Every finding on record at Regency at Shelby Township

This citation pertains to intake 2992237.Based on observation, interview and record review, the facility failed to ensure interventions were implemented and care provided timely for three residents (R903, R904, and R906) of seven reviewed for care plan implementation and care needs. Findings include: R906On 05/05/26 at 9:30 AM, R906 was observed laying on their back in bed. R906's legs were slightly flexed at the knees and the heels rested on the bed. A Pressure Relieving Ankle Foot Orthotic (PRAFO) boot was on an armchair to the right of the bed. R906 reported they had a wound to the left heel and needed help to put the boot on, and staff had not come in, and the boot had not been applied that morning. When asked if they could move about in the bed, the resident reported they had limited movement of the left leg. At 11:55 AM, R906's heels and the PRAFO boot were in the same position as before. The heels rested on the bed. A review of the active physician orders in the electronic medical record (EMR) documented Left heel: Cleanse with normal saline, pat dry. Apply betadine moistened gauze and cover with kerlix dressing. Offload with heel lift boot (PRAFO). Every day (morning) shift for (deep tissue injury caused by pressure) DTI and as needed for DTI. Active. 4/29/2026 09:00.A review of the EMR revealed R906 was admitted into the facility on [DATE]. Diagnoses included Muscle Wasting and Atrophy-Multiple Sites, Bacterial Arthritis of the Left Knee and Chronic Gout. The active care plan initiated 04/28/26 documented, Impaired visual function .Risk for impaired skin integrity . Cue to reposition self as needed .Pressure reduction house stock mattress to bed, pillows for repositioning and floating heels off mattress, heel lift boots . requires Physical Therapy (related to) r/t decline in function or to maintain/slow decline secondary to (left total knee) L TKA, muscle weakness, difficulty walking: Decline in gait/ambulation, Decline in (left lower extremity) LLE (range of motion) ROM. Decline in Transfer skills, Decrease in bed mobility, Decreased LLE strength, Decreased mobility, Decreased (right lower extremity) RLE strength, Decreased sitting balance, Decreased standing balance, pain .requires 1 person assist, max A (assist) for supine sit (edge of bed) EOB bed mobility . ambulates 5 ft using 2 (wheeled walker) ww, max A x 2 person assist . A review of the minimum data set assessment dated [DATE] documented intact cognition with a 15/15 brief interview for mental status score (BIMS) and the need for substantial/maximal assistance for toileting hygiene, showering/bathing, lower body dressing, put on/take off footwear, rolling left and right in bed, and bed to chair transfers. R904On 05/05/26 at 9:38 AM, R904 was lying kitty corner in the bed with their feet off the left lower edge of the bed and their head at the right upper corner of the bed. R904 reported staff are sometimes a little slow, up to thirty minutes when the call light is ringing. R904 reported staff had been in to provide medications and check their vital signs. R904 said they had a stroke and still had some right sided weakness from a stroke and needed assistance. R904 reported they recently had an accident recently and was laying in urine-soaked clothes and the nurse took a long time to come in. R904 reported when the nurse did come in, they declined to help R904 and left them in wet clothes and R904 felt ignored. R904 reported they ended up cleaning themself up and it took them over an hour.A review of the EMR for R904 revealed R904 was admitted into the facility on [DATE]. Diagnoses included Hemiplegia and Hemiparesis (paralysis) of the Right Dominant Side, Muscle Wasting and Atrophy, and Gout. The active care plan initiated 04/17/26 documented, Impaired visual function . is at risk for complications of right Hemiplegia/Hemiparesis r/t Stroke/CVA . Assist with ADLs/Mobility/repositioning as needed . is incontinent of bladder & bowel R/T: weakness, impaired mobility .Check q 2 hr and prn for incontinence. Wash, rinse and dry perineum. Change clothing after incontinence care as needed . A review of the Minimum Data Set (MDS) assessment dated [DATE] documented intact cognition with a 14/15 brief interview for mental status score (BIMS) and the need for partial/moderate assistance for toileting hygiene, showering/bathing, lower body dressing, put on/take off footwear, rolling left and right in bed, and bed to chair transfers. R903On 05/05/26 at 10:12 AM, R903 was observed to be seated in an armchair in their room and had rung (activated call light) for pain meds about 5 PM the day before (05/04/26) and a (certified nursing assistant) CNA staff came in and said they would let the nurse know. R903 reported they waited about 20 minutes and rang again at which time around 6 PM the aide returned and reported they would tell the nurse. At 6:30 PM, R903 reported they walked out into the hall toward the nurse station and saw the nurse and the aide sitting at the nurse station. R903 reported they held up their hands and arms (showed arms extended out and palms up in a questioning gesture) and asked, Ma'am my pain medication? R903 said the staff said they were really busy right now. R903 commented What my pain medication is not important? R903 reported they then waited two and a half more hours until the next shift's nurse gave them their pain medication. R903 further commented, It is ridiculous to wait over two hours for pain medication. At 4:48 PM, the Director of Nursing (DON) reported they may have received a grievance form for this resident concern but had not yet reviewed it. A review of the EMR for R903 revealed R903 was admitted into the facility 04/28/26. Diagnoses included Bladder Cancer and Heart Failure. A review of the active care plans documented at risk for pain and has acute pain from nephrostomy (artificial drain tube for kidneys) tubes and hydronephrosis (swelling/pressure buildup in the kidneys) and chronic pain r/t bladder (cancer) CA and (osteoarthritis) OA. Date Initiated: 04/29/2026 . Administer medications as ordered. Anticipate resident's need for pain relief PRN and respond immediately to any complaint of pain .A review of the Electronic Medication Administration Record (EMAR) note dated 05/04/26 at (9:30 PM) 2130, documented Hydrocodone-Acetaminophen 5-325 (milligrams) mg oral tablet give one tablet by mouth every six hours as needed for back pain. This time would have been on the next shift. The previous pain medication per the EMAR notes was given at 5:38 AM on 05/04/26. An MDS dated [DATE] documented intact cognition with a 15/15 BIMS score and the need for partial/moderate assistance for chair to bed transfers.On 05/05/26 at 12:16 PM, Licensed Practical Nurse (LPN) B and Certified Nursing Assistant (CNA) C reported their unit had a high demand kind of patient. LPN B reported they were assigned 18 residents while the CNA C had 15 residents. It was noted by CNA C that it was busy and hard to get things done and one day they had gone from 20 to thirty patients after one CNA went home. The schedule documented two CNAs were scheduled. On 05/05/26 at 4:21 PM, the Director of Nursing (DON) acknowledged they had staff call offs, but have managerial staff available to pitch in. A review of the facility policy titled, Care Planning revised 06/24/21 revealed, Every resident will have a person-centered plan of care developed and implemented that is consistent with the resident rights .

Based on observation, interview and record the facility failed to ensure medications were labeled and dated when opened in one of four medication carts. Findings include: On 09/22/2025 at 4:49 PM, the Spring Hill medication cart two was reviewed with Registered Nurse (RN) D. Two insulin lispro vials were not dated on the vial, for one active resident and one discharged resident, and a 100-50 MCG/ACT fluticasone-Salmeterol inhaler did not have a resident identifier, nor a date opened. On 09/24/2025 at 12:55 PM, the Director of Nursing (DON) reported the nurse should label the carton and the actual medication in case the carton is lost or damaged. A review of the identified medications on drugs.com documented: for the lispro insulin - Store the vial in a refrigerator or at room temperature and use within 28 days; and for the fluticasone/salmeterol - Write the date you opened the foil pouch in the first blank line on the label. Write the use by date in the second blank line on the label. That date is 1 month after the date you wrote in the first line.A review of the facility policy titled, Medication Management revised 09/22/23, revealed Medications are stored, dispensed and destroyed in a manner to ensure safety and conformance with state and federal laws .Medications will be dated and discarded per manufactures guidelines .

Based on observation, interview, and record review, the facility failed to implement interventions for pressure ulcer healing for one resident (R89) out of three reviewed for pressure ulcers. Findings include:On 9/22/2025 at 10:16 AM, R89 was observed lying in bed. Their feet were hanging off the bed, with the head of bed (HOB) flat and they were laying on their back with no positioning devices in place. A green positioning wedge was observed in the chair next to the bed.A review of the medical record revealed that R89 was admitted into the facility on 9/11/2025 with the following medical diagnoses, Pressure Ulcer of Sacral Region, Stage 4 (Full-thickness skin and tissue loss with exposed muscle or bone in the ulcer) and Moderate Protein-Calorie Malnutrition. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. R89 also required staff assistance with bed mobility and transfers.Further review of the physician orders revealed the following, Ordered: 9/11/2025.Order: Verify wedge pillow is in use and reposition Q2 (every 2) hours as tolerated. Notify MD/WC (Medical Doctor/Wound Care) of any changes.On 9/22/2025 at 1:13 and 2:00 PM, R89 was observed to be eating lunch with the HOB elevated. Their positioning wedge was observed to be in the chair.On 9/23/2025 at 9:57 AM, R89 was observed laying on their back with the HOB flat. No positioning wedge was observed to be in place.On 9/24/2025 at 9:00 AM, R89 was observed to be up in their chair. The positioning wedge was noted to be in the closet. R89 stated they have not had the wedge used in a while and that they did use it for a little while last night because they were complaining of pain in their left shoulder. R89 stated the wedge helped keep the pressure off and helped with the pain.On 9/24/2025 at 10:20 AM, an interview was conducted with Wound Care Nurse (WCN) A. WCN A reported R89 should be repositioned every 1-3 hours as tolerated and that there is an order to verify that the wedge is in place. WCN A reported that R89 can turn a little but does better with assistance which is why they put the wedge in place.On 09/24/2025 at 1:22 PM, a Quality Assurance and Improvement Program (QAPI) meeting was conducted with the Nursing Home Administrator (NHA). The NHA indicated that physician orders and interventions should be followed.A review of a facility policy titled, Skin Management noted the following, .4. Residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing.

