (CPAP) device (a common treatment for obstructive sleep apnea that involves wearing a mask while sleeping that delivers steady air pressure to keep the upper airway open and prevent breathing from stopping and starting) for 1 resident (R8) of 2 residents reviewed for respiratory concerns. Findings include: Water Management Program In an interview on 5/21/2025 at 11:16 AM, Environmental Services Director (ESD) B reported he had been working at the facility since February of 2025 and had not been educated regarding the administration of the water management program at the facility. ESD B reported that he and Regional Maintenance Director (RMD) C were the only staff currently reviewing water management at the facility and the facility had not had any meetings to discuss water management since he had been hired in February. ESD B reported he could not find any documentation regarding control measures the previous ESD had been doing prior to his arrival. The water management binder had a handwritten water flow diagram, but no facility specific water management program describing the flow of water through the facility and the control measures in place. ESD B produced documentation that he had been flushing dead end water lines and plumbing in empty rooms monthly. RMD C reported the water management team included the Nursing Home Administrator (NHA), the Director of Nursing (DON), and ESD B and the team had not been meeting to discuss water management at the facility. RMD C reported the facility did not have a water management plan that had been written yet and this should be done. In an interview on 5/21/2025 at 12:01 PM, the NHA reported the water management team included herself, the DON, and ESD B. The NHA reported the team had not been meeting to discuss water management at the facility. The NHA reported she thought the previous ESD had finished writing a water management plan and she would attempt to locate this. In an interview on 5/21/2025 at 12:59 PM, RMD C reported they had found the facility water management plan. Review of the facility water management plan, which was not dated, revealed control measures that included .quarterly legionella test . flush low-flow pipe runs, dead legs and infrequently used fixtures weekly . However, ESD B had only produced documentation that he had been flushing dead ends and empty rooms monthly. In an interview on 5/21/2025 at 1:06 PM, RMD C reported the facility had been documenting monthly flushing and had not completed legionella testing in 2025. RMD C reported the facility water management team needed to begin meeting and review the water management plan to ensure the water management plan was being followed. 31771 Resident #6 (R6) Review of the medical record reflected R6 originally admitted to the facility 11/23/2011 and had diagnoses that included ventilator dependence. The Minimum Data Set (MDS) dated [DATE] reflected R6 had one unhealed Stage 3 pressure sore. On 5/21/2025 at 12:26 PM Registered Nurse (RN) E reported that the pressure sore on the buttocks of R6 had been present for years. RN E reported the wound had opened and healed repeatedly over time. RN E reported despite current preventative measures R6 was under current treatment for an open wound. Review of the Doctor's Order for the treatment of the open wound on the right buttock of R6 reflected 1. Cleanse with normal saline or wound cleanser. 2. Apply Cerave healing ointment to peri wound skin (around the wound). Apply a thick layer of Cerave healing ointment directly on xeroform (a medicated non-adherent gauze dressing) and then apply Cerave side of dressing to wound bed. 3, Secure with cover with non-adherent superabsorbent dressing. 4. Change daily . On 5/22/2025 at 7:14 AM an observation and interview were conducted with RN H during a wound dressing change for R6. RN H was observed to be appropriately gowned and gloved during the procedure. RN H was observed cleansing the wound on the right buttock using wound cleanser and wiping the wound and wound area with 4-inch square gauze. RN H was observed discarding the soiled gauze after cleansing. RN H was not observed discarding the soiled gloves worn during the cleansing process and performing hand hygiene before resuming the dressing change. While still wearing the soiled gloves worn during the wound cleansing RN H was then observed cutting to the size of the wound bed the xeroform gauze dressing. From a medication cup RN H scooped Cerave ointment with the finger of the soiled glove and directly applied the ointment to the cut xeroform gauze dressing. RN H was then observed placing the xeroform gauze, Cerave ointment side first, directly to the wound bed. RN H then applied the cover dressing over the wound. Following the procedure RN H acknowledged she should have degloved, performed hand hygiene and donned clean gloves before continuing with the application of the ointment to the xeroform dressing and placing it into the wound bed. The policy provided by the facility titled Wound Treatment and Documentation, last revised 2/24, was reviewed. The policy reflected wound treatments would be completed in accordance with current standards of practice and physician orders. The policy provided included a Validation Checklist, Wound Care. The document reflected the Purpose of the checklist was to Determine if the individual performing wound care is doing so in accordance with the facility's practice Guideline. Under the heading of Procedure Observed were numbered task/steps to be checked off during the procedure. The document reflected task/step 11. Cleansed wound thoroughly with prescribed cleansing agent or normal saline. And 12. Removed gloves and performed hand hygiene 28101 Resident #8 (R8) Continuous Positive Airway Pressure (CPAP) and BiPAP (Bilevel Positive Airway Pressure) are machines that are used to keep pressure in the airway to keep the airway open when sleeping generally use(d) to prevent sleep apnea (stopping breathing while sleeping). Review of R8's Admission Review Record revealed she was [AGE] years old and was admitted on [DATE] and had diagnoses that included: dementia, bipolar disorder, anxiety, chest pain, insomnia, traumatic brain injury, epilepsy, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), and asthma. She was not her own responsible party. R8 was observed in her room sitting on her bed on 5/21/25 at 10:40 AM. She had a CPAP machine on her nightstand next to her bed. Her mask was connected to the tubing. The mask was in bag that was placed on the floor next to the head of her bed. She had a gallon bottle of water sitting on the floor next to the mask. There were no cleaning supplies in her room. R8 said no one cleans the machine. R8 reported she is the one that fills the machine with water every night. Review of R8's May 2025 Treatment Administration Record (TAR) revealed, CPAP/BiPAP Mask: Wash with mild soap and warm water. Rinse thoroughly and let air dry. May use CPAP/BiPAP cleaning wipes. Add distilled water as necessary. Every day shift. Do not use any products containing bleach or alcohol. Start date 3/28/25 The boxes were all marked as completed from May 1, 2025, to 5/21/25. During an interview conducted 5/21/25 at 10:45 AM Licensed Practical Nurse (LPN) T reported she documented the cleaning of R8's CPAP mask on the TAR today. The box contained her initials. The Surveyor asked if she cleaned R8's CPAP mask today and she said she did not clean it. When asked why she marked it as complete she said she was in training and was told that the Certified Nurse Aides (CNA's) do the cleaning. Registered Nurse (RN) R was standing by and confirmed that they just mark the box and the CNA's do the cleaning. When asked if they are to verify that the CNA's do the cleaning LPN T and RN R said they do not verify that the CNA's do the cleaning. During an interview with the Director of Nursing (DON) on 5/21/25 at 10:50 AM the Surveyor explained that staff were signing the CPAP cleaning task on the TAR) without cleaning the machine. During an interview with Respiratory Therapist (RT) P on 5/22/25 at 11:18 AM, RT P the Surveyor discussed the lack of CPAP machine cleaning and lack of infection control practice (water and bag with mask being placed on the floor), with RT P. RT P and she confirmed that was not a safe practice. On 5/22/25 at 1:39 PM RT P provided a list of 11 facility residents with CPAP and BiPAP machines. RT P reported she only orders supplies for these machines and denied she assesses or monitors the resident's respiratory status. RT P also denied providing any oversight to ensure safe and proper storage of these devices or their supplies.

Based on interview and record review, the facility failed to keep 1 resident (R36) apprised of progress toward grievance resolution, of 1 resident reviewed for grievances. Findings include: Review of an Admission Record revealed R36 admitted to the facility on [DATE] with pertinent diagnoses which included congestive heart failure and chronic obstructive pulmonary disorder. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R36, with a reference date of 3/31/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R36 was cognitively intact. In an interview on 5/20/2025 at 10:56 AM, R36 reported she had filled out grievances regarding various complaints and missing items and was still waiting for responses from the facility regarding the status of her grievances. Review of R36's recent grievances revealed- Grievance filed by R36 on 5/23/2024 was signed by the Nursing Home Administrator (NHA) 7/18/2024 but the bottom of the form was not signed by R36 as having been given a copy of the decision of the grievance resolution. Grievance filed by R36 on 12/12/2024 was signed by the NHA 12/12/2024 but the bottom of the form was not signed by R36 as having been given a copy of the decision of the grievance resolution. Grievance filed by R36 on 12/27/2024 was signed by the NHA (signature not dated) but the bottom of the form was not signed by R36 as having been given a copy of the decision of the grievance resolution. Grievance filed by R36 on 5/1/2025 was signed by the NHA 5/5/2025 but the bottom of the form was not signed by R36 as having been given a copy of the decision of the grievance resolution. In an interview on 5/22/2025 at 8:00 AM, R36 reported she was still waiting for the facility to discuss the status of her grievances. R36 reported that the facility rarely reviewed grievance resolution status with her or gave her copies of the grievance decision. R36 reported she desired copies of the grievance findings and it was frustrating to her that she rarely heard back from the facility after she filed grievances. In an interview on 5/21/2025 at 3:41 PM, the NHA reported she could not verify that she reviewed the above grievance findings with R36. Review of facility policy/procedure Resident and Family Grievances, last reviewed 6/2024, revealed .Information on how to file a grievance or complaint will be available to the resident. Information may include, but is not limited to . The time frame that a resident may reasonably expect completion of the review of the grievance and a written decision regarding his or her grievance .

Based on observation, interview, and record review, the facility failed to ensure one Resident (R81) was safe to self-administer his medications of twenty sampled residents. Findings included: Review of the facility, Resident Self-Administration of Medication policy dated 06/23 revealed, 1. Each resident who self-administers medication will have and assessment completed. Review of R81's Administration Record revealed he was admitted to the facility on [DATE] and had diagnoses that included: vascular dementia, dysphagia (swallowing difficulty), repeated falls, and cognitive communication deficit. R81 was not his own responsible party. During an observation on 5/20/25 at 1:11 PM, R81 was observed to be eating lunch with no staff in the room and had a cup with several medications in it on his bedside table. The cup had his name on it. R81 said they were his vitamins. During and interview with Registered Nurse (RN) I on 5/20/25 at 1:15 PM, RN I confirmed she left R81's medication in a cup on his bedside table. RN I said he had refused to take his vitamins at breakfast, so she saved them. RN I said R81 was his own person, he is independent and prefers to take his vitamins with his lunch. During an interview with the Director of Nursing on 5/20/25 at 1:55 PM the DON provided R81's self-administration evaluation for taking medications. The DON said R81 failed the assessment due to cognitive issues.

Based on interview and record review, the facility failed to ensure a safe discharge for one Resident (R70) of three closed records reviewed. Finding included: Review of R70's admission record revealed she was [AGE] years old and was admitted to the facility on [DATE] and had diagnoses that included: epilepsy, fall, end stage renal disease, morbid (severe obesity due to excess calories), pain in left hip, diabetes mellitus 2, unsteady on feet, lack of coordination, occlusion and stenosis of bilateral carotid arteries, muscle weakness and acquired absence of kidney. She was her own responsible party. Review of R70's progress note dated 5/15/25 at 10:29 AM revealed, APS (adult protective services) called facility and stated they received a phone call from resident stating that she is not safe to go home. No further documentation of investigation into this allegation was recorded. Review of R70's Social Services progress note dated 5/16/25 at 1:59 PM revealed, Patient was notified that her request for a third extension of her skilled days was denied. discharge date remains tomorrow, 5/16/25. Patient expressed understanding and did not voice any concerns at this time, however, given patient's desire to not return home, she is at risk of displaying risky behaviors and poor decision making between now and her discharge tomorrow. No previous notes or explanations of resident's desire to not return home or the reason for not wanting to return home were available. Review of R70's progress noted dated 5/16/25 at 7:37 AM revealed, Resident noted on floor in front of wheelchair stated did not lock wheels on wheelchair before sitting down and slid to floor on buttock. Complaining of pain right index finger. Will re check right index finger when she returns from Dialysis. Review of R70's progress note dated 5/16/25 at 10:31 AM revealed, Resident discharged home in private vehicle with family today. All personal belongings and medications sent with resident. Discharge instructions reviewed with resident with verbal understanding. Encouraged to call facility with questions. Review of R70's, Discharge Instructions and Recap of Stay dated effective 5/7/2025 at 4:10 PM revealed, R70 was to discharge home with her spouse on 5/14/25. Under barriers -emotional, cognitive, financial, literacy concerns, transportation-appointments/items for daily living, safety, psychological) to discharge and steps taken for discharge documented, R70 has expressed that she would like to live in an assisted living facility but cannot afford to at this time. During an interview with the Director of Nursing (DON) on 5/21/25 at 3:09 PM , R70's progress notes were reviewed which documented R70 had called APS stating she was not safe to go home on 5/15/25. The DON said the Social Worker that did the discharge planning no longer worked for the facility. The DON said she was aware that R70 did not want to go home with her husband. The DON did not know which family members provided the transportation the day of discharge and did not know any details of R70's not feeling safe to discharge home with husband. During a telephone interview on 5/21/25 at 3:30 PM, the former facility Social Worker (SW) U said she did discuss applying for Medicaid but R70 did not want to apply. When asked if she spoke to R70 about calling APS and not feeling safe going home, SW U denied having a conversation or looking at any other options for discharge at that time. SW said R70 did leave the facility with her husband on the day of discharge.

Based on interview and record review, the facility failed to ensure that monthly pharmacy review irregularities and pharmacist recommendations were received and addressed by the physician for 2 of 5 residents (R3 and R53) reviewed for monthly pharmacy medication regimen reviews. Findings include: A review of the facility's Medication Regiment Review policy, last revised 1/24, revealed the Medication Regimen Review (MRR) is a thorough evaluation of the medication regiment of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences (unwanted, uncomfortable, or dangerous effects that a medication may have) and potential risks associated with medication. The policy further revealed the pharmacist shall communicate any recommendations and identified irregularities via written communication within 10 working days of the review . Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Resident #3 (R3) A review of R3's Admission Record, dated 5/22/25, revealed R3 was a [AGE] year-old resident admitted to the facility on [DATE]. In addition, R3's Admission Record revealed multiple diagnoses that included bipolar disorder, anxiety, and depression. A review of R3's Pharmacy Progress Note, dated 4/3/25, revealed, Monthly medication regimen review performed. Potential irregularity identified. See report for Olanzapine (a medication used to treat bipolar disorder) recommendation to nursing. A review of R3's electronic medical record, dated 4/3/25 to 5/22/25, failed to reveal a pharmacy report or any other documentation (e.g., a physician's progress note, a nursing progress note) that indicated what the irregularity was, what the pharmacist's recommendation for the irregularity was, and/or that the physician was aware of the irregularity the pharmacist had identified on 4/3/25. During an interview on 05/22/25 at 02:28 PM, Unit Manager (UM) A verified that she saw the pharmacist had entered a progress note in R3's electronic medical record for a potential irregularity and pharmacy recommendation on 4/3/25. However, UM A stated she did not see the pharmacy recommendation form under the Documents tab in R3's electronic medical record. She stated when the pharmacist sends a written report to the facility, it is put in the resident's electronic medical record under the Documents tab. UM A stated she would try to locate the report with the pharmacist's recommendation and would provide a copy to the surveyor if she could locate it. During a second interview on 05/22/25 at 03:25 PM, UM A stated she still could not locate R3's pharmacy report with the recommendation for 4/3/25. She stated Corporate Health Information Manager ([NAME]) S was trying to locate the missing 4/3/25 pharmacy report for R3. UM A stated [NAME] S was supposed to e-mail the Director of Nursing (DON) the pharmacy report, if she located it. During an interview on 05/22/25 at 4:00 PM, the DON stated the facility could not locate R3's pharmacy report with the recommendation mentioned in the Pharmacy Progress Note, dated 4/3/25. 28101 Resident #53 (R53) During an interview with the Director of Nursing (DON) on 5/22/25 at 1:20 PM R53's Pharmacy Recommendation for the irregularity note date 5/6/25 was not in the electronic medical record. On 5/22/25 at 2:25 PM the DON provided R53's, Summary of Medication Regimen Review for Medical Director dated 5/6/25. This summary recommended, Melatonin 10 mg daily at bedtime for insomnia (order date 1/7/25). To help identify the lowest effective dose, please consider a dose reduction of the Melatonin order. The DON had her initials in the box, Note written to physician. The DON did not have any validation that the physician reviewed this recommendation and R53's physician orders had not been changed.