Based on observation, interview and record review, the facility failed to follow physician orders for three residents (R56, R119 and R117) out of three reviewed for quality of care. Findings include:R56 On 9/22/2025 at 1:15 PM, R56 was observed sitting up in a wheelchair. A gauze wrap and bandage were observed on their right lower extremity (RLE). The bandage was noted to be dated 9/18/2025. A review of the medical record revealed that R56 was admitted into the facility on 5/24/2025 with the following medical diagnoses, Moderate Protein-Calorie Malnutrition and Peripheral Vascular Disease. A review of the most recent Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 3/15 which indicated an impaired cognition. R56 also required staff assistance with bed mobility and transfers. Further review of the physician orders revealed an active wound care order for the right lateral lower leg that was to be changed every Tuesday, Thursday, and Saturday and as needed if missing or soiled for a venous ulcer. A review of the Electronic Medical Record (EMAR) Medication Administration Note noted the following, 9/20/2025 at 14:55 (2:55PM) .Note Text: Unable to complete. Patient was with [their] family celebrating [their] birthday. On 9/23/2025 at 9:33 AM and 12:39 PM, R56 was observed with the same gauze wrap and bandage dated 9/18/2025 on the RLE. The gauze was noted to be soiled. On 9/23/2025 at 2:13 PM, Licensed Practical Nurse (LPN) C was observed changing the dressing. LPN C confirmed that the bandage was dated 9/18/2025 and they were unsure why it was not changed on 9/20/2025 as ordered. On 9/24/2025 at 10:30 AM, an interview was conducted with wound care nurse (WCN) A. WCN A reported they expect for an order to be completed when scheduled. WCN A reported if R56 was busy at the time, the nurse should have come back and tried again or passed it on in report so the as needed portion of the order could be completed on the next shift. R119 On 9/23/2025 at 9:26 AM, R119 was observed laying in bed. R119 was complaining of pain in their legs. R119 was observed to have bilateral above the knee (AKA) amputations and their stumps were laying on the mattress. A review of the medical record revealed that R119 was admitted into the facility on 9/16/2025 with the following medical diagnoses, Infection of Amputation stump, Right Lower Extremity and Moderate Protein-Calorie Malnutrition. R119 also required staff assistance with bed mobility and transfers. Further review of the physician orders revealed the following, Ordered: 9/16/2025.Offload bilateral AKA stumps with pillows at all times while in bed.Active. On 9/23/2025 at 10:09 AM and 11:48 AM, R119 was observed laying in bed with their stumps lying on the mattress. On 9/24/2025 at 8:54 AM, R119 was observed laying in bed. They indicated they were just given something for pain, and they wanted to be repositioned. R119 stated sometimes they put their stumps on pillows and sometimes they do not. R119 was then repositioned by staff with a pillow placed under their right hip, but their stumps were still lying on the mattress. On 9/24/2025 at 10:07 AM, WCN A observed R119's stumps resting on mattress and placed a pillow under them to float them. WCN A indicated physician orders should be followed as written. On 09/24/2025 at 1:22 PM, a Quality Assurance and Improvement Program (QAPI) meeting was conducted with the Nursing Home Administrator (NHA). The NHA indicated that physician orders and interventions should be followed. On 9/22/25 at 1:25 PM, R117 was observed in their room sitting up in the wheelchair with a cup of water by the bedside. R117 stated that they recently had their tracheostomy removed. On 9/23/25 at 10:05 AM and 2:25 PM, R117 was observed in their room sitting up in a wheelchair and a cup of ice was observed by bedside. On 9/24/25 at 10:15 AM, R117 was observed lying in bed watching television with a cup of ice sitting on the bedside table. A record review of R117's medical record revealed, R117 was admitted on [DATE] with diagnoses of Acute Respiratory Failure with Hypoxia, and Peripheral Vascular disease. R117 was cognitively intact. Further review of the medical record revealed a physician order dated 9/19/25 which stated that R117,may have 1-2 ice chips as needed to moisten oral cavity every 30 minutes to 1 hour as requested.DO NOT LEAVE A CUP OF ICE AT BEDSIDE. On 9/24/25 at 10:20 AM, Registered Nurse (RN) F was unable to explain why an order was written regarding leaving a cup of ice at the bedside. On 9/24/25 at 12:33 PM, an interview occurred with the Director of Nursing (DON) asking about their expectations about the ice chips being left at bedside and not following physician orders. The DON indicated their expectation is that the physician orders are to be followed. On 9/24/25 at 2:06 PM, an interview occurred with the Speech Therapist (ST) G and they were asked about the physician's order. ST G stated there is a risk of aspiration (choking) if R117 has too many ice chips or liquids. A review of a facility policy titled, Physician's Orders revealed the following: Treatment rendered to a resident must be in accordance with the specific standing, written, verbal, or telephone order of a physician or other licensed health professional ordering within their scope of practice and clinical privileges.

Based on observation, interview, and record review, the facility failed to respond to residents needs(call lights) in a timely manner for one resident (R81 and R47) and two resident rooms (rooms [ROOM NUMBERS]) fourteen reviewed for call light response. Findings include: R81 On 9/10/24 at 9:59 AM, R81 was interviewed in their room with their daughter present and ask about the care and services they were receiving at the facility. Both R81 and their daughter indicated that call light wait times, Can be long, up to forty five minutes during the early morning and on weekends. A review of R81's electronic medical record (EMR) revealed R81 was originally admitted to the facility on [DATE] with diagnoses that included, aftercare following knee joint prosthesis and weakness. R81's most recent minimum data set assessment (MDS) dated [DATE] revealed R81 had an intact cognition and required partial to moderate assistance with all activities of daily living (ADLs) other than eating and oral hygiene. On 9/12/24 at 3:15 PM, CNA M was interviewed and asked about their ability to respond to and meet resident care needs. CNA M stated, It can be challanging. 09/12/24 03:25 PM, CNA O was interviewed about their ability to respond and meet resident care needs in a timely manner. CNA O stated, If we are fully staffed it's okay, if not then it's difficult. CNA O indicated they frequently work on units that are not fully staffed. 44750 On 9/11/2024 at 9:50 AM, the call light for room [ROOM NUMBER] was observed activated. At 10:00 AM, the light was still observed to be activated, the nurse for the hallway was observed at their cart. At 10:06 AM, the light was still observed to be activated and therapy staff was observed walking past the light. At 10:10 AM, the light was observed still activated and the nurse was noted to be in the hallway. At 10:13 AM, the light was answered by a Certified Nursing Assistant (CNA) and care was rendered. 50223 R47 On 9/11/24 at 1:24 PM, call lights were observed to be on for rooms [ROOM NUMBER] (where R47 resided). On 9/11/24 at 1:25 PM, a therapy staff member, an activities staff member, a Certified nurse assistant (CNA), and a nurse all walked passed all 3 lights. A vendor was observed to leave room [ROOM NUMBER] and went to the nurses station to inform them the resident in room [ROOM NUMBER] needed help. On 9/11/24 at 1:27 PM, the same nurse walked past all 3 call lights again. On 9/11/24 at 1:28 PM, the activities staff member walked past all 3 lights again. On 9/11/24 at 1:29 PM, the same nurse walked past again. On 9/11/24 at 1:29 PM, the Director of Nursing (DON) walked in to room [ROOM NUMBER] and turned the call light off. On 9/11/24 at 1:31 PM, a CNA turned off the light in room [ROOM NUMBER] and exited the room. On 9/11/24 at 1:33 PM, R47 in room [ROOM NUMBER] was yelling out nurse!. When asked if anyone addressed their needs when they turned the call light off R47 stated no. they just turned it off and I gave up on it. R47 said they were yelling because they needed help and no one answered. On 9/12/24 at 10:00 AM, during an interview, The Nursing Home Administrator (NHA) was asked about their expectations for staff when responding to resident needs and explained call lights should be answered within 15 to 30 minutes and explained that lengthy call light times and unanswered call lights is a known problem that has been brought to their attention in resident council repeatedly. The NHA explained the expectation is, all employees answer the lights. On 9/12/24 at 11:30AM, during an interview, the Director of Nursing (DON) said they hope for a prompt answer of call lights and everything is taken care of at that time. The DON explained everybody should be answering call lights. A review of the facility's policy titled Call Lights revealed the following: Call lights will be placed within the guests/residents reach and answered in a timely manner. 1. Identify the location and answer the guest/resident promptly. 2. Knock on the door, identify yourself and ask the guest/resident wat you can help them with. 3. Go to the location of the call light and turn off the light if you are able to meet the guest/resident request. 4. Do what the guest/resident requests of you, if permitted. If you are unsure go, ask the charge nurse. 5. When finished, turn the call light off an replace the call light within guests/resident's reach.

Based on observation, interview, and record review, the facility failed to practice proper infection control practices in a contact isolation room and properly store nebulizer/C-Pap (non-rebreather) mask for five residents (R36, R223, R221, R74, and R11) reviewed for infection control. Findings include: R36 On 9/10/2024 at 12:06 PM, the call light for R36 was seen activated. R36 was noted to be on contact precautions. A sign, as well as personal protective equipment (PPE) was observed on the door. On 9/10/2024 at 12:07 PM, Maintenance Assistant (MA) B was observed going into the room. MA B did not don/doff any PPE, nor perform hand hygiene upon exiting the room. A review of the medical record revealed R11 admitted into the facility on [DATE] with the following diagnoses, Chronic Respiratory Failure with Hypoxia and Major Depressive Disorder. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R11 also required staff assistance with bed mobility and transfers. On 9/12/2024 at 9:44 AM, an interview was conducted with the Director of Nursing (DON). The DON stated anyone who goes into a contact isolation room should be wearing all PPE, including gowns, gloves, and a mask. The DON also stated hand hygiene should occur upon exiting. A review of a facility policy titled, Contact Precautions noted the following, Health care personnel caring for guests/residents on Contact Precautions should wear gloves and a gown for all interactions that may involve contact with the guest/resident or potentially contaminated areas in the guest's/resident's environment. R223 On 9/10/2024 at 9:30 AM, R223 was observed in bed. R223 nebulizer mask was observed sitting n the nightstand. No barrier was observed between the mask and the nightstand. R223 stated they use the mask because they have lung cancer. On 9/10/2024 at 2:42 PM, R223's nebulizer mask was observed still sitting on the nightstand with no barrier in between it. R221 On 9/10/2024 at 10:20 AM, R221 was observed sitting up in their wheelchair. Their nebulizer mask was observed laying on the nightstand with no barrier in between them. R74 On 9/10/2024 at 9:20 AM, R74 was observed sitting in a chair. R74's C-Pap mask was observed laying on the nightstand with no barrier in between them. On 9/11/2024 at 10:20 AM and 11:52 AM, R74's C-Pap was observed laying on the nightstand with no barrier in between them. R11 On 9/10/2024 at 10:00 PM, R11 was observed laying in bed. R11 stated they have been in and out of the hospital a few times for not wearing their C-pap mask. Their C-pap mask was observed on their bedside table with no barrier in between them. On 9/11/2024 at 12:27 PM, R11's C-Pap mask was observed laying on the bedside table with no barrier in between them. On 9/12/2024 at 8:42 AM, R11's C-Pap mask was observed laying on the bedside table with no barrier in between them. On 9/12/2024 at 9:50 AM, an interview was conducted with the Director of Nursing (DON). The DON stated they have order sets for the nebulizer and c-pap mask for them to be cleaned. The DON stated they should be cleaned and set on a paper towel to dry and then put away once dry. A review of a facility policy titled, Noninvasive positive-pressure ventilation, respiratory therapy id not mention storage practices.

Based on observation, interview, and record review, the facility failed to obtain physician orders for colostomy (an opening through the skin) care for one resident (R11) out of one reviewed for colostomy care. Findings include: On 9/10/2024 at 10:00 AM, R11 was observed laying in bed. R11 stated they were about to get up and get ready for lunch. R11 stated they needed their colostomy emptied. R11 stated they have had a colostomy for quite some time. R11 stated the staff does empty it, but they have to remind them. A review of the medical record revealed that R11 admitted into the facility on [DATE] with the following diagnoses, Chronic Respiratory Failure with Hypoxia and Major Depressive Disorder. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status score of 13/15 indicating an intact cognition. R11 also required staff assistance with bed mobility and transfers. The MDS assessment also noted R11 had an colostomy. Further review of the physician's order and task guide did not reveal an order for colostomy care, including changing. On 9/12/2024 at 12:13 PM, an interview was conducted with the Director of Nursing (DON). The DON confirmed R11 was admitted into the facility with a colostomy and stated R11 had been in and out of the hospital and their colostomy care orders must not have been reactivated. A review of a facility policy titled, Colostomy and Ileostomy, appliance care, long-term care did not mention colostomy care orders and task.