Based on interview and record review, the facility failed to provide care in a dignified manner for 2 residents (R16 and R82) of 3 residents reviewed for dignity. Findings include: Resident #16 (R16) Review of an Admission Record revealed R16 admitted to the facility on [DATE] with pertinent diagnoses which included epilepsy and a history of falling. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R16, with a reference date of 2/24/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R16 was cognitively intact. Further review of the same MDS assessment revealed R16 required assistance with toileting. Review of the current activities of daily living Care Plan for R16, initiated 3/3/2023, revealed R16 required extensive staff assisting for toileting every two hours. In an interview on 5/21/2025 at 8:00 AM, R16 reported call lights took about 30 minutes to be answered on night shift a couple times a week. R16 reported a week ago he waited 30 minutes for his call light to be answered and was unable to hold his urine and urinated in his brief. R16 reported staff usually assist him with a urinal at night. R16 stated urinating in his brief didn't feel good and motioned that it made him feel small by pinching two fingers closely together. Resident # 82 (R82) Review of an Admission Record revealed R82 admitted to the facility on [DATE] with pertinent diagnoses which included cirrhosis of the liver and pancreatitis. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R82, with a reference date of 4/8/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R82 was cognitively intact. Review of a current activities of daily living Care Plan intervention for R82, with a revision date of 1/3/2025, revealed R82 required the assistance of 1 staff with toileting. In an interview on 5/20/2025 at 9:48 AM, R82 reported he waited over 30 minutes for call lights to be answered a few times a week. R82 reported 3 weeks ago on Sunday he waited for his call light to be answered from 0900 to 1100 while on the bedpan. R82 reported in January he pressed his call light and waited an extended period for staff to arrive. His urinal was full, and he was unable to hold his urine and urinated in his brief, which was embarrassing. In an interview on 5/22/2025 at 3:17 PM, the Director of Nursing (DON) reported call lights should be answered as soon as possible. Review of facility policy/procedure Resident Rights, revised 2/2024, revealed .The resident has the right to a dignified existence .

Based on observations, interview, and record review, the facility failed to do respiratory monitoring and maintain respiratory equipment in a clean sanitary condition for 1 Resident (R8) reviewed for CPAP Continuous Positive Airway Pressure (CPAP) Findings include: Continuous Positive Airway Pressure (CPAP). CPAP is a machine that is used to keep air pressure in the airway open when sleeping generally use to prevent sleep apnea (stopping breathing while sleeping). Resident #8 (R8) Review of R8's Admission Review revealed she was [AGE] years old and was admitted on [DATE] and had diagnoses that included: dementia, bipolar disorder, anxiety, chest pain, insomnia, traumatic brain injury, epilepsy, obstructive sleep apnea, chronic obstructive pulmonary disease (COPD), and asthma. She was not her own responsible party. R8 was observed in her room sitting on her bed on 5/21/25 at 1040 AM. She had a CPAP machine on her nightstand next to her bed. Her mask was connected to the tubing. The mask was in bag that was placed on the floor next to the head of her bed. She had a gallon bottle of water sitting on the floor next to the mask. There were no cleaning supplies in her room. R8 said no one cleans the machine. She stated she is the one that fills the machine with water every night. R8 was concerned because it has been years since she had a sleep study, and she feels like she is suffocating at night when she sleeps. Review of R8's May 2025 Treatment Administration Record (TAR) revealed, CPAP/BiPAP Mask: Wash with mild soap and warm water. Rinse thoroughly and let air dry. May use CPAP/BiPAP cleaning wipes. Add distilled water as necessary. Every day shift. Do not use any products containing bleach or alcohol. Started date 3/28/25 The boxes were all marked as completed from 5/1/25 to 5/21/25. During an interview conducted 5/21/25 at 10:45 AM Licensed Practical Nurse (LPN) T reported she documented the cleaning of R8's CPAP mask on the TAR today. The box contained her initials. The Surveyor asked if she cleaned R8's CPAP mask today and she said she did not clean it. When asked why she marked it as complete LPN T said she was in training and was told that the Certified Nurse Aides (CNA's) do the cleaning. Registered Nurse (RN) R was standing by and confirmed that they just mark the box and the CNA's do the cleaning. When asked if they are to verify that the CNA's do the cleaning LPN T and RN R said they do not verify that the CNA's do the cleaning. During an interview with the Director of Nursing (DON) on 5/21/25 at 10:50 AM the Surveyor explained that staff were signing the CPAP cleaning task on the Treatment Administration Record (TAR) without cleaning the machine and let the DON know R8 feels like she is suffocating at night when using her CPAP. The Surveyor requested orders and physician notes related to R8's CPAP, any monitoring and documentation related to R8's CPAP use. During an interview with the DON on 5/22/25 at 11:18 AM the DON said the physician orders for R8's CPAP were written on 11/11/24). The DON did not locate any physician notes, assessments, or monitoring of R8's respiratory status related to her CPAP use. The DON said the last time R8 had a sleep study completed was in 2019. During an interview with Respiratory Therapist (RT) P on 5/22/25 at 11:18 AM, RT Psaid she wrote the CPAP order of R8 on 11/11/24. RT P did not have any records of assessing or monitoring R8's respiratory status or CPAP machine. RT P said she orders replacement parts for all residents using CPAP machines in the facility based on their insurance coverage. RT P said she goes by a list she keeps in her office. The Surveyor discussed the lack of CPAP machine cleaning and poor infection control practice (water and bag with mask being placed on the floor) with RT P and she confirmed that was not a safe practice. On 5/22/25 at 1:39 PM RT P provided a list of 11 current facility residents on CPAP and BiPAP (Bilevel Positive Airway Pressure- this machine is like CPAP but provides a different level of air pressure when sleeping). RT P stated she only orders supplies. She also denied doing any assessing or monitoring of their respiratory status.

Based on observation, interview and record review, the facility failed to provide skin care as ordered and do ongoing assessments of skin condition for one Resident (R63) of 20 sampled residents. Findings included: Review of R63's admission record dated May 22, 2025 revealed that he was [AGE] years old and had diagnoses that included: paraplegia (spinal cord injury causing lower extremities to nerve damage with loss of movement and sensation), morbid obesity, and lumbar spina bifida with hydrocephalus (birth defect where the spine doesn't close properly in the lower back area and buildup of fluid in the brain occurs). R63 was observed in bed on 5/20/25 at 11:16 AM. R63's legs were fully covered by compression sleeves that were connected to a lymphedema pump (device used to push fluid out of the legs). R63 was very concerned about the condition of the skin on his legs. He said nursing had not been applying his medicated cream to his legs consistently for two months and he was worried that the skin would break down again. During an interview conducted on 5/21/25 at 12:25 PM, Unit Manager (UM) W confirmed that R63 had a Doctor's Order for Ammonium Lactate 12% cream to bed applied to his legs every night. The boxes on the Treatment Administration Record (TAR) for May 2025 had all been checked, indicating that R63 had been provided the treatment. UM W said a few months ago they were having difficulty obtaining the cream, but it is now a stock item. UM W verified the Ammonium Lactate 12% cream was in the treatment cart and the bottle appeared to be full. During an observation on 5/21/25 at 12:30 PM, R63 was in his room in his power wheelchair. UM W asked R63 about the skin treatment for his legs and he reported he had not received the Ammonium Lactate 12% cream in months. R63 had a tub of personal products on a table in his room and explained he was able to get some staff to occasionally put lotion from his personal supplies on his legs. UM W assessed R63's legs and both legs were covered with thick dead scaly skin. UM W said R63's legs were in very poor condition prior to the use of the Ammonium Lactate but when used consistently the legs do not have the dead scaly skin. Review of R63's physician orders dated 2/6/25 revealed, Ammonium Lactate Solution, apply to BLE (both lower extremities) topically (skin) every night shift. Review of R63's current care plan revealed, I am at risk for impaired skin integrity r/t (related to) morbid obesity, lymphadenopathy . I have been educated on the importance of elevating my feet and legs and continue to decline. Interventions included, assist me to moisturize my skin as needed. Review of R63's skin sweeps dated 5/10/25, 5/13/25 and 5/16/25 revealed no skin concerns.

Based on observation, interview, and record review, the facility failed to post the actual hours worked for licensed and unlicensed nursing staff (i.e., Registered Nurse, Licensed Practical Nurse, Nursing Assistant) directly responsible for resident care on the daily nurse staffing data sheets. Findings include: During an observation on 05/20/25 at 4:00 PM, the [Name of Facility] Nursing Department Daily Staffing sheet, dated 5/20/25, was observed posted on the wall outside of the Scheduling Office. However, the Daily Staffing sheet did not have the actual hours worked for licensed and unlicensed nursing staff listed even though there was an area for actual working hours to be entered by shift on the sheet. A review of the [Name of Facility] Nursing Department Daily Staffing sheets, dated 5/1/25 to 5/21/25, revealed none of the sheets had the actual hours worked for licensed and unlicensed nursing staff listed. During a second observation on 05/22/25 at 9:00 AM, the [Name of Facility] Nursing Department Daily Staffing sheet, dated 5/22/25, was observed posted on the wall outside of the Scheduling Office. However, the Daily Staffing sheet did not have the actual hours worked for licensed and unlicensed nursing staff listed. During an interview on 05/22/25 at 09:30 AM, Scheduler D stated she fills out the [Name of Facility] Nursing Department Daily Staffing sheets. She stated she did not realize that she needed to list the actual hours worked on the Daily Staffing sheets. Scheduler D also stated the Daily Staffing sheets should reflect any staffing changes (e.g., call-in's) that occur during the shift, but she has not been adjusting the Daily Staffing sheets after she completes them for the day to reflect any changes in staffing (i.e., staffing numbers, total number of hours worked).

Based on interview and record review, the facility failed to permit 1 resident (R102) of 3 residents reviewed to return to the facility following hospitalization. Findings include: Review of an admission Record revealed R102 admitted to the facility on [DATE] with pertinent diagnoses which included pneumothorax (a condition when air enters the chest and the lung collapses) and mild intellectual disabilities. Review of R102's Nursing Progress Note dated 3/28/2025 at 4:48 AM revealed R102 was sent to a local hospital complaining of difficulty breathing and was intentionally hitting himself. Review of R102's Transfer Notice dated 3/28/2025 revealed R102's reason for transfer was pneumothorax. Review of R102's Nursing Progress Note dated 3/28/2025 at 12:52 PM revealed R102 was admitted to the local hospital for spontaneous pneumothorax. Review of R102's Social Service Progress Note dated 3/28/2025 at 10:18 AM revealed Social Services Manager (SSM) G suspected undiagnosed mental health issues and requested the local hospital psychiatric department to evaluate R102 before his return to the facility. Review of the Electronic Medical Record (EMR) revealed R102 did not return to the facility and no further documentation was found to explain why he did not return after his hospitalization. In an interview on 5/6/2025 at 9:45 AM, SSM G reported she reached out to the company's admissions staff and requested R102 have a mental health workup while he was at the local hospital prior to his return. SSM G reported she did not know why R102 did not return to the facility following his hospitalization. In a telephone interview on 5/6/2025 at 10:58 AM, local hospital social worker A reported R102 was ready to discharge back to the facility after his 3/28/2025 hospitalization and the hospital therapy department was still recommending sub acute rehab. Local hospital social worker A reported the facility declined to permit R102 to return because of inappropriate behaviors. In a telephone interview on 5/6/2025 at 1:50 PM, facility admission Director B reported the executive team decided not to permit R102 to return to the facility after his 3/28/2025 local hospital admission because of his behaviors. admission Director B reported communication between the facility's admissions staff and the hospital was documented in CarePort, a message center used for facility admissions staff to communicate with local hospitals. Review of R102's CarePort documentation revealed the following: 3/31/2025, 11:37 AM, local hospital staff: He is medically ready for discharge and would like to come back to your facility. Can you please take him back for a short stay? His chest tube is removed. 3/31/2025, 11:42 AM, facility Business Development Manager E: I am sorry but he is on our do not admit list. 3/31/2025, 11:42 AM, facility admission Director D: We no longer have a bed available. Does he have family that can go to the facility to gather his belongings? 3/31/2025, 11:44 AM, local hospital staff: May I ask why for his do not admit list? No, he doesn't have any family that can go to the facility to gather his belongings. 3/31/2025, 12:03 PM, facility admission Director D: He was having behaviors. We also do not have a bed available. In an interview on 5/6/2025 at 3:00 PM, the Nursing Home Administrator (NHA) reported R102 signed a bed hold refusal but there was no documentation in the medical record to explain why he was not permitted to return to a different bed. The NHA reported R102 had made inappropriate comments while at the facility but had not assaulted staff or residents. In a telephone interview on 5/6/2025 at 4:16 PM, R102 reported he desired to return to the facility and did not understand the bed hold refusal that he signed when he discharged . R102 stated, I did not know. Review of R102's Notice of Bed Hold Policy dated 3/28/2025 revealed R102's name and the date was not noted at the top of the form, the staff signature at the bottom was not legible, and the staff signature was not dated. In an interview on 5/7/2025 at 8:30 AM Registered Nurse (RN) Unit Manager F reported she signed the bottom of R102's Notice of Bed Hold Policy dated 3/28/2025 even though she did not witness R102 sign the form. RN Unit Manager F reported she noticed the form was missing information including the x marking the resident designation to not hold the bed and the staff signature. RN Unit Manager F reported she spoke to the night shift nurse to confirm R102 did not wish to hold the bed and then marked the x for the bed hold refusal and signed the form. RN Unit Manager F reported the space for the resident's name and date at the top should have also been filled out. In an interview on 5/7/2025 at 8:07 AM, the NHA reported the decision not to allow R102 to return to the facility after his hospitalization was made without her knowledge. The NHA reported R102 should have been permitted to return to the next available bed. The NHA stated there was no reason the facility could not meet the needs of this resident as many residents in the facility have inappropriate behaviors. In a telephone interview on 5/7/2025 at 9:08 AM, facility Business Development Manager E reported R102 did not return to the next available bed because he was on the do not admit list because of behaviors exhibited while at the facility such as yelling and hitting himself. Business Development Manager E reported she was not sure who made the decision to place R102 on the do not admit list and believed it was a miscommunication. In a telephone interview on 5/7/2025 at 9:50 AM, facility admission Director B reported R102 was mistakenly added to the do not admit list without the approval of the executive team. admission Director B reported if R102 had been deemed safe to return by the local hospital he could have returned to the next available bed, but he did not go through the onboarding process because he was on the do not admit list. Review of facility policy/procedure Transfer and Discharge, revised 3/2025, revealed .In situations where the facility determines a resident's clinical or behavioral status endangers the safety or health of individuals in the facility, documentation regarding the reason for the transfer or discharge will be provided by a provider . Emergency transfers to acute care . The resident will be permitted to return to the facility upon discharge from the acute care setting . Not permitting a resident to return following hospitalization constitutes a discharge. In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of discharge to the resident and resident representative before the discharge, and must also send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman .

This citation pertains to intake #MI00145456. Based on observation, interview, and record review, the facility failed to prevent an elopement resulting in an immediate jeopardy when 1 resident (Resident #106) of 5 residents reviewed for elopement risk, exited the facility unbeknownst to staff. This deficient practice resulted in the elopement and risk for serious harm, injury, impairment, and/or death of Resident #106 and all other residents assessed as an elopement risk. Findings include: The Immediate Jeopardy (a situation in which entity noncompliance has placed the health and safety of residents in its care at risk for serious injury, serious harm, serious impairment or death) began on 6/21/2024 at approximately 5:15 AM when Resident #106 (R106) eloped from the facility. The Nursing Home Administrator was notified of the Immediate Jeopardy on 8/20/2024 at 12:37 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 6/21/2024 and the deficient practice corrected on 6/28/2024, prior to the start of the survey and was therefore past noncompliance. Review of an Admission Record revealed R106 admitted to the facility on [DATE] with pertinent diagnoses which included dementia, bipolar disorder, and suicidal ideations. Further review revealed R106 had an activated Durable Power of Attorney. Review of a Minimum Data Set (MDS) assessment for R106, with a reference date of 7/17/2024 revealed a Staff Assessment for Mental Status score of 2, which indicated R106 was moderately cognitively impaired. Further review of same MDS assessment revealed R106 received antipsychotic, antianxiety, and antidepressant medications. Review of R106's Social Service Progress Note, dated 6/20/2024 at 10:00 AM, revealed resident returned from a short stay at a community psychiatric hospital after being treated for suicidal ideation. Review of R106's Behavior Notes documented by Licensed Practical Nurse (LPN) K, dated 6/21/2024 at 2:31 AM, revealed .Resident exit seeking states want to go home explained that she has lived here and she has a bed here now. Resident is agitated and wants to go home . Tried to explain that she could not go tonight . She would wait until later in morning and discuss with her doctor and her responsible party . Review of R106's Incident Note, dated 6/21/2024 at 6:24 AM, revealed .Resident was reported to be outside of facility. Walking down 57 (a state highway) when arriving staff noted her outside of the facility . Resident stated was trying to go home . In an observation and interview on 8/19/2024 at 2:01 PM, Certified Nursing Assistant (CNA) O reported she saw an elderly woman with white hair and a walker walking on the road near the facility next to the mailbox of the adjacent property at approximately 5:30 AM on 6/21/2024. CNA O reported she did not recognize this person to be a resident and so she did not stop at the time CNA O reported the front door was alarming when she entered the building, but no staff were addressing the door alarm. CNA O reported she found LPN K near the nursing station and asked if there was a missing resident. After describing the woman she saw in the road, LPN K reported that must be R106. CNA O reported she told LPN K to call a code search (internal alert code) and returned to apprehend the resident. CNA O reported R106 had walked further away from the facility and was standing in the state highway when she caught up to her. CNA O reported she was able to turn R106 back toward the facility and additional staff arrived to assist. CNA O showed me exactly where she found R106 both when driving to the facility and when she returned to her. In a telephone interview on 8/21/2024 at 7:26 AM, LPN K reported at approximately 1:30 AM on 6/21/2024 R106 began talking about wanting to go home. LPN K reported R106 had never made a statement like this in the past, was not considered at risk for elopement prior to this incident and did not wear a wanderguard (resident alarm device) at the time. LPN K reported R106 continued talking about wanting to go home the entire night. LPN K reported staff kept an eye on R106 as much as possible and kept her near the nursing station. LPN K reported she came out of a resident room at approximately 5:30 AM, the front door was alarming, and CNA O met her at the nursing station and described a lady that fit the description of R106 that was out in the road. LPN K reported she did not call a code search. LPN K stated, Why should I involve the whole facility when I know who left? LPN K reported CNA O went out the front door on foot to apprehend R106 and she got her car keys. LPN K reported CNA O was walking R106 back toward the facility when she caught up to them a couple minutes later. LPN K was not sure how long the door was alarming and stated, It could not have been more than 5 minutes. LPN K reported she should have put a wanderguard on R106 as soon as she made comments about wanting to leave the facility. LPN K reported the wanderguard alarm is much louder than the door alarm and she would have been able to hear the alarm from the resident's room. In an interview on 8/19/2024 at 2:20 PM, Interim NHA A reported staff were all busy providing cares when R106 exited the building and the front door alarm went off. Interim NHA A reported the facility treated this like an Immediate Jeopardy by educating staff, conducting elopement drills, performing audits, and had been auditing and performing drills since the event. In an observation on 8/19/2024 at 3:35 PM, the distance from the front door to the mailbox where CNA O first observed R106 was approximately 120 yards. The distance from the front door to the state highway where R106 was apprehended by R106 was approximately 230 yards. The speed limit on the state highway where R106 was apprehended was 40 mph, and 55 mph just before the intersection she was found standing in. Review of facility policy/procedure Elopements and Wandering Residents, revised in May of 2024, revealed .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk . The facility may be equipped with door locks and/or alarms to help avoid elopements . Alarms are not a replacement for necessary supervision . Staff are to be vigilant in responding to alarms in a timely manner . The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary . Procedure for locating missing resident . Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code) . The Immediate Jeopardy that began on 6/21/2024 was removed on 6/21/2024 when the facility began education that included the facility's elopement policy, tips to prevent elopement, what to do when a resident who should not be outside is found outside independently, what to do when a door is alarming, when and how to perform a code search, and use of elopement books. Checks of external doors were completed, the Elopement and Wandering Policy was reviewed and deemed appropriate, an elopement drill was conducted, and all residents were re-assessed for elopement risk. The deficient practice was corrected on 6/28/2024 after the facility showed sustained compliance by conducting continued elopement code search drills involving all shifts, weekly audits, and continued education of all staff prior to working the next scheduled shift.

This Citation refers to Intake Numbers MI00141976, MI00142052, MI00142152, and MI00142213. Based on observations, interviews, and record review, the facility failed to provide an adequate Activities Program for seven residents (R7, R9, R10, R11, R15, R16, R17), resulting in boredom and feelings of anger, frustration, and depression. Findings include: Review of a facility policy Activities last reviewed [DATE] reflected It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group and individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. R10: During an interview on [DATE] at 11:11 AM, R10 stated the following, I'm upset about activities. We used to have activities from the time we got up until the time we went to bed. It kept me busy. We used to sit up front by the nurses' desk but now that is not allowed. So now we have NO social outlet. We like to sit, gather, and socialize and people watch and now we can't do that. (As resident is talking, she is becoming more agitated, her face is becoming more flushed, cheeks are redder, shoulders are straighter, residents' hands are opening and closing, until she grabs a tissue, eyes continued to glass over as she talks.) The people that were hanging out talking, we would have been in activities, but now we really have nothing. I feel they are taking the companies financial mistakes out on me/us residents. I am still paying the same amount every month and I am getting less. R10 further stated, I feel bored, depressed, angry and it's not fair! I'm missing my family (Family refers to the activities staff and the residents that attend daily) my connection with everyone. Resident is observed sniffing and her tears are becoming more prominent. R10 further stated, we now have nothing to do on the weekends. We always had less on the weekends, but now we have nothing. Nothing is boring, time just drags so slow all we have to look forward to is Monday! During the interview on [DATE] at 11:11 AM, R10 revealed she had serious concerns about her roommate's well-being. Upon seeing her roommate's bed empty and boxes on top of it R10 revealed that her roommate Resident#11 (R11) has been gone for a while. R10 stated the (Name of R11) was a social butterfly. She went to every activity. After the activities stopped (being all day and went down to 2 a day) she got very depressed, she wouldn't get out of bed, at times she would not eat, get dressed or take a shower. She told me a couple of days before that Sunday I am just going to lay here and die.' (R10 states R11 said this to her before She became very distraught on a Sunday, we had that big storm she couldn't go to church, and she could not get the service to watch on her phone. She got so upset she took a pen to her wrists. They sent her out to the hospital that day and she hasn't been back. R10 reflected R11 was a social butterfly, she went to all the activities. She lost all hope and was depressed. She said she had no reason. She went around activities to be around people. R11: During an interview on [DATE] at 12:11 PM, R11 was asked if she would like to talk about how she was doing. R11 revealed the following, I felt down, all alone, like I had no friends, no religion. I did try to hurt myself a few weeks ago. First my family died , then I got Covid and was stuck in my room, and then right after that all my activity's family were all let go. Resident revealed she came here because her doctor felt she needed to come to a nursing home where she would have other people around her. I went to all the activities, I loved the people, how they talked to us. It was a reason we stayed positive. Activities kept me active; it was enjoyable. We lost everything because of budget cuts. R11 stated, I used to go to activities, have a meal, rest for bit, and go again (to activities). When everything changed it felt like it was overbearing. I felt helpless because we had no change in sight. I was just so alone; the changes were overwhelming and not for the better. (R11 was observed crying during this interview and refused to end the interview multiple times, stating she needed to be heard.) R11 further stated, I want, I need more visits and things to fill my time up. I lost my appetite, but I am trying to get better. I am not trying to end my life; I know I have a reason to live for, but at the time I wanted to. During an interview on [DATE] at 12:15 PM, Activities Director (AD) I revealed that activities use to run from approximately 7:30 AM to 8 PM during the week (averaging 9 a day), with a couple of activities on the weekends. AD I revealed her department had recently lost 5 employees due to staffing cuts and she was now the only member left from her team/department. AD I confirmed activities were now down to two a day during the week, with no activities being schedule on the weekend. AD I then clarified that community volunteers were still providing a church service on every other Sunday. AD I further reflected, 1 on 1 activities have ceased for residents confined to their beds because she didn't have the time or staffing to do everything. During the interview AD I was asked about (Name of R11) and her participation. AD I revealed that (Name of R11) was usually one of the first residents down every morning and usually one of the last to leave. She came to practically every activity. Review of the January Activities Calendar prior to cuts reflected a busy calendar with approximately 9 options for residents to attend during the week. Two of the resident's favorite activities Coffee & News and Bingo were occurring 5 days a week. The after-staffing cuts January Calendar reflected 2 activities during the weekday and no weekend activities. Further review of downgraded calendar reflected coffee being listed as a lone activity and bingo being offered now once a week. R7: During an interview on [DATE] at 1:50 PM, R7 stated he has a problem with activities now being held only 2 times a day. Resident revealed he is upset and feels depressed because activities went from being all day to twice a day, and I now have very little to do. It's not fair, they are not treating us like they should. It's like they are taking away our rights to do activities. We used to have bingo everyday but Tuesday and Sunday, I looked forward to it, I miss it. Now we only play bingo on Mondays we went from 20 days a month to 4 days. Resident asked how this was right? I'm depressed and this does not help. They are doing away with things that relate to our well-being. All these changes are about greed the owner is pocketing money and we are left with nothing. R15: During an interview on [DATE] at 2:20 PM, R15 revealed that she was upset with all the changes going on, it makes me feel like I don't matter and that I'm not important. We did bingo 5 days a week now its 4 x a month. It got me out of my room, I went to a lot of activities it was something I looked forward to. It was every day, all day during the week and a few on the weekends. The (activities) staff were really good about encouraging us to get out of our rooms. The activities staff cared about us. They were like our family. They cared and they talked to us like we mattered. We had people that would play games and do things with us at night, now nothing. We have 2 activities a day now and the last one is at 2 or 3 PM. Sometimes we had choices because some activities would be going at the same time. Now we have hardly anything. I love our aides and nurses, but they are busy. You don't understand what you have until its gone. What they did (all the cuts) it feels like we do not matter. We sit, time just drags now. I don't have things to look forward to. R15 further revealed that she feels like our motivation is gone. I feel disgusted, with the lack of staff and the weekends just drag because of nothing to do. I feel like my life is empty now and I'm sad. I just don't feel important, they took away our choices. We didn't do this; they did this to us. Now I sit on my butt so much I'm worried about getting sores. I have never sat this much. During this interview the resident became very teary and went through several tissues. During an interview on [DATE] at 3:04 PM, Registered Nurse (RN) T was asked if he had noticed any changes in the residents. RN T stated since the cuts we have seen an increase in resident behaviors. Residents are upset, devastated, angry and pissed-off. Our residents use to be busy; we would have to hunt for them. They were happier. R9: On [DATE] at 3:19 PM, R9 was observed sitting on her bed the fitted sheet has slid down the mattress and is bunched up behind her. The resident's hair is unbrushed, her clothing is wrinkled. As the resident is talking, she is sighing and frowning. Her hands are mindlessly clenching and unclenching her fists during the entire interview. R9 states she has several concerns including the Internet being down since last week. R9 revealed she is frustrated with the lack of activities. They had bingo this morning and popcorn was the afternoon activity. Handing out popcorn is not an activity! Now we have nothing. I was used to a full schedule and now we don't. I feel depressed, not much to do makes the days very long. Nothing is going on the weekends; they are so boring and long. We no longer get mail on Saturdays because that was done by the activities staff, and they let them all go. I'm in my room today cause I'm in a bad mood. I want to be busy again. I hate being in my room with nothing to do. I miss the activities people. They always said hello and would check on our moods and would push/encourage us to get up and do things. I'm sad. R17: During an interview on [DATE] at 3:38 PM, R17 stated, I feel like they have taken a lot from us. We no longer get mail on Saturdays since the cuts (staffing) have been made. I pay for the paper 6 days a week. Reading my paper is one of my activities I used to do on the weekends. I am angry because I no longer get my paper on the weekend, and I am forced to wait until Monday for staff to deliver my Saturday and Monday paper. I do not want to read my Saturday paper on Monday. R17 further revealed she was unable to do anything on her tablet (Internet out) which has caused her to be bored since last week. During an interview on [DATE] at 10:45 AM, Certified Nurses Aide (CNA) J was asked if she had noticed any resident changes since staffing cuts occurred, she revealed she had heard a concerning conversation taking place between (Name of R11) and someone on her phone. CNA J stated she heard (Name of R11) yelling and arguing about not going to meeting and not being able to get it on zoom. I reported to the nurse that day that she was not acting her norm. (Name of R11) never got on her zoom meeting, she stated it did not matter, an that nothing mattered. The resident was sent out later that day for trying to self-harm. CNA J revealed (Name of R9) does not want to come out of her room now and she is no longer making her bed. She would always make her bed up in the morning, now she doesn't want to do anything. (Name of R15) now just goes to lunch and that's it. She will not come out of her room. She used to spend maybe a half hour of the morning in her room, now she is in there most of the time. CNA J states (Name of R15) denied herself popcorn yesterday, she had no interest and said [NAME] when it was offered. She loves popcorn. (Name of R10) is snapping at other residents, she is yelling, her behaviors are definitely increasing. She is telling us of her displeasure. CNA J revealed, the residents on the North and South Hall use to live for activities. During a follow-up interview on [DATE] at 2:30 PM, AD I was asked to provide a list of residents in the building that had received 1 on 1 activities from [DATE] to [DATE] and then from [DATE] -[DATE]. After providing both reports to this surveyor the first set activities note revealed the facility had approximately 16 residents were receiving 1:1 activities. The second report AD I provided from ,d+[DATE]-,d+[DATE] revealed there were no 1 on 1 activities during this time-period. When asked what happened, AD I stated, I'm just one person, I can't get it all done. I update resident care plans, attend their care conferences, make calendars, put in management notes, and do two activities a day. I just do not have enough time. R16: Review of R16's care plan reflected the following, I am here for long term, and I am dependent on for all my care needs. I would like to be read books that my wife has brought in for me. I will listen to staff reading to me during 1:1 visits 2 x per week. Date initiated: [DATE]. R16's interventions included, For 1:1 visits, I would enjoy: Harry [NAME] books, Jesus calling and the Bible read to me. These are books my wife brought in for me. Date initiated [DATE]. I am of Baptist religious affiliation and want to participate with religious activities at the facility. Date Initiated [DATE]. Review of R16's activities from [DATE] - [DATE] reflected he received 6 1:1 activities from ,d+[DATE] to ,d+[DATE]. Further review of R16's record reflected all activities ceased for him after [DATE]. During an interview on [DATE] at 2:50 PM, Physical Therapist (PT) S revealed the residents seem to be having a hard time since the cuts have been made in the building. (Name of R7) told me he has no reason to leave his room now. There is no laughter in the hallways. PT S stated, I miss hearing the residents coming down early to the activities room to drink coffee and chat. These guys (residents) are no longer going around joking, they are just sad. During an interview on [DATE] at approximately 3:00 PM, Anonymous Employee (AE) U revealed she has seen an increase in anxiety and sadness among the residents since the activities program has been cut. They are worried about what's going on, what's going to be taken away from them next. We are no longer doing 1 on 1 activities so the residents that are bed bound are just not getting any extra care or attention. They used to be talked to, read to, some would get their nails painted, and they would listen to music together. Now, those residents have nothing. Our residents use to have fun, they had a routine and schedule they liked, they had fun parties. States she is seeing more residents just depressed.