Based on observation, interview, and record review, the facility failed to properly store an oxygen tank for one resident (R221) out of five reviewed for respiratory care. Findings Include: On 9/10/2024 at 10:20 AM, R221 was observed sitting in their room and was receiving oxygen via a nasal cannula. R221 stated they had recently arrived at the facility and needed oxygen continuously. In the corner of the room an oxygen tank was observed freestanding. No stand or cart was noted in the room. A review of the medical record revealed R22 admitted into the facility on [DATE] with the following medical diagnoses, Lung Cancer and Chronic Obstructive Pulmonary Disease (COPD). A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating an intact cognition. On 9/10/2024 at 10:31 AM, Certified Nursing Assistant (CNA) R was asked about the oxygen tank was in R221's room without a stand. CNA R stated they were going to get a stand immediately. A review of a facility policy titled, Oxygen Storage and Assembly noted the following, Oxygen Tank Safety .Store each tank individually, by a chain, on a cart, or on a stand.

Based on observation, interview, and record review, the facility failed to provide services to maintain the functional abilities of one (R70) out of one resident reviewed. Findings include: On 9/10/24 at 9:34 AM, R70 was observed lying in bed. R70 was asked if they had any concerns about their care. R70 explained they can no longer get out of bed as much as they used to and now need help with bathing. R70 explained they were previously getting therapy which was helping them perform their hygiene care and they were getting stronger but now they are on restorative care but haven't been getting it and cannot do anything without help now. 09/11/24 11:51 AM R70 was observed in the bathroom sitting in their wheelchair at the sink. R70 explained it takes them a long time to get washed up because they are much weaker since not receiving therapy. A review of R70s electronic medical record (EMR) revealed they were admitted to the facility on [DATE] with the following diagnosis: Hypothyroidism unspecified. A review of R70's Brief Interview for Mental Status revealed a score of 15 indicating intact cognition. A review of R70's physician orders dated 7/17/24 revealed the following: D/C (discontinue) skilled OT/PT (occupational therapy/physical therapy) tx (treatment) services and refer to RNP (restorative nursing program). A review of R70's therapy restorative program plan revealed the following: Restorative Plan Detail 1. Restorative Plan BUE (bilateral lower extremeities)/LE (lower extremeities) AROM (active range of motion) all available planes 15 reps x2 sets, 1 - 3x weekly for 12 weeks. 2. Date of Plan 08/02/2024 3. Goal(s) To maintain mobility and ADL (activities of daily living) function. 4. Interventions BUE/LE AROM all available planes 15 reps x2 sets, 1 - 3x weekly for 12 weeks. A review of R70's care plan revealed the following: (R70) is at risk for decline in function and requires Restorative Nursing r/t (related to) Impairment in range of motion. BLE AROM all available planes 15 repsx2 sets, 1-3x weekly for 12 weeks. BUE (bilateral upper extremity) AROM all available planes 15 reps x2 sets, 1-3 x weekly for 12 weeks. A review of R70's EMR task list revealed no documentation of receipt of restorative treatment. On 9/12/24 at 1:55 PM, during an interview with Physical Therapist (PT) E was asked if R70 was currently receiving therapy services. PT E explained R70 was not currently receiving physical or occupational therapy and R70 was discharged from physical and occupational therapy on 7/17/24 and was referred to the restorative nursing program to maintain contractures and limitations. On 9/12/24 at 2:20 PM, during an interview, Restorative Nurse F was asked if R70 was currently receiving restorative nursing services. Nurse F explained there are two Certified Nurse Assistants (CNAs) that perform the restorative services and they divide the residents amongst themselves and R70 was scheduled to be seen on Tuesdays, Thursdays, and Saturdays. Nurse F confirmed R70 only received restorative services one time within the 12-week period saying, I'm going to look into it. A review of the facility's policy titled Restorative Nursing revealed the following: Purpose: The facility strives to enable the resident to attain and maintain the highest practicable level of physical, mental, and psychosocial well-being .Nursing restorative is available up to 6-7 times per week and is provided for residents meeting restorative program criteria .If resident refuses to participate then care needs will be managed by nursing and other clinical staff as indicated. Document any refusal in the resident's medical record .Document the resident's daily participation and actual number of minutes participating in the resident electronic health record.

Based on observation, interview, and record review, the facility failed to provide ongoing behavioral health services for one resident (R27) out of eight reviewed for behavioral health. Findings include: On 9/10/24 at 10:00 AM, R27 was observed in bed. R27 explained they used to get out of bed into their wheelchair but does not feel like getting out of bed anymore because they are worried about their son whom they have been supporting financially and is now running out of money to support. On 9/11/24 at 11:24 AM, during an interview, Social Worker (SW) P was asked if they were aware of R27s mood and concerns regarding their son. SW P explained they were aware and they talked to accounts receivable and informed R27 of how much money was left over after they paid the facility. SW P also explained that they provided R27 with the name and phone number of a church and called R27s older son. On 9/12/24 at 11:59 AM, R27 was observed in bed awake with the blinds closed and staring at the wall. R27 was observed to be wearing the same clothes as observed on the previous day. When asked if they had breakfast yet R27 stated they did not feel like eating. R27 stated I feel very bad. I wish to die. I have no money to help my son and he tells me he will be on the street. When asked if they had been eating, R27 stated I eat a little bit. I wish to die today but Jesus Christ told me it's not my time. I ask him to take me away. I don't want to eat. I have no appetite most of the time. This is not your problem, but I have to talk to someone. I wish to die so I don't have to worry anymore. I wish to die. I wish to die. I wish to die. Please Jesus take me away. I am so tired of this life. A review of R27's record revealed they were admitted to the facility on [DATE] with the following diagnosis: pressure ulcer of sacral region; Anxiety disorder unspecified. A review of R27's Brief Interview for Mental Status revealed a score of 15 indicating intact cognition. A review of R27's progress notes revealed a nurses note dated 9/1/24 stated: Guest refused lunch this shift, (R27) is worried about (R27) son and (R27's) sons financial situation, notified social work. Further review of R27's record revealed a psychiatry note dated 7/5/24 stated He has obvious depression . demeanor: calm, pleasant, cooperative. Suicidal ideation: denies. Appetite: good. Notify of changes in mood or behaviors. Will follow. No other psychiatry notes or referrals were found. On 9/12/24 at 11:30 AM, during an interview the Director of Nursing (DON) they explained they (residents) should be seen as needed and for any concerning behaviors or anything out of the ordinary. A review of R27's care plan revealed the following: (R27) has the potential for fluctuation in mood r/t (related to) anxiety. Behavioral health/psych consults as needed and follow recommendations as indicated. Observed and report to SW and/or physician prn (as needed) acute changes in mood or behavior; feelings of sadness; increased anxiety/agitation, depression, withdrawal/loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite/eating habits; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills; how resident interacts with others. On 9/12/24 at 12:12 PM, Certified Nurse Assistant (CNA C) was asked if they were aware of R27s mood and explained they thought R27 was upset and had gotten into a fight with their son. CNA C explained R27 doesn't always seem this way and the depressed mood was new. A review of the facility's policy titled Behavior Management revealed the following: The facility will provide individualized care and services that promote the highest practicable level of function by providing activity/functional programs as appropriate and safety interventions to minimize behaviors .7. Resident may require a referral to psychiatric/psychological services or spiritual care. 9. A Behavior Management meeting will be conducted monthly and PRN or at the resident at risk at least monthly, as needed by the interdisciplinary team and document any changes in the care plan at the meeting. Residents will be reviewed during the meeting are as follows: Residents identified with new or worsening behaviors (including mood changes). A review of the facility's policy titled Social Services Referral to Outside Providers revealed the following: Referrals to ancillary providers will be made to meet the psychosocial and or concrete needs of a resident while safeguarding protected health information .9. Follow up visits will be scheduled as needed. 10. The mood/behavior/psychosocial/trauma or substance abuse issues, that prompted the need for services, are to be monitored and the service provider is to be kept informed of the evaluation of progress.

Based on observation, interview and record review, the facility failed to follow up on physician's orders to scheduled an appointment for one resident (R30) of one resident reviewed for consultation. Findings include: On 09/10/24 at 9:30 AM, R30 was observed sitting on the side of his bed watching television. When asked about concerns with care, R30 stated Yes. I have not seen the wound doctor lately due to my old sore and I have a rash on my side that really itches and burns. A review of R30's medical record revealed a physician's note dated 8/28/24 stating Resident was seen for the Chief Complaint: Requesting dermatology consult. Patient was seen today at their request for rash to the back of left hip and left groin. Resident also reports that it has been on the back for a long time, so this is not new for this patient. The areas appear round and raised, but no scaly or dry skin noted. Resident does report that they are itchy, sore and sometimes burns. They are very difficult to see. Resident states that the hydrocortisone cream did not help. On 9/11/24 at 10:05 AM, Charge Nurse L was queried about the order and its follow up and revealed they were not aware of any follow up appointments. On 9/11/24/at 12:55 PM, an interview occurred with Wound Care Nurse F who stated they did not know about the consult. On 9/11/24 at 1:00 PM an observation of R30 affected area was observed with Nurse F. The observation revealed that R30's whole back, arms and lower back were covered with a rash and several scaly areas. Further review of R30's medical record revealed they were admitted into the facility on [DATE] with diagnoses of Orthopedic Aftercare, Type 2 Diabetes, Hypertension; Sleep Apnea. A review of R30's Minimum Data Set (MDS) assessment dated [DATE] revealed R30's Brief Interview for Mental Status (BIMS) assessment score was a 10 indicating mildly impaired cognition. On 9/12/24 at 10:23 am, during an interview with the Director of Nursing (DON) stated, My expection would be that the appointment would be made by the appropriate party and the residents care would be followed up on. A review of the policy titled Resident Rights and Facility Responsibilities dated 9/01/13 and revised 5/14/24 revealed A resident is entitled to recieve adequate and appropriate care, and to receive, from the appropriate individual within the health facility or agency, information about his or her medical condition, proposed course of treatment, and prospects for recovery in terms that the resident can understand .