This citation pertains to intake M100138599. Based on interviews and record review, the facility failed to protect the resident's right to be free from neglect by not following the care plan when providing care for 1 (Resident #8), resulting in the resident falling out of bed and obtaining fractures. Findings include: Resident #8 (R8) Review of a Face Sheet revealed R8 admitted to the facility on [DATE] with pertinent diagnoses of hemiplegia and hemiparesis (one sided weakness) affecting the left non dominant side, symptoms involving cognitive function and awareness, and anxiety disorders. Review of the Minimum Data Set (MDS) dated [DATE] revealed R8 is cognitively intact and requires extensive assistance of 2 staff for bed mobility, transfers, and toileting. She has limited range of motion (ROM) on one side involving her upper and lower extremities. Review of an Incident Report dated 7/24/23 at 7:20 PM revealed R8 fell out of bed and observed sitting on the floor on her knees holding on to the enabler bars. She had reddened areas on her right and left knee, her pain was a 10/10, and no injuries observed post incident. Xray completed and resulted on 7/25 (at 10:05 PM). There is a nondisplaced fracture of the proximal tibial metaphysis. Other Info: I am care planned for 2 assists with bed mobility. I am at risk for falls r/t weakness, impaired mobility (need for assistive devices), Hemiplegia and hemiparesis following cerebral infarction affecting my left side . Witnesses: (Certified Nursing Assistant (CNA) A) stated I was giving bed bath and resident rolled out of bed. Review of a Corrective Action Form for CNA A dated 7/24/34 revealed she was educated to follow the Kardex when a resident requires 2 people for cares. Review of a Suspension letter dated 7/25/23 revealed CNA A was suspended pending an investigation regarding the failure to follow a direct care plan on 7/24/23. Review of a Radiology Report dated 7/25/23 at 10:02 AM for R8 revealed a nondisplaced fracture of the proximal tibial metaphysis. Cannot exclude extension into the knee joint. In an interview on 8/4/23 at 2:00 PM, R8 was in bed with a leg brace on her left leg and complained of pain with movement of her left leg. R8 reported about a week ago she was getting a bed bath by one staff member who was assisting her when she was leaning on her right side and fell out of the bed onto the floor. She was embarrassed because she was in her birthday suit when she fell on her knees. She did not get an x-ray until the next day when it showed she had a cracked bone. In an interview on 8/11/23 at 11:52 AM, CNA A reported she was giving R8 a bed bath alone when R8 slipped out of the bed. CNA A reported R8 had a soiled brief and needed her bed bath but could not find any staff who would help her. She acknowledged R8 was a 2 person assist with cares. CNA A reported that there is either not enough staff or there is staff who don't like working with each other in their assigned sections and will not help. CNA A reported she and other staff have provided cares for R8 alone in the past and the resident was just fine. There are other residents who require 2 staff for cares and only have one staff assist them. Review of the Activities of Daily Living (ADL) Care Plan for R8 revealed 2 staff members must be present for all bathing, has paralysis on the left side, 2 staff are to assist with turning and repositioning while in bed, initiated 7/16/2018. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: Element #1: The facility identified one CNA provided care for a resident who required 2 staff for assistance as documented in the care plan. Element #2: All residents residing in the facility who are a 2-person care are identified as having the potential to be affected. Residents residing in the facility will be ensured their care plans are being followed. Element #3: Nurses and CNAs were re-educated on the importance of reading and following the care plans, the staff who were not educated, will receive the education prior to the start of their next shift. Element #4: Audits were developed for retraining on 2-person care and following the care plan. Element #5: Compliance date is 7/25/23. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake MI00133904, MI000129511 Based on observations, interview, and record review, the facility failed to prevent and heal one pressure ulcer for 1 Resident (R26) of 3 Residents reviewed for pressure ulcers ), resulting in R26 developing a stage 4 pressure ulcer. Findings include: Review of R26's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: multiple sclerosis, acute osteomyelitis (onset 2/9/23), pressure ulcer of right buttock, stage 4, dependence on wheelchair, and chronic pain. R26 was not her own responsible party. Review of R26's Weekly Skin Sweep dated 3/6/22 at 9:46 AM revealed R26 had no skin concerns. Review of R26's Physician Assessment, dated 3/10/22 at 12:07 PM revealed R26's appetite was good, and her weight was stable. No pressure ulcer or skin concerns were noted. Review of R26's wound care note dated 3/22/22, no time, revealed R26 had a wound evaluation completed. R26 had 2 wounds on her buttock. Wound #1 was on the right buttock and it was an unstageable pressure injury that measured 2.5 cm x 2.5 cm x 0.2. Wound #2 was on the left buttock. This wound was partial thickness shear and measured 2.1 cm x 1 cm. Goals for both wounds listed healing. In addition to wound treatment orders the following additional orders were listed. Facility Pressure Ulcer Prevention Protocol, Pressure Redistribution Mattress per Facility Protocol - APM (alternating pressure mattress) and Turn in bed at least once every 2 hours if able. Review of R26's Practitioner Short Progress note dated 3/21/22 at 2:35 PM revealed R26's wounds on her buttock were getting worse and she was being referred to the wound specialist. Review of a Focused Review: New or Worsened Pressure Ulcer/Injury for R26 date completed and signed 2/20/23. Stage 4 pressure ulcer on the right buttock date of occurrence was 3/10/22. Weight stable since pressure ulcer development. No weight loss has occurred. Gradual weight loss a year prior to wound. Albumin 3.45, total protein 6.8, hemoglobin 13.8. The conclusion noted, Final stage of MS (multiple sclerosis, behaviors and nutritional risk. The box for unavoidable was marked. Review of R26's Kardex, (nurse aide care guide) dated 3/10/23 revealed R26 transferred with a mechanical lift and assist of 2 people. When R26's is in bed she chooses to lay flat because she has a fear of falling. For eating she requires assistance. She is incontinent of bowel and bladder and requires check and change routinely. She required 2 person assists with bed mobility. On 3/8/23 at 8:00 AM, R26 was observed sitting in a geriatric wheelchair (resident is not able to move independently) in the main dining room. On 3/9/23 at 8:00 AM R26 was observed sitting in a geriatric wheelchair (resident is not able to move independently) in the main dining room. On 3/9/23 at 10:58 AM R26 was observed to be cooperative with wound care. Registered Nurse (RN) Q and Certified Nurse Aide (CNA) R assisted R26 roll and stay in position for dressing changes to her buttock. R26 had two new small open areas on her right knee and one small open area on her left knee. The open area was starting to scab and were smaller than a dime. RN Q and CNA R said R26 was not able to move her legs and had no idea how or when R26 injured her knees. CNA R said R26 is a 3rd shift get up and she did not get any report at shift change of any injury. R26 was placed in bed after breakfast and CNA R said she did not see the injury at that time. During a telephone interview with CNA S on 3/9/23 at 4:38 PM, CNA S confirmed that R26 was transferred out of bed at 5:40 AM that day. CNA S said R26 is a two-person mechanical lift to her chair. CNA S said CNA T assisted with the transfer. CNA S said R26 was cooperative. There was no way she bumped anything during the transfer and CNA S did not see any wounds on R26's knees when she got her dressed that morning. CNA S said R26 is generally cooperative and is not able to move around on her own. On 3/10/23 at 7:22 AM, R26 was observed up in her chair. CNA U said 3rd shift got R26 out of bed. CNA U was asked how long R26 can be up in her wheelchair, and she said 2 hours because of the wound on her buttock. CNA U said she did not know what time 3rd shift got R26 out of bed (3rd shift ends at 6:00 AM) but believed she was one of the last people that 3rd shift got out of bed. CNA U said they usually put R26 back to bed after breakfast around 9:00 AM because she eats better when she is up in her chair. On 3/10/23 at 7:43 AM, CNA U said the nurse instructed her to put R26 back in bed because she can not be up more than 2 hours. CNA U said R26 has been a 3rd shift get up (list made by management) for more than 2 months. They normally put her to bed between 9:00 AM and 10:00 AM and get her back up for lunch because she eats better sitting up in her chair. On 3/10/23 at 8:49 AM, R26 was observed getting her breakfast tray in bed. On 3/8/23 at 2:10 PM the Surveyor asked the Director of Nursing for R26 wound orders, information on if the wounds were facility acquired, all wound measurements/assessments, treatment sheets and a timeline showing when all care was provided. On 3/9/23 at 2:50 PM, RN V provided several pages of information on R26's pressure ulcers. The report did not indicate when the facility first became aware of the skin breakdown. There was no indication the wounds were facility acquired and there were no measurements. The DON was informed the information provided did not give a good history on R26's wounds and it did not provide any information that showed the facility was following standards of practice to heal R26's wounds. The DON was notified that the documents requested were still needed and if the facility wanted to provide information that they had followed the standards of care for R26's wounds they had until exit to provide that information. During a meeting with the DON and RN V on 3/10/23 at 10:31 AM the new timeline provided for R26's pressure ulcer was reviewed. The timeline identified the wound on R26's right buttock was facility acquired and first discovered was 3/10/22. There was no measurement or staging identified. Supporting documents for the timeline were not available. The DON confirmed the facility did not have good assessments or documentation of wounds in March 2022. During the interview on 3/10/23 at 10:31, the DON was asked how they can verify R26 is not sitting up more than 2 hours and is getting, checked, changed and turned every 2 hours. The DON said they do random audits. The DON was not able to provide any random audits for R26. The DON was informed that observations and interviews this week did not support that the facility was doing check, change, repositioning, and limiting time up in the chair to 2 hours for R26. R26 is a 3rd shift get up and staff normally keep R26 up for breakfast as they report she eats better siting up. The DON was not able to provide any information that showed the facility was compliant with check, change, repositioning every 2 hours and limiting R26's up time. The facility provided their final documentation on R26's pressure ulcers on 3/10/23 at 12:04 PM. The document noted R26 had a facility acquired stage 4 pressure that developed on 3/10/22 no measurements. The first wound assessment was done on 3/22/2022 and the wound measured 2.5 x 2.5. x 0.1. Diagnosis r/t (related to) wound development. Multiple sclerosis, hx (history) of covid, wheelchair dependence, incontinent of bowel and bladder, unspecified lack of coordination, need for assistance with ADL's, vitamin d deficiency, impaired mobility, HTN hx (history) of right buttock stage 3 pressure injury. The facility timeline showed R26's wound deteriorated on the following dates: 12/13/22, 12/27/22, 1/31/23, and 2/2/23. The timeline showed R26's wound became infected on 2/6/23 and she required a PICC line placement for Intravenous (IV) antibiotic treatment on 2/9/23. The last measurement of R26's wound was completed on 3/7/23 and it was stage 4, 0.6 x 0.2 x 1.9. As of 3/10/23, R26 remains on IV antibiotics for her infected wound. The timeline and medical record review did not indicate the facility evaluated R26' pressure relief program or increased her pressure relief when they were aware on multiple occasions that R26's wound on her buttock was deteriorating. No clinical evidence was provided as to how the facility determined R26's wound was unavoidable. R26's weight remains stable, and her appetite remains good. R26 was dependent on staff for incontinence care and mobility when these wounds were discovered, and she remains dependent on staff for this care. Observations and interviews showed the facility has been non-compliant with check, change, repositioning, and up times or greater than 2 hours. The facility does not consistently accommodate R26's needs to be up in her chair for best meal intake and back in bed after mealtimes.

Based on observation, interview, and record review, the facility failed to implement measures to prevent/maintain pressure ulcers in 1 (Resident #39) of 19 residents reviewed, resulting in an unstageable pressure ulcer and the potential for existing pressure ulcer to be compromised. Findings include: Review of a Wound Treatment Management and Documentation Policy last revised 5/2019 revealed: Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence based treatments in accordance with current standards of practice and physician orders. Dressing changes may be provided outside the frequency parameters in certain situations: a. The dressing has disrupted. B. The dressing is soiled or is wet. Treatments will be documented on the Treatment Administration Record.Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. Wound treatments are documented at the time of each treatment. Review of a policy titled Skin and Pressure Injury Risk Assessment and Prevention last revised 07/18 revealed: It is our policy to perform a skin assessment and pressure injury risk assessment as part of our systematic approach to pressure injury prevention and management. Review of a Face Sheet revealed Resident #39 is an [AGE] year old female originally admitted to the facility on [DATE] with pertinent diagnoses of [MEDICAL CONDITIONS] and a stage 4 sacral pressure ulcer. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #39 had a Brief Interview for Mental Status (BIMS) indicating she is severely cognitively impaired and is totally dependent on two staff for transfers and extensive assist of two staff for care. Resident #39 had a urinary catheter and no diagnoses indicated on section I and a urinary tract infection within 30 days, a feeding tube. Section M revealed one stage 4 pressure ulcer and no unstageable pressure ulcer. During an observation and an interview on 10/8/19 at 1:58 p.m., Resident #39's husband reported she was admitted to the facility with a pressure ulcer that has improved since admission. Resident #39 was in bed on her back with pillows behind her. She had been in the same position since 12:00 p.m. and had puff boots on bilateral feet. Review of the Facility Matrix revealed Resident #39 had a stage 4 pressure ulcer, enteral tube feeding, indwelling catheter, [MEDICAL CONDITION], and infections. During an observation and an interview on 10/8/19 at 3:10 p.m., Resident #39 observed on her back in the same position she was in at 1:58 p.m. when Certified Nursing Assistant (CNA) F and CNA [NAME] entered the room to assist with incontinence care and pressure ulcer dressing change. Resident #39 had a bowel movement that saturated the bottom half of the dressing that was also not adhered to cover the pressure ulcer. Feces was noted inside and outside of the dressing and adhered to the resident at the top half of her coccyx. At 3:22 p.m. Licensed Practical Nurse (LPN) G entered the room for the coccyx pressure ulcer dressing change. LPN G had dressing supplies on a disposable tray on the nightstand next to the residents' bed. The tray had a stack of 4x4 unpackaged gauze dressings, an open long cotton swab, a spray bottle of wound cleanser, a paper cup with 25% Dakin's solution sitting in it, and an Opti foam dressing. A cloth towel draped partially over the tray. LPN G removed the dressing and the pressure ulcer was approximately a golf ball size in width and the edges had undermining. A large area of the surrounding skin was light pink and blanchable. LPN G continued to clean the wound and pack it with a gauze saturated in the Dakin's solution and placed the Opti foam dressing over it but did not adhere the dressing at the cleft of the buttocks. LPN G reported Resident #39 gets 2 dressing changes a day and received this dressing change late in the day because she has many bowel movements. LPN G reported she got the dressing supplies from the treatment cart and if Resident #39 had a sterile dressing change, she would have covered the supplies up, but since it was a clean dressing change, she did not need to do that. LPN G observed using the same gloves to remove old dressing and continue to clean and add new dressing. Review of a Weekly Wound Note dated 9/12/19 for Resident #39 revealed: Clarification: Wound is located on the sacrum. Review of a Weekly Wound Note dated 9/18/19 (Late Entry) for Resident #39 revealed: Stage IV Pressure ulcer/Sacrum, 4cm x 4.5 cm x 2 cm, no tunneling or undermining. Review of a Weekly Wound Note dated 9/18/19 (Late Entry) for Resident #39 revealed: Right Heel/Stage II Pressure, 2.2 cm x 1.5 cm. Review of a Weekly Wound Note dated 9/27/19 for Resident #39 revealed: Sacrum/Stage IV, 4.3 cm (centimeters) x 3.5 x 1.5 cm. Review of a Weekly Wound Note dated 9/27/19 for Resident #39 revealed: Right heel/Unstageable, 2 cm x 1 cm. Review of a Weekly Skin Sweep document for Resident #39 dated 9/12/19 revealed: . Right heel: blanchable redness and blister, tx in place. Left heel: blanchable redness, tx in place. Review of a Weekly Skin Sweep document for Resident #39 dated 9/19/19 revealed: . Right heel: redness to heel where blister popped, tx in place. Sacrum: open are to sacrum, tx in place. Did not mention left heel In an interview on 10/10/19 approximately 1:00 p.m., the Director of Nursing (DON) reported she had a call out to the nurse who does wound measurements because she did not have the current weekly wound measurements for Resident #39 and the measurements were not in the medical records. DON reported the wound nurse worked the late shift the night before and had the measurements on her desk but did not know where. The last documented measurements in electronic medical records were 9/27/19. The handwritten Monthly QA (Quality Assessment) Measurable Wound Log was provided at the end of this day for Resident #39 and it revealed: 10/1/19, admitted with stage IV pressure on sacrum 3.3 cm x 3.8 cm x 1.2 cm, unstageable pressure on right heel 2 cm x 1.2 cm. On 10/7/19 stage IV pressure on sacrum 3 cm x 3.5 cm x 1 cm and unstageable on right heel 2 cm x 1 cm. Review of Physician Notes for Resident #39 from 8/27/19 to 9/23/19 revealed the Physician is not aware of the pressure ulcer on her heel and not monitoring/overseeing the care of her pressure ulcer on her sacrum. Review of an Order Summary Report dated 8/1/19 to 10/31/19 for Resident #39 revealed no orders for pressure ulcer on the heel and no orders for [DIAGNOSES REDACTED]. Review of the medical records for Resident #39 revealed no Baseline Care Plan. When this surveyor requested the Baseline Care Plan, Care Conference Summaries were provided along with Progress Notes. Request for medical records was ongoing and repeated several times during this survey. No further documentation provided, and management staff was not available as they worked the night shift and unavailable for questions. Review of the CNA Kardex for Resident #39 revealed: Skin Integrity: I need 2 staff assist to turn/reposition at least every 2 hours, more often as needed or requested. Off Load Pressure to: Sacrum and Heels. Eating/Nutrition: I need the HOB elevated to 30 degrees during and one hour after tube feed. Bladder/Bowel: CATHETER: Position catheter bag and tubing below the level of the bladder and covered for dignity. Review of the Care Plan for Resident #39 revealed: Focus: 9/12/19- I have a blister on my right heel. Date initiated 8/10/19, revision on 9/17/19. Interventions: Off Load Pressure to: Sacrum and Heels, initiated 9/12/19. Review of a policy titled Skin and Pressure Injury Risk Assessment and Prevention last revised 07/18 revealed: It is our policy to perform a skin assessment and pressure injury risk assessment as part of our systematic approach to pressure injury prevention and management.

This citation pertains to intake number MI 276. Based on observation, interview and record review the facility failed to provide adequate supervision, ensure the safety, and prevent elopement in 1 of 3 sampled residents (#101) reviewed for elopement, from a total of 5 sampled residents, resulting in an Immediate Jeopardy when, on 10/27/13, Resident #101 eloped out the front door at 5:50 am unsupervised, resulting in the potential for serious harm. This deficient practice placed 7 residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death. Findings include: Review of Resident #101's Face Sheet revealed Resident #101 was admitted to the facility on [DATE], resided in Room 144-2, and had a history of [REDACTED]. According to the Minimum Data Set (MDS), dated [DATE], Resident #101 was a [AGE] year old male who had a serious mental illness, and did not wander, but was independent with locomotion off the unit with a walker or wheelchair. A review of Resident #101's Care Assessment Areas (CAA's) revealed he had a Guardian for decision making, was taking antipsychotic and neuroleptic (anti-seizure) medications, and was at an increased risk for falls. According to Resident #101's Care Plan (untitled), dated 10/09/13, Resident #101's had a care plan in place with the Focus: "I am at risk for elopement, a wanderer; exhibit Exit seeking behavior. I wander aimlessly." The Goal was documented as, "I will not leave the facility unattended..." Interventions included: "I need direct supervision while outside the facility..." Review of Resident #101's Progress Notes, dated 10/09/13, revealed LPN "B" documented, "(Resident #101) has been propelling self in his w/c (wheelchair) thru out the facility...placed on 15 minute checks r/t (related to) wondering in the hallway in the w/c since admit to the facility." Review of an Elopement Risk Assessment, dated 10/16/13, revealed Resident #101 was at risk for elopement, and was on 15 minute checks. On 10/28/13 at 3:00 PM, in the presence of Administrator "A", Resident #101 was observed to be a tall, well-nourished white male who had an unsteady gait. Resident #101 told Administrator "A" he went outside on 10/27/13, "to see what was going on", and was seen by a "blond hair nurse" when he was re-entering the building. Resident #101 stated he was wearing "a long sleeved shirt" and had been outside for 10-15 minutes. Resident #101 said, "Yeah, it was cold out there. I just want to get out and walk around. It made me feel so good to be able to walk outside last week." When asked how he exited, Resident #101 stated a "man in a black suit, a doctor or preacher, dressed so nice, held the front door." When asked why he went outside, Resident #101 replied, "I just had to go." When Administrator "A" reminded Resident #101 that he had his wheelchair with him when he went outside, Resident #101 said, "If I wouldn't have had it, I would have fell . I would have been in big trouble. I don't know how I would have gotten back in if I fell out there." Administrator "A" reported the facility did not have a wander alarm system or a security camera system at the facility. When surveyor asked what had been put into place to prevent the same scenario from happening again, Administrator "A"responded, "When someone elopes, they immediately become a one-on-one...Don't ask me why he was up at that time." According to Historical Weather at Wunderground, at 6:00 AM on 10/27/13, it was dark outside and the temperature was 35 degrees Fahrenheit. (www.wunderground.com/history/airport/KY70/2013/10/27 <http://www.wunderground.com/history/airport/KY70/2013/10/27>...). Review of a Witness Statement, (not dated), revealed LPN/Licensed Practical Nurse "A" did not witness Resident #101 leave the building, but saw Resident #101 when she (LPN "A") was "carrying my crock pot; I was going to take it out to my car." Review of the 10/27/13 Nursing Notes and Incident Report regarding Resident #101, revealed no evidence that a head to toe assessment or vital signs were performed, or that the physician or Resident #101's guardian were notified of the elopement. Review of Nurse's Notes from 10/27/13 revealed only the following documentation: "(7:45 PM) (Resident #101) was seen coming in the front door via wheelchair at (6:05 AM). Was asked who let him out and he responded with 'I caught the door' Management was called and a head count was done." On 10/28/13 at 3:40 PM, it was observed the facility had two doors (the front entrance and the service entrance at the back of the building) that could be exited without activating a "screamer alarm". Office Administrator "C" reported both doors required an identical code be entered into a key pad on the wall to exit the building; the front entrance required only that a button be pushed to enter the building, and the back entrance required that the same code be entered on a key pad to open the door to enter. On 10/29/13 at 1:00pm, Administrator "A" was notified that the the facility was placed in Immediate Jeopardy as a result of the facility's failure to prevent the elopement of Resident #101 from the building. On 10/31/13 at 9:30 am, this surveyor ( ) verified the facility completed the following to remove the Immediate Jeopardy: On October 27, 2013: 1. On October 27, 2013 at 5:41 am and 5:45 am visual checks for Resident #101 were documented with the location of "hallway". 2. A new Elopement Risk assessment was completed for Resident #101 and care plan was updated. 3. Resident #101 placed on 1:1 supervision. 4. A "head count" was completed between 6:15 and and 6:30 am on 10/27/13 to ensure there were no missing residents. 5. Maintenence was notified at 6:30 am on 10/27/13 and codes were changed on all doors by 10:00 am. The front and back doors have different codes. 6. All door alarms and mag-locks in the building were checked by Maintenence for proper function and no problems were found. 7. The Policy and Procedure regarding "Elopement" was updated to include: a. "tear and go" sheet which states that once a resident is returned a licensed nurse will be assigned to complete a head to toe assessment of the resident including vital signs and recorded in the resident's record. b. The front door locked timeframe will begin at 10:00 pm and unlocked at 8:00 am daily. 8. Door codes will be re-coded on a monthly basis. On 10/30/13: 1. There will be an assigned person positioned to monitor the front door around the clock. 2. Education began on 10/29/13 at 2:30 pm for "Resident Elopement and Missing Person" procedure. 107 of 152 employees have been educated at this time. 3. All staff will be educated prior to working thier next assigned shift. 4. Elopement drill are done quarterly and all staff has refresher training annually on missing person procedures. Although the Immediate Jeopardy was removed on 10/30/13, the facility remained out of compliance as a scope of pattern and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to the facility had not yet completed all education and sustained compliance had not yet verified by the State Agency. /