Based on interview, and record review, the facility failed to ensure one resident (R25) was catheterized (straight cathed-tube inserted into the bladder to help drain urine) timely out of one reviewed for dignity, resulting in the potential for feelings of sadness. Findings include: On 09/11/24 at 2:27 PM, an interview with R25 occurred and R25 stated Because I am one of the youngest ones here, I try not to cause trouble. I was up by 5:00 AM and cathed for my doctor's appointment. Upon returning from the appointment at 1:00 PM, I asked the nurse to cath me again because it was hurting. I had to wait until 3:00 PM. I was really upset and sad about waiting so long to be cathed. It made me feel sad like the nurses don't care about me or how I feel. A review of R25 medical record revealed they were admitted into the facility on [DATE] with diagnoses of Scoliosis, Insomnia, Hypertension, and Neuromuscular Dysfunction of Bladder. A review of R25's Minimum Data Set (MDS) assessment dated [DATE] revealed, R25's Brief Interview for Mental Status assessment score was a15 indicating intact cognition. On 09/12/24 at 12:25 PM, an interview occurred with the Director of Nursing (DON) regarding the expectations of residents rights regarding dignity and care. The DON stated, It is my expectation the resident needs would be cared for once they asked for assistance A review of the policy titled Resident Rights and Facility Responsibilities dated 9/01/13 and revised 5/14/24 revealed Dignity, Respect & Quality of Life. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on observation, interview, and record review, the facility failed to provide one resident (R56) of three residents reviewed for accommodation of needs with a comfortable bed, resulting in feelings of dissatisfaction and discomfort. Findings include: On 9/10/24 at 2:58 PM, R56 was observed in bed with their feet on the end of the bed on the bed board, a pillow was underneath their feet. R56 was observed to be obese and their was very little room in the bed on either side of their body. R56 was interviewed about the comfort of their bed and indicated they were uncomfortable and dissatisfied with their bed. R56 stated, Can you talk to them about getting me a better bed. On 9/10/24 at 3:05 PM, Certified Nurse Assistant (CNAG) entered R56's to provide them with fresh water and was asked about R56's bed. CNA G stated, We need better beds. On 9/11/24 at 10:46 AM, R56 was observed in bed on their back with very little room in the bed on either side of their body. R56 stated, I cannot move in this bed. Once they put me in bed, I can't move. R56 again indicated they would like assistance with obtaining a more comfortable bed. On 9/11/24 at 12:35 PM, an interview was conducted with Nurse/RN (Registered Nurse) H regarding R56's bed and R56's discomfort with their bed. Nurse H stated, I don't know why [R56] doesn't have a bariatric bed (Heavy-duty bed wider than a standard hospital bed). On 9/11/24 at 2:20 PM, Unit Nurse Manager (UNM)/RN I was interviewed regarding R56's bed and the discomfort expressed by R56 regarding their bed. UNM I stated, I believe [R56] has a bariatric bed. On 9/11/24 at 4:33 PM, R56 was again visited in their room and was observed in bed on their back with very little room in the bed on either side of their body. R56 was further interviewed about their bed and stated, I need a bigger bed. On 9/11/24 at 4:44 PM, Environmental Services Director (ESD) J was interviewed about the bed in R56's room and indicated that R56's room was a bariatric room and should have a bariatric bed in it. EVS J and the surveyor then proceeded to go to R56's room and observed their bed. Upon observation of R56's bed, EVS J stated, That's not a bariatric bed. I'm going to have to look into that. On 9/12/24 at 10:37 AM, the Administrator (NHA) was interviewed regarding their expectations for ensuring that obese residents have comfortable beds and are comfortable when in bed. The NHA indicated that all beds in the facility are considered to be bariatric, It's by weight, not by dimension. The NHA was asked specifically about R56's bed and R56's expressed discomfort when in their bed. The NHA stated, Rolling (moving side to side) was the issue, we discussed a positioning bar for [R56]. We don't have a bigger bed, but are not opposed to it if necessary. A record review of R56's electronic medical record (EMR) revealed that R56 was admitted to the facility on [DATE] with diagnoses that included Morbid obesity and Muscle weakness. A review of R56's vitals revealed on 9/12/24 R56 was weighed and had a weight of 384 pounds. A review of R56's most recent minimum data set assessment (MDS) dated [DATE] revealed that R56 had an intact cognition and was dependent upon staff for all activities of daily living (ADLs). A review of a facility policy titled, Bariatric bed use Revised: May 20, 2024 revealed the following, Introduction: .Various types of bariatric beds are available, ranging from [a] simple larger version of the standard bed to a bed with a low air mattress that provides pressure relief. A bariatric bed provides more comfort for a patient with obesity then a standard-sized hospital bed. A bariatric bed also preserves the self-esteem of a patient with obesity by fitting the patient's larger body size easily and providing special side rails that help the patient with turning and repositioning . A review of the manufacture's product summary for Adjustable-width long-term care bed revealed the following, Product Description: The innovative [Product identification number] adjusts from 36 (Inches) to 39 to 42 .One bed can accommodate most residents in comfort safety, including many bariatric residents . .

Based on observation, interview, and record review the facility failed to develope a comprehensive care plan for one (R103) out of six residents reviewed for care plans. Findings include: On 9/10/24 at 10:20 AM, 2:05 PM, and 4:22 PM, and on 9/11/24 at 8:29 AM, 9:52 AM, 12:05 PM, 1:23 PM, and at 4:22 PM, R103 was observed lying in bed and a back brace was observed in R103's room. On 9/12/24 at 8:49 AM, R103 was observed standing in the hallway with their walker. Certified Nurse Assistant (CNA) C stated, Where is your back brace, you need to have it on at all times. CNA C was then observed applying R103's back brace. A review of R103's medical record revealed they were admitted to the facility on [DATE] with a diagnosis of Wedge compression fracture of fifth lumbar vertebra, subsequent encounter for fracture with routine healing. A review of R103's Brief Interview for Mental Status revealed a score of four, indicating cognitive impairment. A review of R103's physician orders revealed an active order which documented, Lumbar brace when OOB (out of bed). Check skin integrity under brace q (every) shift. Report any abnormal findings to MD/NP (medical doctor/nurse practitioner). A review of R103's care plan and Kardex (guide to resident care) revealed no documenteation of the back brace. On 9/11/24 at 12:00 PM, during an interview, CNA C was asked how they ensure they have accurate information about a resident and confirmed they use the Kardex which has information about their care. On 9/12/24 at 9:30 AM, during an interview, Licensed Practical Nurse (LPN) D was asked if R103 is supposed to wear a back brace. LPN D replied No, (they) are not. LPN D was asked how would they knew if R103 was supposed to wear a back brace and said, I would look in the residents' careplan and if they are to wear a brace. On 9/12/24 at 11:30 AM, during an interview, the Director of Nursing (DON) was asked to review R103's orders and careplan and was asked if R103 is supposed to be wearing a back brace. The DON stated (R103) does have an order for one so yes (they) should be wearing it. The DON was reviewing R103's care plans and confirmed the back brace should be included in the care plan. A review of the facility's policy titled Care Planning stated the following: Every resident in the facility will have a person-centered plan of care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessments and prepared by an interdisciplinary team who includes but not limited to; attending physician, a registered nurse who is responsible for the resident, a nurse aide, a member of food/nutrition services, the resident or resident representative, therapy staff as required and any other ancillary staff.

Based on observation, interview, and record review, the facility failed to revise a care plan to reflect interventions for wandering behaviors for one resident (R76) out of one reviewed for behaviors. Findings include: On 9/10/24 at 10:13 AM, R76 was observed lying in bed sleeping soundly. On 9/10/24 at 4:00 PM, R76 was observed sitting up in bed watching television. On 9/10/24 during a confidential resident council, three residents discussed R76 wandering and behaviors at night. One resident stated, I have complained about (R76) coming into to room at all hours of the night. R76 doesnt pay attention to 'stop signs' on doors or if door is closed. I have to yell for the staff to come and help. R76 hits the staff and is difficult with them as well. A review of the record revealed R76 was admitted into the facility 02/05/24 with following diagnoses: Alzheimer's Disease, Dementia, Hyperlipidemia, Catatonic Schizophrenia and Depressive disorder. A review of the Minimum Data Set (MDS) assessments on 8/14/24 revealed, Brief Inverview Mental Status assessment score was 00 indicating severely impaired cogntition. Further review of the active care plans revealed: -A care plan, (R76) is at risk for elopement and/or wandering R/T (related to) dementia initiated 02/05/24, revised 08/23/24 with no noted new interventions since 2/05/24. -A care plan, (R76) is at risk for decline in cognition and has impaired cognitive function or impaired thought processes r/t Alzheimer's, impaired decision making, poor safety awareness, inability to follow directions and short term memory loss care plan initiated 2/07/24 and last revised 03/07/24 was noted with no new interventions since 2/07/24. The care plan did not represent the intrusive behaviors identified. On 9/12/24 at 10:00 AM, along with Social Worker (SW) K a review of R76's care plans and interventions occured. SW K stated interventions are discussed and used to try to keep R76 from going into other residents rooms and areas. On 9/12/24 at 12:26 PM, an interview with the Director of Nursing (DON) occurred and confirmed the interventions should be changed and be effective related to residents care plans. A review of the policy titled, Care Planning implemented 9/01/11 and revised 6/24/21, revealed, Every resident inthe facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that included measurable objectives and time framesto meet a residents medical, nursing, mental and psychosocial needs .The results of the interdisciplinary assessments will be used to develop, review and revise the residents care plans.