Based on interview and record review, the facility failed to report the mistreatment of [REDACTED].#100) resulting in the resident being fearful. Findings include: According to medical record Resident #100 was a [AGE] year old female readmitted to the facility on [DATE] with acute and chronic respiratiory failure, maglignant [MEDICAL CONDITIONS] status and dysphagia oropharyngeal phase. Electronic Medical record also reflected that she had a brief mental interview score of 15 out of a total 15, which reflected no cognitive impairment. On 10/1/13 at 10:00 am, during an interview with resident #100, she described 3 incidents in which Respiratory Therapist "T" (RT "T") became argumentive. Resident #100 stated there were many more, but she described the 3 major incidents. Resident #100 stated ever since RT "T" began working with her, RT "T" has had a problem with her and she doesn't know why. Resident #100 began with the incident that occurred on 9/6/13. During the interview with resident #100 she stated there is a certain way " it feels when her water is low or no water. " (Sterile water to humidify respiratory tract) Resident #100 stated that her secretion pack was not wet, which was another sign her water needed changing. Resident #100 put her call light on and when nurse aide "H" answered her call light, Resident #100 asked nurse aide "H" to get Respiratory Therapist "T" to change her water. When RT "T" entered the room Resident #100 requested that her water be changed. RT "T" told resident #100 her water did not need to be changed, and asked 'do you want me to show you how much water is left?' Resident #100 replied it doesn't matter how much water was left in the bottle, she needed the water bottle to be changed. Then Resident #100 said RT "T"" said the water bottle cost $50.00. Then Resident #100 told RT "T" " I wasn't getting any air." Respiratory Therapist "T" then stated "I went to school " for this job and I know how to do my job. Then Resident #100 said you may have gone to school for your job, but I know what I need. Then RT "T" walked out of the room. Resident #100 stated she could feel the warm air in her throat and it was hard for her to breath. Resident #100 stated it took RT "T" 10 to 15 minutes before she re-entered the room, and changed it (with an attitude). Resident #100 stated she did not report it to anyone but when I woke up the Administrator was in my room, and she reported what happened to the Administrator. There was an undated, typed written explanation by RT "T" of what happened, which corroborated resident #100's story. RT "T" stated in her written statement that nurse "E" was the only nurse at the nurses' station. Nurse "E's" written statement (undated) reflected she was at the medication cart "ulling meds " when RT "T" went into resident #100's room and started yelling at resident (#100) stating she was not going to change the aerosol because it was not empty and she knows her job and went to school for it. Nurse "E" stated she was unable to hear Resident #100 ' s responses. Nurse "E's" statement to resident #100 was "no you listen to me I know what I am talking about and you don't." Nurse "E's " statement further explained that RT "T" tone was very abrasive and loud. RT "T" "stormed out of room." On 10/1/13 at about 6:50 am, Nurse "E" stated she did not have any idea whyRT "T" was upset, and confirmed she was yelling and the Administrator was informed. On 10/1/13 at 6:25 am during an interview with nurse "F" stated she overheard RT "T" yelling at Resident #100, that this was about 2 weeks ago and the Administrator and Respiratory Therapy Supervisor "C" were made aware. Nurse "F" stated there was another confrontation, but that was a while ago. On 10/1/13 at 7:25 am, per telephone call nurse "F" stated after Resident #100 got the water in her bottle, Resident #100 did have increased anxiety, and she sat with her for a half an hour. Nurse "F" stated she was angry and tearful until she fell asleep. On 10/1/3 at about 7:45 am, during an interview with Respiratory Therapist Supervisor "C" he discussed the incident involving RT "T" and Resident #100 on 9/6/13 (his letter says (9/7/13) resulted in a verbal counseling session and a 60 day probation, furthermore, she was not to enter resident #100's room unless accompanied by another staff member. On 10/3/13 at about 2:30 pm during an interview with the Administrator, the Administrator admitted she had not reported this incident to the State Licensing Agency, and accused 3 witnesses of having ulterior motives. ( ) On 10/1/13 at about 11:15 am, Guardian Angel "R" (Guardina Angel is a program initiated by the facility for staff to routinely visit with an assigned resident to ensure their needs were being met) stated he visited resident #100 on 9/9/13 and she reported RT "T" had adjusted her vent settings last night and she intentionally, left something off of the vent. Resident #100 said she knocked on the table but RT "T" ignored her. Resident #100 further stated that RT "T" did not immediately turn around, but RT "T" eventually fixed the problem. This incident was written on the Guardian Angel form and reported to Unit Manager "S" who had nurse aide "H" report to her. Unit Manager "S" could be heard speaking to Nurse Aide "H" when Nurse Aide "H" was asked "what we need to improve on." Review of the Guardian Angel form dated 9/19/13 reflected "Last night (RT "T") ignored her saying she couldn't breathe. Nurse Aide "H" helped Resident #100. Something on vent was loose and not functioning. (Resident #100) feels (RT "T") tampered with the vent to make (Resident #100) suffer. 2nd time happened. " Nurse Aide "H" documented her witness statement dated 9/19/13 reflected when the respiratory lady was putting her on the vent a hose fell off. The resident (#100) said that hurt. The respiratory therapist said I am sorry I did not mean to do that. Then put the tubing on the vent and asked was everything okay and resident #100 said yes. Nurse Aide "H" returned to room and Resident #10 said "I think she did that on purpose, I don't want her in my room." On 10/1/13 at 10:00 am during an interview with Resident #100 she stated from the beginning of time she and RT "T" did not get along, but "I never did anything to her." Resident #100 said because of the rude way respiratory Therapist " T " has been treating her, an extra staff person has to be with RT "T" whenever she goes into Resident #100's room. On 10/1/13 at 10:00 am, during an interview, Resident #100 explained both Nurse Aide "H" and RT "T" were in her room on the evening of 9/18/13. Resident #100 explained that RT "T" does an exceptional job and nothing ever happened before this night. She stated she put her on the vent and suddenly "I couldn ' t breathe." I tried to beckon her by hitting the table and moving the ventilator, Resident #100 called RT "T"'s name while banging on the table, she called RT "T's" name saying "I can't breathe" while knocking on the table. This went on for about a period of 20 seconds and the alarm was sounding. RT "T" would not look at her, so she tried to get Nurse Aide "H" attention, she called Nurse Aide "H's" name and said "I can't breathe." Nurse Aide "H" responded saying "you can't breathe?" Nurse Aide "H" was putting dirty linen in a bag. So " I turned back to RT "T" who never looked at Resident #100. Resident #100 said while I am crying out and the siren is going off, RT "T" said the machine is telling me something is off. Then RT "T" looked at me in an eerie way. One of the vents was unattached. Resident #100 stated "May God kill me if I'm lying." Nurse Aide "H" came back into the room and that was when Resident #100 told her RT "T" did that intentionally, and Nurse Aide "H" said "you think she did that on purpose?" RT "T's" written statement dated 9/9/13 reflected she noticed that Resident #100 was "not getting the set VT. I checked the cuff pressure which was good. I then looked for a leak and found the exhalation valve leaking ... " RT "T" did not try to console her at all. On 10/1/13 at 7:45 am Respiratory Therapist Supervisor "C" stated he was made aware of what happened on 9/18/13 the next morning. On 10/3/13 at about 2:30 pm during an interview, the Administrator assured that she reviewed all of the Guardian Angel forms daily however, she denies having any knowledge of what transpired on 9/18/13 between Resident #100 and RT "T" until 9/22/13 when Resident #100's guardian called and informed her. The Administrator stated her staff did not immediately report this incident to her. Thus the above incident was not reported to the State until 9/23/13. The facility's investigation report dated 9/22/13 reflected that Resident #100 could do her own [MEDICAL CONDITION] and vent care. However, during an interview with the Respiratory Therapist supervisor "C" he stated she could not do her own ventilation care at facility. On 10/1/13 at about 5:50 am, during an interview with RT "T" she stated since she hired in January 2013, she has always had conflict Resident #100. RT "T" stated Resident #100 would not always agree with her recommendations and felt Resident #100 was expressing that she did not know how to do her job. Several nurses RT "T" disagreed with it but would do what the resident wanted in the end. During this same interview with resident #100 on 10/1/13 at 10:00 am, there was a 3rd incident that took place earlier in the year. Resident #100 explained that she needed to be changed and as the nurse aides rolled her over, she began to have difficulty breathing and requested the RT "T" to be suctioned. The nurse aides stopped care to get the respiratory therapist. A nurse came into suction her but she could not get it all, so Resident #100 said she was still choking. That was when RT "T" would not come. It took 4 requests before she would come, the nurse made RT "T" come back to complete the suctioning. Resident #100 stated she never saw RT "T" again that shift. Resident #100 stated she reported this to the Director of Nursing (who is no longer at the facility) Resident #100 believed the Director of Nursing reported this to the Respiratory Therapist Supervisor "C" On the morning of 10/1/13, immediately after the interview with Resident #100. Respiratory Therapist Supervisor "C" stated he was not aware of that situation in which Resident #100 was left with incomplete suctioning. On 10/1/13 at about 11:00 am, the Administrator was asked was she aware that Resident #100 reported to prior Director of Nursing that RT "T" refused to come back into her room to suction her. The Administrator stated she was not aware, and could find no written information on that incident. This incident was not reported to the State Licensing Authority. ( ) This citation pertains to intake number MI 850 According to the Facility 24 hour report dated 9/19/13 received via online submission on 9/23/13 (4 days later) Resident #100 was reported to have alleged her ventilator was not functioning correctly at the start of the application and this was intentional by Respiratory Therapist (RT) "T". In an interview on 10/2/13 at 3:20 PM, Certified Nurse Aide (CNA) "H" reported she had been present during the alleged incident when the venttilator was not functioning correctly. CNA "H" reported ventilator care was provide with 2 staff present and when care was completed both RT "T" and CNA "H" had left the room. Resident #100 had approximately 8-10 minutes later put her call light on and reported to CNA "H" that she felt that RT "T" had dropped the ventilator tubing on purpose. CNA "H" reported Resident #100 stated she remains afraid of RT "T" and possible retaliation. The incident was reported to her charge nurse. In an interview on 10/3/13 at 2:10 PM Licensed Practical Nurse (LPN) "I" reported Resident #100 had an additional incident on 9/19/13 at approximately 2:30 PM. LPN "I" reported Resident #100 was tearful and reported RT "T" had been harsh and belittled her earlier in the day. LPN "I" reported she had notified Team Leader/charge nurse (LPN) "G" who was responsible to notify the administrator of abuse allegations for that shift. LPN "I" reported she had considered the incident reported when LPN "G" was informed. According to the facility "Abuse," Policy dated 6/20/10, "1. POLICY: The resident has the right to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. 3. Reporting/notification a. Any alleged or actual resident violation shall be reported to the Administrator. e. Immediately (no later than 24 hours) notify BHS of all allegations by one of the following methods: 1. complete the BHS-OPS-362 online submission form found on the BHS website or... 4. Investigation a. The administrator or designee shall thoroughly investigate all allegations. b. document date and time of all notifications." The facility failed to report an alleged incident immediately. ( ) Review of facility investigation/staff facility statements dated 9/6/13 revealed incident of alleged verbal abuse was not reported within the mandatory time frame. On 10/2/13 at 3:30 PM, during an interview, Certified Nurse Aide (CNA) "H" reported Resident #100 had requested her water bottle to be changed and reported she had informed RT "T" of the request. On 10/2/13 at 2:35 PM, Licensed Practical Nurse (LPN) "F" verified a statement written on 9/6/13 (no time) for an alleged incident dated 9/6/13 and reported she heard a request from Resident #100 for a change in her water bottle for her ventilator. LPN "F" reported RT "T" was heard to state to Resident #100 the bottle was costly to change. LPN F reported RT "T"'s voice was heard loud enough it could be heard outside of Resident #100's room and it was not in a helpful tone of voice. LPN "F" reported "unit manager" "J" was notified and was instructed to not have RT "T" provide Resident #100 Respiratory care or enter her room. LPN "F" reported Administrator "A" was notified but was unable to recall the time. On 10/2/13 at 2:20 PM, LPN "E" verified a statement written on 9/6/13 (no time) for an alleged incident dated 9/6/1/3 and reported she heard RT "T" yelling in an abrasive loud tone getting louder and louder to Resident #100. LPN "E" reported RT "T" then immediately walked out of the room. RT "T" was reported to have informed Resident #100 the bottle was going to cost $50.00 and it was not empty. LPN "E" reported LPN "F" notified Unit Manager, LPN "G" and ADM "A" and were instructed to write statements and not allow RT "T" to go into Resident #100's room except to do ventilator checks then someone had to go in with her. LPN "E" reported, "Not that what she did was ok it was not physical, she was safe." According to the facility "Abuse," Policy dated 6/20/10, "1. POLICY: The resident has the right to be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. 3. Reporting/notification a. Any alleged or actual resident violation shall be reported to the Administrator. e. Immediately (no later than 24 hours)0 notify BHS of all allegations by one of the following methods: 1. complete the BHS-OPS -362 online submission form found on the BHS website or... 4. Investigation a. The administrator or designee shall thoroughly investigate all allegations. b. document date and time of all notifications. The facility failed to prevent re-occurring episodes of verbal abuse, and accurately document, investigate or report the alleged incidents immediately. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PROVIDE IMMEDIATE RESPIRATORY CARE FOR 1 OF 6 RESIDENTS (# 6 ) WITH A [MEDICAL CONDITION] WHO WAS HAVING SIGNS AND SYMPTOMS OF ACUTE RESPIRATORY DISTRESS AND WAS UNABLE TO CLEAR THEIR AIRWAY RESULTING IN PUTTING RESIDENT (#6) IN IMMEDIATE JEOPARDY AND THE POTENTIAL FOR INCREASED RISK OF RESPIRATORY COMPROMISE AND POTENTIAL DEATH. FINDINGS INCLUDE: THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 5/8/12 AT 2:45 PM. WHEN RESIDENT #6 WAS OBSERVED TO BE COUGHING ALMOST CONTINUOUSLY, WITH A VERY RED FACE, TEARS RUNNING DOWN HER FACE AND WITH THE APPEARANCE OF PANIC AND DISTRESS WITH HER WHOLE CHEST BEING USED IN AN ATTEMPT TO OBTAIN A BREATH. DURING THIS PERIOD 2 SEPARATE PROMPTING'S FROM THE SURVEYOR OF REPORTING RESIDENT #6'S SIGNS AND SYMPTOMS TO 3 STAFF MEMBERS, CHARGE NURSE "A," RESPIRATORY THERAPIST "B" AND CHARGE NURSE "C", FAILED TO IDENTIFY AND ASSESS THE RESIDENT'S ACUTE RESPIRATORY DISTRESS SIGNS AND SYMPTOMS ACCORDING TO THE CARE PLAN. THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 5/10/12 AT 11:55 AM. THE IMMEDIATE JEOPARDY WAS REMOVED ON 5/10/12 AT 4:45 PM BUT NOT CORRECTED WHEN THE FACILITY ADMINISTRATOR PROVIDED THE CORRECTION PLAN TO REMOVE THIS IMMEDIATE JEOPARDY. THE CORRECTION PLAN IMPLEMENTED TO REMOVE THE IMMEDIATE JEOPARDY CONSISTED OF THE FOLLOWING: 1) SIX RESIDENTS WITH TRACHS WERE IDENTIFIED AND ASSESSED AND FOUND TO HAVE NORMAL BREATHING PATTERNS WITH OUT DISTRESS. 2) CONTINUE TO ASSESS AND IDENTIFY OTHER RESIDENTS AT RISK FOR RESPIRATORY DISTRESS 3) EDUCATION OF 28 NURSING AND 8 RESPIRATORY STAFF BEGAN IMMEDIATELY WITH NURSES "A" AND "C" AND THERAPIST "B" WILL NOT BE ALLOWED TO WORK UNTIL EDUCATION IS PROVIDED. ANY NURSING OR RESPIRATORY STAFF NOT EDUCATED TODAY WILL NOT BE ALLOWED TO WORK UNTIL THE EDUCATION IS PROVIDED 4) EDUCATION WILL BE REPEATED QUARTERLY FOR NURSING AND RESPIRATORY THERAPISTS PROVIDED BY THE LICENSED RESPIRATORY THERAPIST. THE LICENSED RESPIRATORY THERAPIST WILL FILL OUT A COMPETENCY CHECKLIST AND REPORT THE FINDINGS TO THE DON AND ADMINISTRATOR THROUGH THE QUALITY ASSURANCE QUARTERLY PROCESS. C.N.A. (CERTIFIED NURSE AIDE) STAFF WILL BE INSTRUCTED ON IDENTIFYING CHANGES IN BREATHING PATTERNS AND TO REPORT SIGNS TO THE NURSE. 5) CHART REVIEWS ON RESIDENTS WITH IDENTIFIED RESPIRATORY ISSUE WILL BE DONE DAILY FOR FOUR WEEKS THEN MONTHLY FOR THREE MONTHS TO ASSURE PROPER INTERVENTION, DOCUMENTATION AND FOLLOW UP AS APPROPRIATE. THE RN. UNIT MANAGERS WILL VISUALLY SPOT CHECK TWO RESIDENTS, WITH IDENTIFIED RESPIRATORY ISSUES, PER WEEK TO OBSERVE FOR PROPER ASSESSMENT OF LUNG SOUNDS, VITALS, AND APPROPRIATENESS OF TREATMENT FOR TWO MONTHS REPORTING OUTCOME TO THE DON. THE DON WILL REPORT RESULTS OF THIS AUDIT AND THE CHART AUDITS TO THE MONTHLY QUALITY ASSURANCE. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, SUSTAINED COMPLIANCE COULD NOT BE VERIFIED AND REMAINED AT POTENTIAL FOR MORE THAN MINIMAL HARM AT A PATTERN RELATED TO SIX RESIDENTS CURRENTLY IN THE FACILITY WITH A [MEDICAL CONDITION]. ACCORDING TO THE PHYSICIAN ORDERS [REDACTED].#6 WAS A [AGE] year OLD FEMALE WITH ACCUMULATIVE [DIAGNOSES REDACTED]. ON 5/8/12 AT 2:45 PM, RESIDENT #6 STATED TO CHARGE NURSE"A", "I HAVE A SORE THROAT." AT THIS TIME, RESIDENT #6 WAS OBSERVED TO BE IN CONTINUED RESPIRATORY DISTRESS. CHARGE NURSE "A" FINISHED REPORT AND THEN CHARGE NURSE "A" PROCEEDED TO ENTER THE MEDICATION ROOM. RESIDENT #6 WAS LEFT ALONE AT THE NURSING STATION IN DISTRESS AND WAS NOT BEING ATTENDED TO AT THIS TIME. CHARGE NURSE "A" RETURNED AT 2:50 PM. RESIDENT #6 WAS COUGHING TO THE POINT OF HER FACE TURNING RED (RUDDY) IN COLOR, TEARS RUNNING DOWN HER FACE AND WITH THE APPEARANCE OF PANIC AND DISTRESS WITH HER WHOLE CHEST BEING USED IN AN ATTEMPT TO OBTAIN A BREATH. ACCORDING TO RESPIRATORY ASSESSMENT IN ADULTS NURSING STANDARD, PAGE 52, DATED APRIL 19, 2007, "PROLONGED HYPOXEMIA (DEFICIENT OXYGENATION OF THE BLOOD) CAN LEAD TO ERYTHROCYTOSIS (EXCESS OF RED BLOOD CELLS) AND PRODUCES A RUDDY APPEARANCE OF THE SKIN... IT IS IMPORTANT TO NOTE THAT ANAEMIC ([MEDICAL CONDITION] LACK OF RED BLOOD CELLS AND IRON IN THE BLOOD) PATIENTS MAY HAVE INSUFFICIENT HEMOGLOBIN TO PRODUCE THE BLUE COLOUR OF THE MUCOUS MEMBRANE THAT CHARACTERIZES CYANOSIS (CAUSED BY A LACK OF OXYGEN IN THE BLOOD)." ON 5/8/12 AT 2:55 PM, RESPIRATORY THERAPIST "B" INSTRUCTED RESIDENT #6 TO WHEEL HERSELF TO HER ROOM. WHILE IN DISTRESS RESIDENT # 6 WAS ATTEMPTING TO WHEEL HERSELF TO HER ROOM. RESPIRATORY THERAPIST "B" FINALLY ASSISTED RESIDENT #6 TO HER ROOM. ON 5/8/12 AT 2:57 PM, UPON RESPIRATORY THERAPIST "B" LEAVING RESIDENT #6'S ROOM, THIS SURVEYOR INQUIRED OF THE TREATMENT PROVIDED. RESPIRATORY THERAPIST "B" RESPONDED THAT [MEDICATION NAME] (A LOCAL ANESTHETIC) AROUND THE STOMA WAS PROVIDED. RESPIRATORY THERAPIST "B" DENIED COMPLETING ANY RESPIRATORY ASSESSMENT OR LISTENING TO RESIDENT #6'S LUNG SOUNDS. RESPIRATORY THERAPIST "B" RETURNED RESIDENT #6 BACK TO THE NURSING STATION SITTING IN HER WHEEL CHAIR. ON 5/8/12 AT 3:15 PM, (35 MINUTES LATER) CHARGE NURSE "A" WHO HAD BEEN SITTING AT THE NURSES' STATION SINCE FINISHING REPORT AT 2:50 PM WAS ASKED IF HE WAS GOING TO CONSIDER ASSESSING RESIDENT #6'S RESPIRATORY STATUS. CHARGE NURSE "A" REPORTED "(NAME OF RESIDENT #6) IS NOT MY RESIDENT, I WENT OFF AT 2:30 AND I AM BUSY MAKING APPOINTMENTS." CHARGE NURSE "A" REPORTED HE TOLD CHARGE NURSE "C" OF RESIDENT #6'S CONCERNS DURING REPORT. CHARGE NURSE "C" THEN CAME TO THE NURSES' STATION AND GAVE RESIDENT #6 SOME COUGH SYRUP. NO RESPIRATORY ASSESSMENT WAS COMPLETED AT THAT TIME BY EITHER CHARGE NURSES. RESPIRATORY THERAPY "B" WAS AGAIN CALLED WITH THIS SURVEYOR'S PROMPTING DUE TO THE RESIDENTS CONTINUED RESPIRATORY DISTRESS. ON 5/8/12 AT 3:30 PM RESIDENT #6 WAS TAKEN TO HER ROOM BY CHARGE NURSE "C" AND RESPIRATORY THERAPIST "B." CHARGE NURSE "C" ASSISTED RESIDENT #6 BY REMOVING THE DRESSING AROUND THE [MEDICAL CONDITION] AND THE RESIDENT WAS STRONGLY ENCOURAGED TO COUGH. RESIDENT #6 WAS THEN ABLE TO COUGH UP A GRAYISH YELLOW, MUCOUS PLUG WHICH WAS OBSTRUCTING THE RESIDENT'S AIRWAY. CHARGE NURSE "C" REPORTED THE MUCUS PLUG TO BE "SOFT IN THE MIDDLE, FIRM IN THE CENTER, APPROXIMATELY AS BIG AS THE END OF THE PINKY FINGER AND GRAYISH YELLOW IN COLOR." RESPIRATORY THERAPIST "B" THEN PREPARED TO PROVIDE A NEBULIZER TREATMENT AND SUCTION RESIDENT #6. LUNG SOUNDS REPORTED BY RESPIRATORY THERAPIST "B" WERE REPORTED AS COURSE AND DIMINISHED. PULSE OXYGEN SATURATION LEVEL WAS RECORDED AT 88 PERCENT (NORMAL RANGE IS 98-100 PERCENT) AFTER MUCOUS PLUG WAS REMOVED AND BEFORE TREATMENT WAS STARTED. POST TREATMENT PULSE OXYGEN LEVEL WAS AT 90 PERCENT. IT TOOK 45 MINUTES FOR RESIDENT #6 TO HAVE THE MUCOUS PLUG DISLODGED FROM HER AIRWAY WHICH WAS CAUSING RESPIRATORY DISTRESS. ON 5/9/12 AT 12:00 PM, DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) AND THE RESPIRATORY THERAPIST "B", RESPIRATORY THERAPIST "B" REPORTED IF A RESIDENT IS HAVING DIFFICULTY BREATHING WITH A [MEDICAL CONDITION], THE PROTOCOL WAS TO FIRST REMOVE THE INNER CANNULA, SUCTION AND IRRIGATE WITH SALINE IF NEEDED. THE PROTOCOL WAS NOT NOTED TO BE FOLLOWED AND THE CARE PLAN WAS NOT INITIATED. RESPIRATORY THERAPIST "B" FAILED TO GIVE A REASON WHY RESIDENT #6 WAS NOT ASSESSED. RESPIRATORY THERAPIST "B" REPORTED OBSERVING THAT RESIDENT #6 WAS COUGHING SO SHE DIDN'T FEEL SHE WAS IN ANY DISTRESS. THE DON REPORTED RESIDENT SHOULD HAVE BEEN ASSESSED. RESPIRATORY THERAPIST "B" REPORTED IF THE RESIDENT COULD GET AWAY WITH IT SHE WOULD BE SUCTIONED ALL THE TIME AND REPORTED RESIDENT #6 WAS PLACED ON A EVERY 2 HOUR SUCTION SCHEDULE. RESIDENT #6'S CARE PLAN "I HAVE ALTERED RESPIRATORY STATUS/DIFFICULTY BREATHING R/T (RELATED TO) TRACHIAL STENOSIS", DATED 4/9/12 REFLECTED, INTERVENTIONS OF MAINTAIN CLEAR AIRWAY WHICH INCLUDED: REASSURE THAT HELP IS AVAILABLE IMMEDIATELY, ENCOURAGE RESIDENT TO CLEAR OWN SECRETIONS WITH EFFECTIVE COUGHING, IF SECRETIONS CANNOT BE CLEARED SUCTION AS ORDERED REQUIRED TO CLEAR SECRETIONS, MONITOR FOR SIGNS AND SYMPTOMS OF RESPIRATORY DISTRESS SUCH AS COUGHING, USE OF ACCESSORY MUSCLE USAGE, SKIN COLOR CHANGES BLUE GREY, PURSED LIP BREATHING, NASAL FLARING AND TO NOTIFY THE PHYSICIAN. ON 5/9/12 AT 10:05 AM, RESIDENT #6 NODDED HER HEAD UP AND DOWN INDICATING "YES" WHEN ASKED IF HER [MEDICAL CONDITION] HAD EVER BECOME PLUGGED. RESIDENT NODDED HER HEAD UP AND DOWN INDICATING "YES" WHEN ASKED IF [MEDICAL CONDITION] PLUGGED VERY OFTEN AND SHE NODDED HER HEAD "YES" SEVERAL TIMES. RESIDENT WAS ASKED HOW IT MADE HER FEEL WHEN HER THROAT HURT AND SHE WAS COUGHING THE DAY BEFORE AND RESIDENT STATED "SCARED". ( )

This citation pertains to intake #MI 767 Based on observation, interview, and record review the facility failed to provide adequate supervision and functional safety devices in 4 of 5 sampled Residents ( Residents #101, #102, #104, #105) from a total of 5 sampled Residents, resulting in Resident #101 sustaining actual injury after a fall (head laceration) and the potential for Residents #102, #104 and #105 for a fall with injury due to non-functional safety devices. Findings include: Resident #101 Review of the face sheet and the Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 was a [AGE] year old female originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #101 had a score of 11/15 (moderate cognitive impairment) on her Brief Interview for Mental Status (BIM'S) and required limited assistance of one person for transfers and extensive assistance of one person for ambulation. Review of the Activity of Daily Living (ADL) Guide dated as Reviewed 2-17-12, 2-25-12, 3-5-12 and 3-16-12 revealed Resident #101 had a tab alarm for the wheelchair and a pressure alarm for her bed. Review of the Fall Reduction/Prevention Care Plan with date starting on 2-17-12 revealed Resident #101 was at risk for falls and the following interventions were initiated on 2-17-12; "bed and chair alarm and tab alarm, stay with patient in bathroom and supervised ambulation". Review of the Incident/Accident Report dated 2-17-12, at 8:10 PM, revealed Resident #101 was left on the toilet with out supervision, stood up, fell and hit her bead. Resident #101 sustained a 2 centimeter (cm) x 1.5 cm laceration (cut) to the back of her head. Review of the Post Fall Investigation Worksheet for Resident #101, dated 2-17-12 at 8:10 PM revealed that Resident #101 was confused and a Certified Nurses Assistant (CNA) left Resident #101 unattended on the toilet while she went to assist another Resident get ready to shower. Review of a Corrective Action Form dated 2-20-12 for CNA #1, revealed CNA #1 left a known Fall Risk Resident (Resident #101) alone on the commode in the bathroom. Resident #101 fell off commode chair hit her head and sustained a Laceration requiring an emergency room visit. Resident #101 required staples to her head and received a concussion. Review of a typed document dated 2-17-12, and signed by Director of Nursing (DON) #2 and Unit Manager (UM) #1 revealed that DON #2 and UM #1 had a conversation with CNA #1 regarding Resident #101's fall on 2-17-12. CNA #1 admitted to leaving Resident #101 alone on the commode, knowing Resident #101 was a fall risk and knowing she required supervision on the commode. Review of the Nurses Notes dated 2-18-12 at 5 AM, revealed Resident #101 was sitting up in her bed, holding her head and complaining of a severe headache. The Physician was notified and ordered a Hospital emergency room Evaluation. Review of the Resident Transfer Form dated 2-18-12, revealed Resident #101 was transferred to the Hospital due to a fall at 8 PM last night and Resident #101 was complaining of a severe headache. Review of the Hospital Discharge Summary dated 2-18-12 at 6:27 AM, revealed Resident #101 was treated for [REDACTED]. Resident #101 was observed on 3-29-12, at 3:30 PM in her room with a bed alarm in place. Resident #101 was dressed and laying on top of the bed covers. When the Surveyor greeted Resident #101, she sat up independently at the edge of the bed to talk. The Surveyor asked if she recalled falling the day she was admitted and she explained she had some memory of that event. The surveyor asked what happen and all Resident #101 could recall was that she slid to the floor. During an interview on 3-29-12 at 2:15 PM, CNA #1 stated she knew Resident #101 was a fall risk but she thought she could leave her alone on the toilet for a few minutes because she told her to stay and another Resident needed her assistance. CNA #1 said she did not intentionally harm Resident #101 and said, "I made a bad judgement." CNA #1 said that she knew that all fall risk Residents are to be supervised while in the bathroom. During an interview on 3-29-12, at 2:30 PM, Licensed Practical Nurse (LPN #1) said she was in charge the night Resident #101 fell in the bathroom and sustained a laceration to her head. LPN #1 stated that 5 minutes prior to the fall she had taken Resident #101 to the toilet and assisted her back to bed and Resident #101 had a bed alarm on her bed. LPN #1 stated all staff are aware if a Resident has a fall alarm they are a fall risk and are not to be left in the bathroom alone. ( & ) Resident #102 Review of the face sheet and the Minimum Data Set ((MDS) dated [DATE] revealed Resident #102 was a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #102's Brief Interview for Mental Status (BIM'S) score was 2/15 (severely cognitively impaired), and that she required extensive assistance on one person for transfers and extensive assistance of one person for ambulation. Review of the Activities of Daily Living (ADL) Care Guide dated as reviewed 1-2-12 revealed Resident #102 was a fall risk and did not have any safety interventions marked. Review of Resident #102's Fall Reduction/Prevention Care Plan , dated reviewed 1-9-12 revealed Resident #102 had a wheelchair alarm. Resident #102 was observed on 3-29-12, at 8:15 AM sitting in a wheelchair at the nurses station. Resident #102 had an alarm box on the back of her wheelchair. The Surveyor asked Director of Nursing (DON) #2 and Unit Manager (UM) #2 to demonstrate that Resident #102's wheelchair alarm was functional. DON #2 and UM #2 stood Resident #102 up and the alarm did not sound. UM #2 checked the alarm box and found that the cord was unplugged. UM #2 plugged the alarm cord in and the alarm sounded. During an interview on 3-29-12, at 9:50 AM, CNA #4 stated she was assigned to Resident #102 that day and had taken her to the bathroom at 7:15 AM and had forgot to replace Resident #102's alarm box cord when she was done. ( & ) Resident #104 Review of the face sheet and the Minimum (MDS) data set [DATE] revealed Resident #104 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS indicated Resident #104's Brief Interview for Mental Status (BIM'S) dated 3-2-12 had a score of 5/15 (severe cognitive impairment). According to the MDS, Resident #104 required extensive assistance of one person for transfers and limited assistance of one person for ambulation. Review of the Activity of Daily Living (ADL) Guide dated 7-3-11, revealed Resident #104 was a fall risk and had a self-releasing alarming seat belt when up in her wheelchair. Review of the Fall Reduction/Prevention Care Plan with a starting date of 9-7-11 revealed Resident #104 had a wheelchair alarm, a chair alarm, and a pressure alarm. During an observation on 3-29-12 at 8:17, Resident #104 was observed sitting in her wheelchair near the nurses station. Resident #104 had a tab alarm sitting on the right side of her wheelchair seat (not attached to the wheelchair) and an alarming seat belt in place. The Surveyor asked UM #2 to demonstrate that the seat belt alarm was functioning. UM #2 opened the seat belt and it did not alarm. UM #2 did something to the alarm box on the back of the wheelchair and it began to alarm. UM #2 picked up the tab alarm that was in Resident #104 chair and said, "she does not need this alarm." During an interview on 3-29-12 at 10:00 AM, CNA #3 stated she was assigned to Resident #104 that day and recalled providing care for her at 7:00 AM, placing the TAB alarm on the right side of the residents seat and placing the alarming seat belt. CNA #3 recalled both alarms functioning. The Surveyor explained that the tab alarm was not attached to the wheelchair and CNA #3 said she was not instructed to have the alarm box attached to the wheelchair (tab alarm will not function if the box is not attach to something so that the magnet will pull off the box when the resident attempts to stand). The Surveyor informed CNA #3 that the seat belt alarm did not sound earlier that morning when UM #2 tried to demonstrate it was functioning. The Surveyor asked CNA #3 to explain what could have caused the alarm not to function at that time. CNA #3 said she had been working in the dinning room after providing care for Resident #104 and if Resident #104 would have needed to use the bathroom another CNA might have assisted her and forgot to turn the seat belt alarm on. ( & ) Resident #105 Review of face sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #105 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #105's Brief Interview for Mental Status (BIM'S) dated 1-20-12 documented a score of 0/15 (severe cognitive impairment). The MDS indicated Resident #105 required extensive assistance of two people for transfers and did not walk. Review of the Activity of Daily Living (ADL) Guide, dated reviewed 1-16-12 and 2-1-12, revealed Resident #104 was a fall risk, had a pressure alarm in her wheelchair and on her bed. During an observation on 3-29-12 at 8:45 AM, Resident #105 was seated in her wheelchair in the dinning with a pressure alarm on her wheelchair. The Surveyor asked CNA #3 to demonstrate that Resident #105's wheelchair alarm was functioning. CNA #3 removed the cord from the alarm box that went to the pressure pad and the wheelchair alarm did not immediately sound. UM #2 came over to assist CNA #3 with the alarm and CNA #3 told UM #2 that the alarm did not sound right away when she pulled the cord out from the box. The Surveyor returned to the Dining room at 9:00 AM observed Resident #104 was still at the table and the wheelchair alarm box on the back of Resident #105's wheelchair was dated 2-6-12. The Survey ask CNA #3 to demonstrate Resident #105's wheelchair alarm was functioning. CNA #3 unplugged the cord out of the alarm box and the alarm did not immediately sound. The Surveyor asked UM #1 to demonstrate if Resident #105's wheelchair alarm was functioning correctly and she responded that Resident #105 would need to stand to check the alarm. UM #1 and CNA #3 stood Resident #105 and the alarm did not immediately sound. UM #1 and CNA #3 said the alarm was not functioning properly because it did not sound immediately and when the Resident stood up. UM #1 initiated replacing Resident #105's wheelchair alarm at this time. Review of the manufactures instruction sheet provided by the facility for Resident #105 wheelchair pressure alarm revealed that if the alarm failed to sound they are to immediately discontinue the use of the alarm. ( & )