This citation pertains to Intakes: MI00135903 and MI00135359. Based on observation, interview, and record review, the facility failed to provide an environment free from verbal abuse, physical abuse, and neglect from staff to resident for one of one sampled resident (R51) reviewed for abuse resulting in, abuse, neglect and the likelihood of mental anguish using the reasonable person concept. Findings include: A review of Intake called into the State Agency: MI00135903 revealed the following, (R51) had called Certified Nursing Assistant (CNA L) an '[expletive]' and [they] replied, 'no you are an [expletive]' .(R51) and (CNA L) exchanged verbal remarks back and forth and then (CNA L) slapped (R51) on (their) bare bottom and said to (them), who is your daddy? . On 7/24/23 at 10:00 AM, R51 was observed lying in bed and asked about the incident that took place on 3/13/23 between them and CNA L. R51 explained that they have problems with their memory, and did not remember the incident. A review of R51's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included, Heart Failure, Dementia, Diabetes, and Fibromyalgia. Further review of R51's medical record revealed a quarterly Minimum Data Set assessment dated [DATE] revealing a Brief Interview for Mental Status score of 12/15 indicating an intact cognition. In addition, R51 required extensive assistance of 2 persons for bed mobility, transfers, dressing and toilet use. Further review of R51's medical record revealed the following progress note: 3/16/2023 16:05 (4:05pm) Social Services Note. SW (social worker) checked on resident again r/t (related to) prior incident. When SW asked if resident is okay resident replied 'I am fine.' .Resident expressed to SW that [they were] in fear to tell someone about the prior incident. SW assured resident that they did the right thing . On 7/25/23 at 10:18 AM, a phone call was attempted to CNA L to no avail. A message was left however, they did not return the surveyor's call by the end of survey. A review of the local police departments police report regarding the incident between R51 and CNA L revealed the following interview of CNA L: (Police officer) made contact with (CNA L) regarding this incident. He stated he has been doing nursing home care for [AGE] years and this incident was a big misunderstanding. He stated that he was requested to come help with changing (R51). He stated that (R51) immediately started calling him an a**hole. He says that (R51) scratched his arm while he was rolling (them) so he did call (R51) an a**hole back .(CNA L) stated that while he was holding (R51) his grip slipped and he grabbed (their) hips. He stated (R51) called him a bastard at this time and he stated that he told (R51) I know who my daddy is. He said he never slapped (R51's buttocks) .I asked (CNA L) if he ever threatened to drop (R51) on the ground and he stated he did not. I asked him about how he moved (R51) back up on the bed and he stated that they did not have to. He stated he left the room and was called into the office and fired for swearing at (R51) A review of CNA L's personnel file revealed that their effective date of separation from the facility was on 3/21/23 for Residential Abuse. Also noted on the separation notice was the following, Describe the reason(s) for disciplinary action towards patient. Employee interviewed and readily admitted that [they] used a**hole when speaking with a patient. Pt. (patient) called employee an a**hole and employee responded with You're the [expletive], I'm trying to help you. On 7/25/23 at 10:32 AM, Registered Nurse (RN) M was interviewed regarding the incident they witnessed between R51 and CNA L. RN M explained that they needed to complete a skin assessment on R51 who was newly re-admission from the hospital. RN M explained that they asked CNA N to assist with turning R51 during the skin assessment however, upon entering the room at approximately 10:00 AM, R51 was covered in stool which was seeping out of their brief. RN M explained that the stool was a mess and had never seen and cleaned up so much stool before, as it had seeped up the resident's back and was all over the sheets. RN M explained that they asked CNA N to obtain assistance from R51's assigned CNA for the day, CNA L to assist with cleaning the resident up. RN M explained that as CNA L walked into the room, R51 stated, Oh, it's you, (to CNA L). RN M explained that at that time, CNA L took their hand and smacked R51's exposed skin near their buttocks area and stated, Who's your daddy? RN M explained that during the process of cleaning the resident, they were yelling and afraid that they were going to fall off the bed, and stated, Don't drop me. RN M stated that CNA L grabbed and shook R51's shoulders stating, Don't make me drop you. RN M also explained that instead of CNA L using a drawsheet to reposition R51 along with their assistance, CNA L used R51's shoulders and roughly repositioned the resident. RN M explained that R51 is a larger resident, but CNA L threw [them] in the middle of the bed in which the resident screamed out. RN M explained that CNA N made a statement toward CNA L that she could have assisted him with repositioning. RN M also explained that CNA L told the resident, I didn't miss you while you were gone, I'm glad you were in the hospital. and that CNA L called the resident an expletive as least twice during their care. On 7/25/23 at 11:05 AM, CNA N was interviewed via phone and asked about the incident regarding CNA L and R51. CNA N explained that she was in the resident's room with RN M who needed to complete a skin assessment on R51 however, upon rolling the resident over, they observed that the resident had a large bowel movement and needed to be cleaned up, so she went to get CNA L to assist with cleaning the resident. CNA N explained that when CNA L entered the resident's room and began to assist, he took his hand and slapped R51 on the bare buttocks and stated, Who's your daddy? CNA N stated that R51's response was, You're an [expletive] in which CNA L's response was, It takes one to know one, you're an [expletive]. CNA N explained that CNA L was pulling and tossing R51 around on the bed during care in which CNA L stated to the resident, You're lucky that I don't throw your [expletive] on the floor as he kept pulling and pushing R51 closer to the end of the bed. CNA N explained that R51 was screaming and stating that they were going to call the police on him. On 7/26/23 at 9:21 AM, a phone call was made to R51's family member, Family Member Q and was asked if R51 had mentioned anything to them about the incident with CNA L, and they explained that due to R51's memory loss, they hadn't mentioned anything recently, but shortly after the incident, had concerns that CNA L was going to come back into the facility. A review of the Facility Reported Incident documentation including their abuse investigation completed by the facility revealed the following regarding their interview with R51, .Resident was not able to fully describe events 90 minutes prior (date: 3/13/23). (R51) indicated that [they] did swear at the employee and that the employee did swear back at [them]. (R51) also indicates that at some point today (3/13/23) the same employee placed his hand over [their] mouth when [they] told [they were] going to report him. However, the patient was unable to accurately identify the employee other than that to say it was the same person . Further review of the facility's abuse investigation revealed the following, .In conclusion, the facility completed a thorough investigation and did substantiate the employee did use profanity and called the resident an [expletive]. The termination of employment of this employee was processed due to violation of company policy . On 7/26/23 at 11:09 AM, the Director of Nursing (DON) was asked about the incident regarding CNA L and R51, and why they had not substantiated that physical abuse occurred toward R51 based on the observation by RN M and CNA N . The DON explained that they did not substantiate physical abuse because CNA L denied that physical abuse took place, and the resident wasn't able tell them what occurred. A review of the facility's Abuse Prohibition Policy revealed the following, .Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment .Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .Verbal Abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the guest/resident to experience humiliation, intimidation, fear, shame, agitation, or degradation .Physical Abuse include hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment .Neglect is the failure of the facility, its employees or services provides to provide goods and services to a guest/resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .

Based on observation, interview, and record review, the facility failed to ensure food items were labeled and stored at the appropriate temperature, failed to maintain sanitary conditions, failed to ensure staff donned a beard restraint, and failed to ensure handwashing to prevent cross contamination. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 7/24/23 between 8:45 AM-9:15 AM, during an initial tour of the kitchen with Culinary Manager A, the following items were observed: In the dry storage room, the flour, sugar, bread crumbs and oatmeal bins were all observed to be unlabeled with the contents inside. Culinary Manager A confirmed the bins should be labeled. According to the 2017 FDA Food Code section 3-302.12 Food Storage Containers, Identified with Common Name of Food, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. Dietary Staff B was observed serving breakfast from the steam table. Dietary Staff B was observed with a beard, but was not wearing a beard restraint. When queried, Culinary Manager A stated Dietary Staff B should be wearing a beard restraint. According to the 2017 FDA Food Code section 2-402.11 Effectiveness, (A) Except as provided in (B) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. The clean dishware rack located adjacent to the steam table was observed with cobwebs along the bottom rack and along the side of the top shelf. When queried about the cobwebs, Culinary Manager A provided no explanation. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 7/24/23 at approximately 8:45 AM, numerous boxes were observed stacked outside the walk-in cooler and freezer. Culinary Manager A stated stock had just been delivered. On 7/24/23 at 11:55 AM, most of the boxes remained outside the walk-in coolers, and Dietary Staff B was observed putting stock away into the freezer. 4 boxes each containing 1 pound containers of chicken salad were observed in the stack of boxes waiting to be put into the cooler. The internal temperature of the chicken salad was measured to be 53 degrees Fahrenheit. Culinary Manger A stated staff needed to move quicker when getting the stock put away into the cooler. According to the 2017 FDA Food Code section 3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding, 1. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be maintained: 1. (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 C (130 F) or above; P or 2. (2) At 5 C (41 F) or less. On 7/24/23 at 12:05 PM, Culinary Manager A was observed helping to put stock away. Culinary Manager A carried a box into the oven/grill area, and placed the box inside the reach-in cooler. Culinary Manager A then went directly to the grill, and began placing slices of bread onto the grilled cheese sandwiches that were cooking on the flat top grill. Culinary Manager A did not wash her hands after handling the boxes of stock before changing tasks and handling food items. According to the 2017 FDA Food Code section 2-301.14 When to Wash, Food employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles P and: .(F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (H) Before donning gloves for working with food; P and (I) After engaging in other activities that contaminate the hands.

This citation pertains to Intake MI00133827. Based on observation, interview and record review the facility failed to ensure care needs were met timely for five sampled Residents (R24, R41, R65, R234, R236) of six reviewed for activities of daily living needs, resulting in dissatisfaction with the care provided, a delay in care needs being met and the potential for unmet care needs. Findings include: R65 On 7/25/23 at 2:40 PM, the call light was observed to be activated for R65. R65 was observed lying on their back, and explained that they had decided to remain in bed today, as their stomach was uncomfortable due to constipation. R65 explained that their brief had not been changed all day and that this is the reason their call light was on. R65 was asked if the padding underneath them was wet, and they responded with, I think so. Along with Certified Nurse Assistant (CNA) R R65's brief was checked. Upon CNA R pulling R65's covers off them, a strong pungent smell of urine permeated the room. The brief was observed as extremely wet, and had saturated the padding and linen that was underneath the resident, as confirmed by CNA R. Review of R65's medical record (post 2:40 PM observation) the following progress note was entered and revealed the following: 7/25/2023 15:10 (3:10pm) Nurses Notes. Pt (patient) pressed call light to alert staff [they] needed incontinent care at 2:45pm. Brief and linens saturated with high volume urine output. Pt choosing to remain in bed all day. This AM when CNA offered AM care, pt declined. CNA told pt to press call light when she wanted brief to be changed. Writer asked pt why [they] didn't call staff earlier (pt A&Ox3, verbalizes toileting/incontinent care needs) Pt stated she just called now because she needs it now. Writer educated pt to request incontinent care more frequently to prevent skin breakdown. Pt agreed . A review of R65's care plan revealed the following, Focus: [R65] is at risk for impaired skin integrity/pressure injury R/T (related to) : Incontinence bowel and bladder, weakness Date Initiated: 12/08/2022 .Interventions: Provide incontinence care with each incontinent episode and as needed and apply moisture barrier cream/ointment per facility policy/orders Focus: [R65] is at risk for decline in cognition and has impaired cognitive function or impaired thought processes r/t BIMS (mental score) score of 9. Date Initiated: 12/09/2022 .Interventions: Anticipate needs from non-verbal indicators and past preferences as known. Date Initiated: 12/09/2022 .Assist resident with decision making as needed. Date Initiated: 12/09/2022 . A review of R65's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included, Cerebrovascular Disease, Diabetes and Hypertension. Further review of the medical record revealed that the resident has a moderately impaired cognition, and required extensive assistance for toilet use. 39918 R234 On 7/24/23 at 10:27 AM, Confidential Witness I was observed to be very frustrated and going in and out of R234's room, at times approaching various staff members out in the hallway. Witness I was approached and agreed to be interviewed at the bedside of R234. An attempt was made to interview R234, however, the resident did not respond to inquiry. Witness I indicated that R234 has Alzheimer's disease and would not be able to answer any questions. Witness I lifted the lid on R234's breakfast tray, which was observed to be untouched. Witness I stated that R234 needs to be fed and expressed frustration that no one had come to feed the resident. Witness I commented that the resident's food is now cold. Witness I stated they brought a banana and grapes from home that they provided to the resident, but emphasized that no staff had come in all morning to assist the resident with eating/drinking or other care. R234 was observed lying in bed, with their bare shoulders exposed. R234 had on a hospital type gown but it was noted to have come undone. Witness I continued to express their frustration that the resident was not up and out of bed and continuously pulled up R234's covers/gown so that their chest was not exposed. Witness I explained that R234 was normally able to ambulate and be taken to the bathroom as long as they have assistance. Witness I stated that they have visited the facility multiple times (staying for hours at a time) since the resident's admission on 7/22/23 (Saturday) and claimed that the resident has not been moved up and out of bed since arriving. Witness I continued to be express their frustration and was asked at 10:34 AM to activate the resident's call button. Certified Nurse Assistant (CNA) J entered the room at 10:36 AM but stated that she was not R234's assigned aide for the shift. CNA J left and came back with Unit Manager Licensed Practical Nurse (LPN) C. CNA J and LPN C then provided morning care and incontinence care to R234 as Witness I went to retrieve clothing for the resident to change into. When queried, LPN C was unsure of where R234's assigned CNA was, but indicated that the assigned aide (CNA O) had come in a little late today. A review of R234's record revealed the following: -7/22/2023 17:11 (5:11 PM) Nursing Summary Note Text: Guest arrived around 1530 (3:30 PM) .Guest is alert and orient to self (confused). No denture, glasses, assisted 2 person with ADLs (activities of daily living), toileting, transfer. Guest is a 1:1 feeder . R41 On 7/24/23 at 10:56 AM, during the initial tour, R41's call light was observed to be activated. R41 was observed lying in bed wearing a hospital type gown and was interviewed at this time. R41 was queried regarding concerns at the facility. R41 expressed frustration that they have been waiting for 2 hours to get up and dressed and stated, I would do it myself but I don't want to hurt myself. R41 pulled out their cell phone and showed this surveyor that they had called a number for the facility six times this morning. Certified Nursing Assistant (CNA) P entered the room without knocking on the door and informed R41 that she would help them. When queried, CNA P did not know who R41's assigned aide was for the day. A review of R41's record revealed that the resident was most recently admitted into the facility on [DATE] and is cognitively intact. Further review revealed that the resident requires the assistance of one staff member for dressing, transfers, and mobility. R236 On 7/24/23 at 11:26 AM, R236 was observed slowly propelling themselves in their wheelchair into their bathroom. R236 indicated that they were taking themselves to the toilet. A raised toilet seat with handles was observed in the resident's bathroom. When queried regarding concerns at the facility, R236 stated they had pressed their call button this morning for help getting dressed, but no one came, so they had to do it themselves. R236 added that they also requested that their bed be made this morning. R236's bed was observed with disheveled sheets and was not made. R236 indicated that they do require some assistance to use the bathroom, but they usually just take themselves because staff doesn't come when they call. R236 added that approximately two days ago, they, messed their pants, while waiting for bathroom assistance. At 4:11 PM, R236 was observed in their room and had a visitor. R236's bed remained disheveled and un-made. A review of R236's record revealed that the resident was most recently admitted into the facility on [DATE] and is moderately cognitively impaired. Further review revealed that the resident requires the assistance of one staff member for dressing, transfers, and toileting. R24 On 7/26/23 at 9:05 AM, R24 was observed lying in bed. This surveyor entered R24's room with Licensed Practical Nurse (LPN) E and LPN H. R24 informed the nurses that their incontinence brief needed to be changed. R24 stated that their brief had not been changed since last night and no staff had been in yet this morning to check their brief or provide morning care. R24 added that yesterday (7/25/23), their brief was, Loaded with urine .I sat in it for 3 hours. R24 stated that they had hit their call button to be changed, but care was not provided upon their request. R24 stated, They don't have the help they need. At 9:13 AM, LPN E and LPN H provided incontinence care to R24. R24's green incontinence brief was observed to be completely saturated with urine. The bottom edge of the resident's gown, back of their bare legs, and cloth pad (chux) underneath their bottom were also observed to be wet. R24's skin on their buttocks was observed to be moisture-laden but intact, and reddened with white indentations/wrinkles - indicative of being in the same position for an extended period. This observation was also confirmed by LPN E. A review of R24's record revealed that the resident was recently readmitted into the facility on [DATE] and is cognitively intact with medical diagnoses of Fracture of Shaft of Right Ulna (Broken Arm), Acute Osteomyelitis, Olecranon (Elbow) Bursitis, Weakness, Anxiety, and Depression. A review of R24's Kardex (pulled from the care plan) revealed the following: -Brief usage: Resident uses disposable briefs. Change prn (as needed). -Check q 2 hr (every 2 hours) and prn for incontinence . -Provide incontinence care with each incontinent episode and as needed . - .Resident requires 1 person assistance to reposition and turn in bed. -Keep skin clean and dry . On 7/26/23 at 1:14 PM, the Director of Nursing (DON) was interviewed. When queried regarding resident ADL care observations and concerns, the DON indicated she would not expect to see residents with outstanding ADL care concerns unless there is an acute/urgent event happening on the unit. The DON stated the facility is fully staffed and ADL's are brought up in daily quality rounds. A review of the facility's policy/procedure titled, Routine Resident Care, Last Revised 3/7/2023, revealed, Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene .Residents are encourages or assisted to dress in appropriate clothing and footwear daily .Residents are provided assistance to the restroom or with the bedpan, urinal, or bedside commode as needed .Incontinence care is provided timely according to each resident's needs .Resident's call lights are answered timely and resident's requests are addressed, if permitted. Call lights should be placed within easy reach of the resident.