This citation pertains to intake #MI 120 Based on observation, interview, and record review, the Facility failed to provide the necessary care and services (thorough pain assessment and treatment ) in 1 of 4 sampled Residents (#102) from a total sample of 4 residents, who complained of pain in her left arm on 5/14/11, was not thoroughly assessed or treated in a timely manner, who was ordered an x-ray of her left arm on 5/20/11 which was not completed until 5/21/11 that revealed a fractured left arm, and then was not sent to the Hospital for treatment until 5/22/11 resulting in increased soft tissue damage and prolonged pain due to an untreated fracture. Findings include: An observation and interview on 6/2/11 at 9:02 AM, revealed Resident #102 was lying in bed on her back. Her left arm was in a cast. Resident #102 had a tracheotomy (surgical opening in the neck for breathing) and the Charge Nurse applied a microphone type device for Resident #102 to speak to the Surveyor. When questioned, Resident #102 stated she did not know how the fractured arm occurred. Review of the face sheet of the clinical record for Resident #102 revealed that she was an [AGE] year old woman, first admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. According to the Minimum (MDS) data set [DATE], Resident #102 was alert, orientated, and dependent on staff for Activities of Daily Living. Review of the nurse's notes dated 5/14/11 revealed Resident #102 complained of left arm pain, however there was no comprehensive pain assessment done until 5/20/11 and there was no documentation that the Physician was notified of Resident #102's arm pain. There were no other nurse's note entrees made until 5/20/11 when a large bruise (no color description to determine how old the bruise had been), was noted on the anterior (underneath) area of Resident #102's left arm as well as [MEDICAL CONDITION] (swelling). The nurses notes revealed on 5/20/11 that the Guardian and Physician were notified. According to the Physician orders [REDACTED].#102. Review of the nurse's note dated 5/21/11 at 11:34 AM revealed the x-ray for Resident #102 that had been ordered 21 hours prior, was still not done. The nurse's note dated 5/21/11 at 6:30 PM revealed the x-ray had been done and a left arm fracture was found. The nurse's notes dated 5/22/11 at 7:00 AM, revealed that the Physician was notified of Resident #102's fractured left arm (12.5 hours later) and that at 7:30 AM, the Physician called back and ordered Resident #102 to be sent to the Hospital. On 5/22/11 at 9:30 AM, according to the nurse's notes, the Guardian and Family were notified that Resident #102 was sent to the Hospital for evaluation and treatment of [REDACTED]. Review of the pain assessment, signed but not dated by RN "L", revealed Resident #102 complained of tenderness and shooting left arm pain as well as swelling that started on 5/13/11. The pain occurred with movement, according to the report. The report also indicated that pain medication had been ordered on [DATE]. In an interview on 6/2/11 at 10:00 AM and 11:00AM, while Registered Nurse (RN "J") reviewed the clinical record of Resident #102, RN "J" stated, Resident #102 had [MEDICAL CONDITION] previous to 5/13/11 but "when it became localized to her left arm that is what prompted the shoulder x-ray". RN "J" said Resident #102 had "brittle bones" and had been in "this state" (completely depended on staff for ADLs), for a long time. When asked why vital signs weren't taken on 5/13/11 when Resident #102 had arm pain and increased localized swelling. RN "J" said, "I can't think of any particular reason. I can see what you mean if she had an issue for the Physician (to be aware of)". In an interview on 6/2/11 at 2:00 PM, RN "L" was asked when she did a pain assessment for Resident #102. RN "L" said, "its dated 5/20/11" and indicated that she probably did the assessment on 5/20/11. When asked why she didn't complete a pain assessment sooner, RN "L" said, "I just missed it" and stated it probably should have been done sooner. Review of the X-Ray report dated 5/21/11 revealed Resident #102's left elbow had, "an acute comminuted displaced angulated [MEDICAL CONDITION] humeral metaphysical region with bony overlap and without dislocation. Follow up imaging until complete healing is recommended. (fractured upper arm near the elbow that showed healing started but was not completed)." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Physician order [REDACTED]. The Physician's Assistant (PA) #1 said in an interview on 6/7/11 at 11:30AM, that she assessed Resident #102 on 5/13/11 because she complained of left upper extremity pain and she had significant swelling to her left arm. When asked why she didn't order an X-Ray of Resident #102's left arm and only ordered an X-Ray of her left shoulder, PA #1 stated because that is where she said the pain was on 5/13/11. PA #1 said it was difficult to determine exactly where the pain was and said Resident #102's daughter was with her as she assessed Resident #102. PA #1 indicated that she determined the pain was in Resident #102's left shoulder and that is why she ordered the x-ray of her shoulder. Review of the physician progress notes [REDACTED].#1 revealed the following written note; "patient seen today for increased [MEDICAL CONDITION] and pain in left upper extremity. Patient says she doesn't feel good and complaint of pain in left arm. Daughter states she complained about this for the past 3 days without improvement.....Alert and orientated times 1......positive for pain with range of motion of left arm, positive for pain with palpitation of left shoulder, decreased range of motion left extremity. Check x-ray to rule out fracture verses [MEDICAL CONDITION]. Ultrasound to rule out [MEDICAL CONDITION], patient has had recent IV, PRN pain medication." Review of the Physician order [REDACTED].#102 to the ER (emergency room ), via stretcher for evaluation and treatment of [REDACTED]. Review of the Resident #102's care plans revealed that there was no care plan in place for the pain and swelling in Resident #102's left arm until 5/22/11 (7 days after she complained of pain in her left arm). The Director of Nursing (DON) said in an interview on 6/2/11 at 10:15 AM, that the Orthopedic Physician told her the fractured left arm of Resident #102 appeared to have occurred a couple weeks ago because it had started to heal. (# )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS FOR 1 OF 4 RESIDENTS (#11) WITH PRESSURE ULCERS FROM A TOTAL SAMPLE OF 19 RESIDENTS, RESULTING IN MULTIPLE PRESSURE ULCERS (STAGE 3 RIGHT SCROTUM/PERINEUM, STAGE 4 RIGHT HIP, AND STAGE 3 RIGHT SIDE OF SCROTUM) AND SEVERE PSYCHOSOCIAL DISTRESS (MENTAL ANGUISH). FINDINGS INCLUDE: RESIDENT #11 WAS A [AGE] year OLD, ALERT AND ORIENTED MALE FIRST admitted to the facility on [DATE] AND REadmitted on [DATE] WITH [DIAGNOSES REDACTED]. THE HISTORY AND PHYSICAL REPORT DATED 8/23/10 FROM THE HOSPITAL REFLECTED THAT THE resident had a history of [REDACTED]. HE ALSO HAD A LEFT BELOW-KNEE AMPUTATION DUE TO AN INFECTION TO HIS LEFT LOWER LEG BONES. ON AUGUST 24, 2010 THE resident underwent [REDACTED]. THE NURSING NOTES DATED 8/31/10 THROUGH 5/17/11 REFLECTED THAT THE RESIDENT HAD GONE THROUGH MULTIPLE EPISODES OF PRESSURE ULCER DEVELOPMENTS, TRIPS TO THE WOUND CARE CLINIC AND THE HOSPITAL. THE NURSING NOTES DATED DURING THE SAME PERIOD ALSO REFLECTED THE RESIDENT'S DEPRESSION, ANGER, EMOTIONAL OUTBURSTS TOWARD STAFF AND BEHAVIORAL UPHILL BATTLES RELATED TO RESTRICTIONS IMPOSED ON HIM FOR THE WOUND HEALING. THE NURSING NOTE DATED 12/29/10 REFLECTED THE RESIDENT HAD 2 NEW OPEN AREAS; ONE MEASURED 1.5 CM X 0.5 AND ANOTHER 2.0 CM X 0.5 NEAR THE SCROTUM. THE NURSING NOTES DATED 12/30/10 REFLECTED THE RESIDENT HAD GONE HOME FOR A FAMILY HOLIDAY GATHERING. THE NURSING NOTES DESCRIBED THE RESIDENT HAD GONE FROM 9:30 A.M. TILL 7:00 P.M., APPROXIMATELY FOR 10 HOURS. ON 1/26/11, LESS THAN A MONTH LATER, NURSING NOTES REFLECTED ONE AREA (NURSING NOTES DID NOT SPECIFY WHICH OF THE TWO AREAS) DETERIORATED TO 3 CM X 0.8 X 0.2 IN SIZE WITH SEROSANGUINEOUS DRAINAGE. ON 5/17/11 THE MEASUREMENT WAS 6.8 CM X 4.8 X 0.2. ACCORDING TO THE "SKIN GRID-MEASUREABLE WOUND FORM": THE CENTER PRESSURE ULCER AND RIGHT SIDE OF SCROTUM PRESSURE ULCER WERE DOCUMENTED AS HAVING OCCURRED ON 1/26/11 AND WERE DESCRIBED AS A REOPENED AREA. HOWEVER, THERE WAS NO PREVIOUS ONSET DATE AVAILABLE. AGAIN NO STAGING OF TISSUE DESTRUCTION HAD BEEN DOCUMENTED. THE GROIN PRESSURE ULCER (BETWEEN THE RIGHT LEG AND SCROTUM) MEASURED 2 CM X 1.5 X 0.2 ON 5/8/11 WITH MODERATE BLOODY DRAINAGE, AND REFLECTED THAT THE WOUND BECAME LARGER ON 5/17/11 MEASURING 4 CM X 1.5 X 1.8. ON 5/19/11 AT 10:15 A.M., THE UNIT MANAGER "A" STATED THE WOUND WAS NOW A STAGE 3 PRESSURE ULCER. THE RIGHT HIP GRAFT SITE PRESSURE ULCER DATED 9/21/10 THROUGH 5/17/11 REFLECTED THE WOUND MEASURED 4 CM X 1.5 X 1.8 ON 5/17/11 AND REFLECTED THAT IT HAD NEVER BEEN COMPLETELY HEALED IN OVER 8 MONTHS. SINCE IT WAS LABELED AS AN INCISION IT WAS NOT STAGED AS PRESSURE RELATED TISSUE DESTRUCTION, THUS NO DOCUMENTATION OF STAGING COULD BE FOUND. THE WOUND CONSULTATION FORM DATED 10/27/10 INSTRUCTED THE RESIDENT TO LIE ON HIS LEFT SIDE POSITION, NO PULLING OF DRAW SHEETS AND NO PRESSURE ON RIGHT HIP AND THIGH TO PROMOTE HEALING OF THIS WOUND. THE WOUND CONSULTATION FORM DATED 12/13/10 RECOMMENDED SPECIFIC INSTRUCTIONS OF USING "ROHO," A PRESSURE RELIEVING CUSHION, AND NO PRESSURE ON RIGHT HIP WHILE HE WAS AT HOME. ON 5/18/11 AT 10:00 A.M., RESIDENT #11 WAS OBSERVED PLAYING CARD GAMES ON A COMPUTER IN HIS BED. WHEN HE WAS INQUIRED ABOUT THE COMPUTER USE, HE SAID, "THIS IS ONLY THING THAT KEEPS ME FROM GOING INSANE." THE RESIDENT HAD A LARGE UPPER BODY FRAME. HIS MOST RECENT DOCUMENTED WEIGHT (UNDATED) WAS 250 POUNDS AND HE WAS 71 INCHES TALL. THE RESIDENT NEARLY OCCUPIED THE WHOLE WIDTH OF THE SPECIAL MATTRESS BED AND THERE WAS NOT ENOUGH ROOM TO TURN AT THE SIDES. THE RESIDENT WAS ALSO OBSERVED HAVING AN INDWELLING URINARY CATHETER. THE RESIDENT WAS ASKED ABOUT HIS BED SORES ON HIS BUTTOCK AND WHETHER THESE WERE AFFECTING HIS ACTIVITIES AND DAILY LIVING IN THE FACILITY. HE STATED HE DID NOT UNDERSTAND HOW HE ACQUIRED THE BED SORES, AND HE STATED THAT HE WAS OUTRAGED BECAUSE HE WAS NOT ALLOWED TO GET OUT OF BED FOR ONE AND ONE-HALF YEARS. THE RESIDENT'S VOICE BECAME SUBDUED AND HE TRIED TO RESTRAIN HIMSELF FROM CRYING. HE STATED HE FELT LIKE A CAGED ANIMAL, FURTHER STATING HE COULD NOT STAND STAYING AT THE FACILITY ANY LONGER AND WAS GOING HOME TOMORROW (5/19/11) WITH HELP FROM THE AGENCY FOR AGING. ON 5/18/11 AT 10:30 A.M., THE UNIT NURSE, (STAFF "C") AND THE EAST UNIT MANAGER, (STAFF "A") BEGAN TO CHANGE DRESSINGS ON THE RESIDENT'S PRESSURE ULCERS IN HIS ROOM. THERE WAS A LARGE AMOUNT OF BLOODY DRAINAGE STAINED ON THE LINEN. THREE WOUNDS WERE OBSERVED: 1. ONE ON THE CRACK NEXT TO THE RIGHT SIDE OF SCROTUM (REFER TO CENTER), THE ENTIRE SURFACE LOOKED RAW WITH BRIGHT RED BLOODY DRAINAGE. 2. ONE BETWEEN THE RIGHT LEG AND SCROTUM (REFER TO GROIN) 3. ONE OVER RIGHT UPPER HIP (REFER TO GRAFT SITE). DURING THE DRESSING CHANGE, THE UNIT MANAGER "A" STATED THAT THE GROIN WOUND WAS IDENTIFIED AS BETWEEN A STAGE 2 (PARTIAL THICKNESS SKIN LOSS INVOLVING EPIDERMIS, DERMIS, OR BOTH, SOMETIMES LOOKED LIKE A SHALLOW CRATER) AND A STAGE 3 (FULL THICKNESS TISSUE LOSS INVOLVING DAMAGE TO, OR NECROSIS OF, SUBCUTANEOUS TISSUE THAT MAY EXTEND DOWN TO, BUT NOT THROUGH, UNDERLYING FASCIA). THE WOUND WAS COVERED WITH SEROSANGUINOUS DRAINAGE WITH WHITE SLOUGH (DEAD TISSUE) ALL AROUND THE EDGES AND HAD A SCAR TISSUE APPEARANCE. NURSE "C" CLEANSED THE WOUNDS WITH SALINE AND APPLIED [MEDICATION NAME] DRESSING TO THE RIGHT HIP WOUND, AND [MEDICATION NAME] TO BOTH GROIN AND CENTER WOUNDS. SHE THEN COVERED THE WOUNDS WITH FOLDED UP 4 X 4 GAUZE INSTEAD OF THICKER "ABD" PAD THAT WAS ORDERED BY THE PHYSICIAN. WHEN SHE TRIED TO APPLY MEDIPEX, A STICKY COVER DRESSING INSTEAD OF THE PAPER TAPE (WITH LESS CHANCE OF PULLING THE SKIN OFF) THAT WAS ORDERED BY THE PHYSICIAN, SHE WAS HAVING DIFFICULTY MAKING THE DRESSING STICK TO THE SKIN SMOOTHLY. AFTER THE SECOND TRY NURSE "C" APPLIED THE COVER DRESSING WITH VISIBLE WRINKLES WHICH WOULD CAUSE PRESSURE. IMMEDIATELY AFTER THE DRESSING CHANGE OBSERVATION ON 5/18/11, THE UNIT MANAGER "A" STATED THE RESIDENT DID NOT WANT TO STAY IN BED, AND WANTED TO GO OUT TO SMOKE AND SHE ADDED THAT THE RESIDENT REFUSED PROTEIN DRINKS THAT WOULD HELP TO INCREASE HIS LOW PROTEIN LEVEL. THE CARE PLAN FOR RISK OF ALTERATION OF SKIN INTEGRITY DATED 9/21/10, MOST RECENTLY REVIEWED 5/4/11 REFLECTED THAT THE RESIDENT HAD A "CLINITRON," A BED SPECIALLY DESIGNED FOR PRESSURE RELIEVING. THE "CLINITRON" BED HAD BEEN DISCONTINUED ON 11/20/10 AND REPLACED BY A "[MEDICATION NAME]" AIR BED ON 3/11/11. ON 5/19/11 AT 10:15 A.M., THE "PARC" UNIT MANAGER, (STAFF "B") STATED THE RESIDENT HAD BEEN ON AN EXTRA WIDE AND LONG "BIG BOY," BED ( A PERIOD OF OVER 3 MONTHS) BETWEEN THE CLINITRON BED AND THE [MEDICATION NAME] BED. STAFF "B" STATED THE BED CHANGE WAS PROMPTED BY THE WOUND CLINIC CONSULTATION FORM DATED 11/15/10, INSTRUCTING TO GET A LARGER BED SO THE RESIDENT COULD BE TURNED EASILY. CURRENTLY THE RESIDENT HAD A "[MEDICATION NAME]" AIR MATTRESS BED WHICH WAS NOT LARGE ENOUGH FOR STAFF AND HIMSELF TO BE TURNED EASILY FROM SIDE TO SIDE. THE OCCUPATIONAL THERAPY PROGRESS SUMMARY FOR THE PERIOD 12/15/10 TO 12/21/10 REFLECTED THE RESIDENT WAS PROVIDED A "ROHO" CUSHION. ON 5/19/11 AT 11:30 A.M., THE OCCUPATIONAL THERAPIST, (STAFF "D") STATED SHE WAS NOT PRESENT WHEN THE CUSHION WAS ISSUED TO THE RESIDENT, BUT SHE STATED THE DEPARTMENT USUALLY GAVE OUT WHATEVER CUSHION THEY HAD AT THE TIME. ON 5/19/11 AT 10:30 A.M., THE RESIDENT'S WHEELCHAIR CUSHION WAS OBSERVED SMALLER THAN THE SEATING SURFACE, SHOWING GAPS ALL AROUND THE EDGES AND FLATTENED IMMEDIATELY WITH ONE HANDED PRESSURE. BOTH UNIT MANAGER "A" AND "B" WERE ASKED TO TEST THE FIRMNESS OF THE CUSHION AND BOTH AGREED THAT IT WAS COMPLETELY FLAT AND HAD NO SUPPORT TO KEEP PRESSURE OFF THE RESIDENT'S WOUND. THE UNIT MANAGER "B" ADDED THAT THE RESIDENT DID NOT USE HIS WHEELCHAIR VERY MUCH AT ALL BECAUSE HE WAS ON STRICT BED REST STATUS MOST OF THE TIME. HOWEVER, THE RESIDENT HAD CONTINUOUSLY SAT OVER A 10 HOUR PERIOD WHILE HE WAS AT HOME ON 12/30/10. REVIEW OF THE PERTINENT LABORATORY VALUES OF [MEDICATION NAME] AND HEMOGLOBIN A1C REQUIRED FOR WOUND HEALING INDICATED THE RESIDENT HAD POOR DIABETIC CONTROL WITH HEMOGLOBIN A1C VALUE OF 6.1 % (NORMAL: 4-6 %) ON 8/24/10 AND INCREASED TO 9.0 % ON 1/19/11. HE ALSO HAD POOR PROTEIN STORE WITH DECREASED [MEDICATION NAME] LEVEL OF 3.0 G/L (NORMAL: 3.5-5.0) ON 8/24/10 TO 2.7 G/L ON 5/13/11. THE NUTRITIONAL/HYDRATION CARE PLAN DATED 4/26/11 REFLECTED THE RESIDENT'S NUTRITIONAL NEEDS COULD NOT BE MET DUE TO HIS SEVERE NON-COMPLIANCE. THE RESIDENT STATED HE COULD NOT DRINK THE PROTEIN SUPPLEMENT BECAUSE IT TASTED "NASTY." HE ADDED THAT THE DIETITIAN WAS GOING TO MIX IT WITH FLAVORED ENSURE, BUT HE HAD NOT RECEIVED THE MIXED PROTEIN DRINK. ACCORDING TO THE CLINICAL RECORD THE RESIDENT HAD A FUNCTIONING STOMACH TUBE THAT HE HAD NOT USED SINCE NOVEMBER 2010. THIS WOULD HAVE ALLOWED EASY ACCESS FOR PROTEIN SUPPLEMENT ADMINISTRATION UNTIL APRIL 2011 WHEN THE STOMACH TUBE WAS DISCONTINUED. ON 5/19/11 AT 11:30 A.M., SHORTLY BEFORE DISCHARGE RESIDENT #11 STATED HE COULD NOT DESCRIBE HOW HE FELT. HE SAID "I HAVE A SHORT FUSE, I HAD DONE A LOT OF MEDITATION TRYING TO COPE WITH ANGER AND FRUSTRATIONS. NOW I AM GOING HOME TO HEAL MY ULCERS." RESIDENT #11 WAS NEARLY CHOKED UP WITH EMOTIONS. ( )