Based on interview and record review the facility failed to transmit Minimum Data Set (MDS) assessments to the Centers for Medicare and Medicaid Services (CMS) within 14 days after completion for four (R59, R95, R103, and R107) of four residents reviewed for resident assessment transmission, resulting in potential for inaccurate tracking of resident assessment, admission and discharges. Findings include: A review of R59's MDS assessments noted, R59 was admitted on [DATE] and discharged on [DATE]. The list of assessments completed revealed, Entry [DATE] accepted, Admission/Medicare 5 day accepted [DATE]. R59 discharged home on [DATE]. R59's medical record did not reveal a completed and submitted discharged MDS assessment. A review of R95's MDS assessments noted, R95 was admitted on [DATE] and discharge [DATE]. The list of MDS assessments complotted revealed, Entry [DATE] entry, Admission/Medicare 5-day [DATE]. R95 discharged to the hospital on [DATE]. R95's medical record did not reveal a completed and submitted discharged MDS assessment. A review of R107's MDS assessments noted, R107 was admitted on [DATE] and discharge on [DATE]. The list of MDS assessments completed revealed, Entry [DATE] Accepted and Admission/Medicare 5 day [DATE] Accepted. R107 discharged to the hospital on [DATE]. R107's medical record did not reveal a completed and submitted discharged MDS assessment. A review of R103's MDS assessments noted, R103 was admitted on [DATE] and discharge on [DATE]. The list of MDS assessments completed revealed, Entry [DATE] Accepted, Admission [DATE], Medicare 5 day [DATE] completed, Discharge Return Anticipated [DATE] Accepted. The MDS Nurse explained that R103's assessment was completed late. On [DATE] at 12:59 PM, the MDS Nurse D was ask when are the assessments due and stated, You have 14 days after discharge to complete the ARD (Assessment Reference Date). A review of the facilty's policy titled, Submission of MDS dated , [DATE], noted, Long Term Care Facilities are required to submit MDS records for all residents in Medicare or Medicaid certified beds regardless of the pay source. Medicare Part A MDS's must be submitted prior to billing for Part A services Procedure 1. Once MDS's are completed and verified for accuracy they will be readied for transmission. 2. Completed MDS's are to be transmitted to CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (APAS) system in a timely manner in accordance with CMS policies a. Comprehensive assessments must be transmitted within 14 days of the V0200C (care plan completion date). b. All other MDS's must be transmitted within 14 days of the Z0500B (MDS Completion Date). c. Entry, re-entry and Death in facility tracking forms must be transmitted within 14 days of entry, re-entry or death date. d. Discharge tracking must be transmitted with 14 days of the Z0500B date .

This citation pertains to Intake MI00137843. Based upon interview and record review, the facility failed to provide timely notification of a fall with injury to the family member/responsible party of one (R481) of five residents reviewed, resulting in family member/responsible party not knowing right away that the resident fell and causing a delay in the opportunity to participate in medical decisions regarding care and treatment. Findings include: Review of the facility record for R481 revealed an admitted [DATE] with diagnoses including Dementia, Hypoglycemia, Diabetes Mellitus and Acute Kidney Failure. The Minimum Data Set (MDS) assessment dated [DATE] indicated R481 required maximum/total assistance for self care. Additional review of the facility record pertaining to R481's reported fall revealed a Certified Nurse Assistant (CNA) found the resident on the floor of their room on 06/16/23 and the resident was found to have a bump next the left eye and no further obvious injury upon further assessment. R481 was reported to be alert and orientated x 3 and indicating that they attempted to ambulate to the bathroom without calling for assistance and using a bedside table as an assistive walking device. Following initial assessment of the resident and assisting them back to bed, the incident/accident report and related progress note indicated the on-call provider (physician) was notified and requested that the resident's eye be iced, the resident continue to be monitored and not sent to hospital at that time. There is no indication or report of the responsible party being notified directly following the incident. The incident/accident report (dated 06/17/23) states that the responsible party was notified on 06/19/23. Review of the facility policy titled Fall Management dated 07/14/21 includes the following Practice Guideline: 6. The licensed nurse will notify the attending physician and the responsible party of the fall, and document the notification in the medical record. On 07/26/23 at 9:52 AM, the facility Director of Nursing (DON) reported that the expectation is that staff report a resident fall/accident to the responsible party in a timely manner and acknowledged that notification was not provided in this case until the responsible party inquired about the fall during a visit. The DON reported that upon discovery of this deficiency, the corrective action was initiated. During the onsite survey, it was found that the facility identified and corrected their deficient practice prior to the survey team entry. The facility did the following to correct its deficiency: Facility QAPI Plan / Past Non-compliance. Delay in Notification to Responsible Party. Date of Report: 06-19-23 Date of Event: 06-16-23 discovered on 06-19-23. Description of Deficient Practice (why and how did it happen): Family of resident alerted facility of failure to notify family after an incident. The facility nurse failed to notify the responsible party secondary to a lack of knowledge, despite having orientation within the building stating otherwise. A Review of the facility Incident and Accidents policy was reviewed and was deemed appropriate. The resident was noted on the floor near her bathroom, face down, presumably pushing an over bed table to use the restroom. Bump noted to right eyebrow area. Patient assessed and physician services notified. Order for ice and monitoring was received. The facility failed to notify the responsible party of the incident. Plan of Correction: The facility identified all residents with a current incident since 6-16-23 to ensure notification of responsible party had occurred. No deficient practice was noted. Corrective action taken for resident affected. Resident (481) continues to reside in the building, no other residents affected by this deficient practice. Facility nurses will be inserviced on the need to notify responsible parties after incidents occur. The facility immediately provided education to facility nurse on the need to notify responsible parties after an incident occurs. The administrative nurses will audit every incident to ensure responsible parties are notified after an incident. Any deficiencies will be immediately addressed and parties will be notified. Said nurse involved in deficient practice will be offered additional education. The administrative nurses will complete an audit all patients having an incident weekly x 4 weeks and then monthly x 2. The Director of Nursing will review the audits concerns will be addressed. Results will be reported to QA monthly for 3 months, to ensure substantial compliance. Director of Nursing will be responsible to sustain compliance. Date of completion of plan of correction: 06-30-23.

This Citation Pertains to Intake # Based on observation, interview and record review, the facility failed to implement planned interventions and maintain accurate documentation of multiple pressure ulcers for 1 (#703) of 2 sampled residents reviewed for pressure ulcers, from a total sample of four, resulting in the development of multiple, reoccurring pressure ulcers, lack of consistent and timely documentation, inability to adequately determine continuity of pressure ulcer location, and the potential for delayed healing, infection, and pain. Findings include: Record review on 10/15/17 at 11:15 AM revealed that resident #703 was recently readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 9/26/17, revealed Resident # 703 was severely cognitively impaired, was incontinent of bowel and bladder, and required total assistance to perform Activities of Daily Living (ADL's). The MDS further revealed the Resident had a Stage 3 (III) pressure ulcer. Skin and Ulcer Treatments listed on the MDS included Pressure reducing device for chair and Pressure reducing device for bed. The MDS treatment entitled Turning/repositioning program was not checked as being included in current interventions. On 10/15/17 at 12:00 PM, an interview was conducted with Nurse E and Nurse F. When queried regarding Resident #703, Nurse E stated, We sent (Resident #703) to the hospital and they came back for Rehab and then moved to another unit and was admitted to Hospice. When queried further regarding the dates that the Resident had been admitted and discharged from the facility, Nurse F stated, They were admitted [DATE], discharged [DATE], and returned 9/19/17. When queried regarding wound treatments for Resident #703, Nurse E stated, They have Triad paste for their coccyx wound and a foam pad on their right heel. When asked about wound measurements, Nurse F replied, We don't do that. The wound nurse does it. When queried regarding documentation of Resident #703's wound measurements, Nurse F stated, I think the wound care nurse keeps a log. With further inquiry regarding nursing access to wound measurements and how nursing staff know if the wounds were improving or getting worse without having measurements to compare, Nurse E replied, If it looks worse, we let (Wound care nurse) know. On 10/15/17 at 12:10 PM, Resident #703 was observed in the main dining area of the facility. The Resident was sitting in a Geri-chair. A pressure reduction cushion was not in place on the Geri-chair. Nursing Assistant D was assisting the Resident to eat. When queried regarding a pressure reduction cushion on Resident #703's chair, Nursing Assistant D stated, No, I guess it's because it's a Geri-chair. With further inquiry, Nursing Assistant D stated, They (Resident #703) has never had one on their chair. On 10/15/17 at 12:30 PM, record review of Resident #703's medical record did not reveal documentation of wound care notes with wound measurements and descriptions for all wounds. Review of Resident #703's care plans revealed an active care plan entitled, (Resident #703) has actual impairment to skin integrity r/t (related to) coccyx pressure injury and right heel blister. (Date Initiated: 5/4/17, Revised 10/10/17). Care plan interventions included: Observe location, size and treatment of [REDACTED]. Treatment to skin impairment per order. (Revised: 6/5/17) Apply PR (Pressure Reduction) cushion to protect skin while up in chair (Revised: 9/26/17) Apply PR hospice mattress to protect the skin while in bed. (Revised: 9/26/17) Ensure that properly fitted brief is worn. (Initiated: 6/5/17) Wound care following (Initiated: 7/14/17) On 10/15/17 at 1:00 PM, an interview was completed with the acting Director of Nursing (DON). When queried regarding Resident #703's pressure ulcer measurements and wound on the Resident's right heel, the DON replied, The wound care nurse is not here today but I will look through the documentation. The Resident's wound documentation was requested for review. Record review of Resident #703's Admission Assessment, dated 5/4/17, on 10/15/17 at 1:05 PM indicated the Resident had bruises on both their arms, scabs on their left shin, the big toe and second toe on their left foot and on their second toe on their right foot. The documentation revealed the Resident did not have a pressure ulcer when they were admitted to the facility. On 10/15/17 at 1:15 PM, observation occurred of Resident #703's wounds with Nurse E and Nurse F. Upon entering the room, the Resident was observed lying in their bed positioned on their back. Resident #703 was observed to have an opened area on their coccyx that was irregularly shaped and approximately the size of a half dollar. The wound bed was bright red in color with small amount of white tissue and unattached edges. The area surrounding the open pressure ulcer was deep red and purple in color and spanned across Resident #703's bilateral buttocks. Resident #703's right heel was observed to have a dark area and black in color. The area was in the shaped like a circle and approximately the size of a dime. The Resident was also observed to have scattered areas of scabbing along their right shin and an abrasion on their right elbow that was approximately the size of a half dollar, was slightly red in color and appeared to be raised and slightly swollen. When queried regarding the area on Resident #703's elbow, Nurse E stated, That happened a while ago. We put ice on it. It looks better. On 10/15/17 at 1:40 PM, Resident #703 was observed lying in their bed positioned slightly on their left side. A blue air cushion was observed sitting on the Resident's Geri-chair in their room. On 10/15/17 at 1:45 PM, an interview was conducted with Nurse E. When queried regarding the blue air cushion observed sitting on Resident #703's Geri-chair, Nurse E stated, I just put that in there. When queried further regarding why the Resident did not have a pressure reduction pad in place on their chair previously, Nurse E was unable to provide an explanation. On 10/15/17 at 2:20 PM, an interview was conducted with Nursing Assistant D. When queried regarding the blue air cushion observed sitting on Resident #703's Geri-chair, Nursing Assistant D replied, The nurse must have just put it on there. When asked how often the Resident sits in their wheelchair, Nursing Assistant D replied, Every day. We (staff) try to get them up for meals. When queried regarding how long the Resident is up in the chair at a time, Nursing Assistant D replied, It depends. With further inquiry, Nursing Assistant D replied, Between an hour to a few hours. Record review of Resident #703's pressure ulcer and wound documentation entitled Wound/Skin Healing Note occurred on 10/15/17 at 2:30 PM. Review revealed documentation of the following pressure ulcers, wounds, and locations: -Right Buttocks (Wound noted 5/25/17) -Penile Meatus Ulcer (Wound noted 6/2/17) -Left Buttocks Pressure Ulcer (Wound noted 7/19/17) -Right heel (Wound noted 9/19/17) -Coccyx Pressure Ulcer (Wound noted 9/19/17) Record review documentation authored by Nurse Practitioner P dated 7/26/17 revealed, (Resident #703) does have some breakdown running across from the gluteal fold across left buttock. The whole area measures 2.5 X 4.1 X 0.1. Scant amount of serosanguinous drainage . Assessments: Buttock wound, bilateral . Review of documentation authored by Nurse Practitioner P dated 9/6/17 revealed, The left buttocks has deteriorated . Left buttocks wound, total area open is 6.1 X 2.4. Scant amount of serosanguinous drainage. There is no [MEDICAL CONDITION] .Assessments: Buttock wound, bilateral . On 10/15/17 at 3:00 PM, an interview and record review was conducted with the acting DON. When queried if Resident #703's Right Buttocks wound first noted by the facility on 5/25/17, was a result of pressure and facility acquired, the acting DON reviewed the documentation and stated, The wound care nurse is not here but it appears so. Documentation dated 5/25/17 revealed the following: Wound noted on 5/25/17. The wound is as follows: Right buttock Length = 2.9 (centimeters -cm), width 1.2 cm, Depth = 0.1 cm, - Stage N/A . denuded macerated skin from multiple incontinence loose stools . Documentation indicated the wound was Healed on 7/5/17. When queried regarding the origin of the wound on Resident #703's penile meatus, first noted by the facility on 6/2/17, the acting DON reviewed wound documentation and stated, Good question. Record review with the acting DON revealed no documentation of wound size was present in Wound/Skin Healing Note documentation. The acting DON then reviewed nursing note documentation and stated, It looks like it was caused from the diaper rubbing. When queried if an ulcer caused by rubbing or friction would be considered a pressure ulcer, the acting DON replied, Yes. When queried regarding the lack of documentation of wound description and size, the acting DON was unable to provide an explanation. Review revealed a Wound/Skin Healing Note indicating the pressure ulcer was Healed on 6/14/17. When queried regarding the left buttocks pressure ulcer, first noted by the facility on 7/19/17, the acting DON reviewed Resident #703's medical record and stated, There is other documentation of it being on the sacrum and ether a Kennedy Ulcer (type of pressure ulcer characterized by rapid onset and rapid tissue breakdown, often seen at end of life) or deep tissue injury. Additional review of Wound/Skin Healing Note revealed the area was consistently documented as Left buttocks. With further inquiry regarding the classification and determination of the pressure ulcer, the acting DON stated, I guess it wasn't a Kennedy (ulcer). Review of wound measurements for left buttocks/sacrum pressure ulcer revealed the following measurements: -7/26/17: 2.5 cm X 4.1 cm X 0.1 cm, Stage N/A -8/2/17: 2.7 cm X 2.8 cm X 0.1 cm, Stage N/A -8/9/17: 1.8 cm X 2.1 cm X 0.1 cm, Stage N/A -8/16/17: 1.8 cm X 2.1 cm X 0.1 cm, Stage N/A -8/23/17: 1 cm X 0.5 cm X 0.1 cm, Stage N/A -8/30/17: 0.8 cm X 0.5 cm X 0.1 cm, Stage N/A -9/6/17: 6.1 cm X 2.4 cm X 0.1 cm, Stage N/A Documentation on 9/20/17 entitled, Wound/Skin Healing Note revealed a coccyx pressure ulcer first noted by the facility on 9/19/17. The note indicated, The wound is as follows: Coccyx- Pressure. Length = 6 (cm), Width = 3.4 (cm), Depth = 0.2 cm, Stage III. When queried, the acting DON stated, That was when they (Resident #703) returned from the hospital. (Resident #703 was discharged from the facility on 9/8/17 and readmitted on [DATE].) When asked if the coccyx pressure was the same pressure ulcer documented as both sacrum and left buttocks by facility staff, the acting DON replied, It could be. I have not seen it but the measurements make it seem like it. When queried regarding hospital documentation of the pressure ulcer, the acting DON reviewed Resident #703's medical record and stated, The only thing we have is the discharge (documentation) and they (hospital) labeled it as coccyx. When asked if the pressure ulcer would be considered facility acquired, the acting DON stated, I don't want to answer that but I guess it would be. Additional documentation review at this time revealed a Wound/Skin Healing Note dated 10/4/17, with the following, The wound is as follows: Coccyx- Pressure. Length = 6.9 (cm), Width = 2.2 (cm), Depth = 0.2 cm, Stage III. When queried if wound measurements were of the open area or of the entire discolored area, the acting DON stated, I can't get a hold of the wound care nurse to ask and I don't know. When queried how often wounds are supposed to be measured and have documentation per facility policy, the acting DON stated, Weekly. When asked about the lack of documentation for the week of 10/8/17 to 10/14/17, the acting DON was unable to provide an explanation. When queried regarding interventions in place to prevent the pressure ulcer from worsening, the acting DON stated, Treatments, repositioning, and pressure reduction devices. When queried if Resident #703 should have a pressure reduction device on their Geri-chair, the acting DON stated, Yes. When queried further regarding why the Resident did not have a pressure reduction pad on their chair until today, the acting DON was unable to provide an explanation. When queried regarding why Resident #703's MDS did not indicate they were on a Turning/repositioning program, the acting DON replied, Just because it isn't checked on the MDS doesn't mean we aren't doing it. When asked how often Resident's should be repositioned, the acting DON replied, I will have to check what the policy says. On 10/15/17 at 4:00 PM, Resident #703 was observed lying in bed in their room, positioned slightly on their left side. On 10/15/17 at 4:05 PM, an interview was completed with Nursing Assistant G and Nurse H. When queried regarding how often Resident #703 is repositioned when sitting up in their Geri-chair, Nursing Assistant G replied, (Resident #703) moves and slides down in the chair so we have to move them up. Nurse H then stated, That is why (the Resident) has the piece of dysem (thin, anti-slip product) on their chair. With further inquiry regarding scheduled repositioning of Residents that are sitting in chairs, Nursing Assistant G replied, No, we don't do it (reposition) at specific timeframes. Record review of facility policy entitled, Skin Management (Revised 8/2016) revealed, Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal Resident outcomes. The policy further revealed, The licensed nurse will initiate documentation in the electronic health record which includes a description of the pressure and non-pressure injury as follows . document weekly until the area is healed . Resident's with pressure injury will be assessed, measured, and staged weekly in accordance with the practice guidelines until healed.

Based on observation, interview and record review, the facility neglected to assess the appropriateness and obtain a physician's order for an unaccompanied leave of absence (LOA) from the facility for 1 (#711) of 6 residents reviewed for elopement risk from a total sample of 24 residents, when Resident #711 became frustrated and left the faciity on [DATE] via a motorized wheelchair in search of food, after the resident's meal tray did not arrive within 2 hours, and went 1/2 mile down the road, where the wheelchair became stuck in a crack in the sidewalk and the resident called 911 for help and was assisted back to the facility by the police. An Immediate Jeopardy arose when the resident asked the Administrator how to get out and the Administrator pointed to the front door and Resident #711 proceeded past the Administrator and exited the facility via the front door in a motorized wheelchair. The facility Identified Resident #711 with multiple comorbidities: recent hospitalization (8/6/17-8/11/17) with pneumonia and sepsis (a systemic blood stream infection), respiratory failure, metabolic [DIAGNOSES REDACTED], muscle weakness, [DIAGNOSES REDACTED], low back pain, diabetes and was ordered a mechanical soft diet, due to recent episodes of choking, but was allowed to leave the facility unaccompanied, resulting in the potential for serious harm,injury or death. The Administrator was notified on the Immediate Jeopardy (IJ) on 8/15/17 at 12:30 PM. A plan to remove the immediacy was requested. The IJ was identified on 8/14/17 at 1:00 PM. The IJ was removed on 8/15/17 based on the facility's implementation of the plan removal as verified onsite. Although the IJ was removed, the facility's deficient practice remains as isolated. No actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings Include: On 8/14/17 at 11:30 AM, record review revealed that Resident #711 was initially admitted into the facility on [DATE] and discharged to the hospital on [DATE], after having a choking episode, unstable vital signs and a mental status change. The resident was readmitted on [DATE], after receiving treatment for [REDACTED]. There was no Social Services assessment to evaluate the resident's cognitive function (Brief Interview for Mental Status-BIMS) or Nutrition assessment to address the resident's diet and recent choking episode. The assessments had not been completed from the time of initial admission on 8/4/17 to the present (8/14/17), after readmission on 8/11/17. There was no diet order in the electronic medical record. Review of the Nursing Comprehensive Evaluation, dated 8/11/17, indicated Resident #711 had weakness in both lower extremities and mild dyspnea (shortness of breath). The Nursing assessment also provided, Focus: (Resident #711) is at risk for respiratory distress and receives Oxygen Therapy related to COPD at 3 liters/minute. Intervention: Oxygen Settings: Resident has oxygen via nasal cannula @ 3 liters continuously humidified. Chewing and Swallowing difficulty. 2 person assistance with transfers, bed mobility, toileting and ambulation with device (wheelchair). Review of the Physician's Progress Notes, dated 8/11/17, indicated, .Is an elderly male patient who appears disheveled chronically ill-appearing. He is alert and oriented times 3. The physician made no indication the resident was medically stable to leave the facility on his own, without his oxygen. There were 2 conflicting orders in the electronic medical record (EMR) dated 8/11/17: May not go on leave of absence, and May go on leave of absence. The order not allowing leave was discontinued after the resident left the building on 8/14/17. As of 8/14/17 at 2:00 PM, there was no Care Plan for Nutrition, Social Services/cognitive abilities or the ability to leave the facility independently without supervision. The ADL care plan did not provide information on how much assistance the resident needed with ADL tasks. On 8/14/17 at 12:15 PM, Resident #711 was observed sitting in an electric wheel chair, in their room, wearing oxygen via nasal cannula from an oxygen concentrator. The resident was watching TV and stated, I ordered it (a lunch tray) at 11:00 am. It normally doesn't take this long. I just had therapy. At 3:10 PM on 8/14/17, the resident was observed looking disheveled, with their shorts positioned so high on the resident's leg, that it appeared they were not wearing any. The resident's incontinent brief appeared wet, dark yellow, grayish in color and hanging about 8 inches below the bottom of the shorts. The resident verbalized leaving the building about 2:00 PM and returning about 2:30 PM and was, Looking for something to eat .I told them I was going to leave if they did not bring my tray. They need to get it right. I'm not eating that crap (mechanically ground food). Resident #711 indicated feeling anxious and needed medication before being assisted by the CNA's with ADL (activities of daily living) care and toileting. The resident said they had not received toileting or ADL assistance since the morning between 6:00 am and 7:00 am. On 8/14/17 at 3:14 PM, CNA's F and G were queried if the resident left the building and CNA F stated, I was told (the resident) left the building. From my understanding (Resident #711) got stuck on the side of the road and had to call 911. When the CNA's were queried on the amount of assistance the resident needed with care, they indicated the resident needed, Extensive assistance with 2 persons. CNA F was asked how she would know that and she indicated it was on the Kardex (written care guide). When asked to see the Kardex, CNA F provided a visual of the Kardex on the EMR. It did not indicate how much assistance the resident needed. At 3:20 PM, on 8/14/17. Nurse W, stated, At 1:00 PM the nurse (Nurse I) was informed (the resident) left the building. The ambulance followed (the resident) back and (they) returned at 1:45 PM. A record review, on 8/14/17 at 3:30 PM indicated the following: Review of a Nursing note dated 8/6/17 at 3:34 PM, Nurse X wrote, the resident was observed, coughing forcefully, and complained of choking on the strawberry shortcake. Guest agreed to have (their) diet downgraded until (they) saw speech. Later that night, at 10:56 PM, the resident was sent to the hospital for unstable vital signs, with a heart rate of 104 beats per minute (high) and an oxygen saturation rate of 88% (low) with 4 liters of oxygen given via nasal cannula and a temperature of 103 (high) degrees Fahrenheit. The resident was readmitted to the facility on [DATE], after receiving treatment for [REDACTED]. There was no clarification in the electronic medical record (EMR) to indicate what diet the resident was currently receiving, as of 8/14/17. The physician progress notes [REDACTED]. A prior order initiated on 8/6/17 revealed, 2 gram sodium restricted diet, Level 3, Advanced (Mechanical Soft) texture, was discontinued on 8/11/17 at 11:15 am. An interview with Receptionist H, on 8/14/17 at 4:20 PM revealed she saw the resident in a motorized wheelchair coming towards the front door, from the hallway in front of the Administrators office and stated, Yes, (the resident) went out the front door about 1:00 PM. When the receptionist was queried if Resident #711 signed out at the reception desk, she indicated the resident should sign out at the Nurse's Desk. On 8/14/17 at 4:50 PM, the Director of Nursing (DON) was asked if Resident #711 had a Care Plan for Cognitive Status and the ability to take themselves out of the building independently. None were noted in the EMR. None were provided. At 4:54 PM, on 8/14/17, the Administrator was queried if Resident #711 had left the building unaccompanied and stated, Yes, (the resident) has a BIMS (Brief Interview for Mental Status score) of 15. He can choose whether (the resident) wants to leave or not. No BIMS score was present in the medical record. On 8/15/17 at 8:40 am, Resident #711 was interviewed and clarified what occurred on 8/14/17 when the resident left the building, I went to get some food that I could actually eat. No one would listen to me. I went right (out of the facility driveway) and didn't find a store. I went to the light (1/2 mile away from the facility). Resident #711 was queried if the resident signed in after returning to the facility, They asked me to sign a paper quite a while after I came back. It was after you saw me (3:10 PM on 8/14/17). The resident indicated they had oatmeal, eggs and a fruit cup for breakfast on 8/15/17 at 7:00 am and was pleased. Resident #711 also stated, I was going to let my daughter take over because I was feeling so strange. Resident #711 further provided, She (the one who runs the place) came in last night and asked me to stay. They told me I can't go to the store. They told me that last night after I came back. There are still things that I need from the dollar store. The following interviews were conducted on 8/15/17: 9:00 am: CNA B was queried if she knew whether the resident was able to leave the building on their own and stated, The nurse told me to sign (the resident) out, because (the resident) is able to go in and out. 1:40 PM: Dietitian C was queried about the nutritional plan for Resident #711 and stated, (The resident) is relatively new to us. I haven't met (the resident) yet and they do not have an assessment yet. When asked what the resident's diet was, Dietitian C responded, A Consistent Carbohydrate diet with regular texture. When queried on why the resident was receiving a mechanical ground diet,that was ordered on [DATE], prior to the hospital discharge, the dietitian responded, The 2 systems (EMR and Nutritional system) do not connect. The previous order reactivated. I did that (changed the order to a regular diet) yesterday morning. It wouldn't change until they printed a new sticker. We took the Regular diet order from the hospital orders. It sounds like it wasn't updated on the tray card. When queried if the resident had been assessed for the appropriate diet, Dietitian C replied, Not that I know of. I don't know if (the resident) would have a Care Plan yet. After the dietitian looked in the EMR, she responded, There is nothing in there yet. 1:50 PM: Certified Dietary Manager (CDM) D was queried on whether Resident #711 was receiving a mechanically ground diet and stated, Yes, this morning was the 1st day (the resident) got a regular diet. CDM D indicated the resident stated yesterday at lunch, When you get my diet right, send it to my room. On 8/16/17 at 9:50 am, the police department was contacted to obtain a copy of the police report from 8/14/17, when Resident #711 called 911 for assistance after leaving the facility. No report was received by the time of exit. On 8/16/17 at 11:50 am, Nurse I was queried on what occurred on 8/14/17 when Resident #711 left the building and stated, (The resident) was verbalizing that (they) wanted to leave and go to a restaurant nearby and get some fast food. When asked if the resident was receiving a mechanical ground diet, Nurse I replied, I would assume so yes. Only the Speech Therapist can change the diet. Nurse I was further queried if the resident signed themselves out prior to leaving the building, the nurse stated, (The resident) wasn't in the building. We got an OK from the Administrator to sign (the resident) out. At 11:08 am on 8/16/17, Speech Therapist E was asked if Resident #711 was assessed for swallowing ability and stated, No, the diet order was followed from the hospital discharge papers. The nurse should have put the order in. The resident should not have received a mechanical ground diet. On 8/16/17 at 2:55 PM, Social Worker Y was queried if the BIMS score, social services assessment and care plan were completed for Resident #711 and stated, I have 7 days to complete the BIMS score and social services assessment. The assessments were completed on 8/15/17, after the resident left the building. On 8/16/17 at 3:10 PM, a review of the facility policy titled, Resident Leave of Absence, dated 9/13 revealed, All residents leaving the facility on an extended leave must be signed out and have an appropriate physician order, They must have a doctor's order indicating that the resident is medically stable and able to go out on a leave, The sign-out register must indicate who is responsible for the resident while he or she is signed out, Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once, Resident's must be signed in upon return to the facility Element 1: Resident #711 resides at the facility he was initially admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. UNSPECIFIED(G82.20), EDEMA, UNSPECIFIED(R60.9), CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED(J44.9), TOBACCO USE(Z72.0), TYPE 2 DIABETES MELLITUS WITH DIABETIC NEUROPATHY, UNSPECIFIED(Ell.40), ESSENTIAL (PRIMARY) HYPERTENSION(IlO), [DIAGNOSES REDACTED], UNSPECIFIED(E78.5), UNSPECIFIED OSTEOARTHRITIS, UNSPECIFIED SITE(M19.90), METABOLIC [DIAGNOSES REDACTED](G93.41), VENOUS INSUFFICIENCY (CHRONIC) (PERIPHERAL) (I87.2), OTHER MALAISE(R53.81), LOW BACK PAIN(M54.5), SOLITARY PULMONARY NODULE(R91.1), DISEASE OF PANCREAS, UNSPECIFIED(K86. 9), OBESITY, UNSPECIFIED(E66.9), MUSCLE WEAKNESS (GENERALIZED)(M62.81), SEPSIS, UNSPECIFIED ORGANISM(A41.9), ACUTE AND CHRONIC RESPIRATORY FAILURE WITH HYPERCAPNIA(J96.22), ACUTE EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VEINS OF LOWER EXTREMITY, BILATERAL(I82.403), ANXIETY DISORDER, UNSPECIFIED(F41.9) Patient is a [AGE] year-old male who admitted to the hospital for increased confusion. During his hospitalization patient was found to have abnormal troponins as well as a pancreatic mass. Patient did not have any physical edema. During his hospitalization patient seen by cardiologist with GI medicine. In addition patient seen by urology secondary retention. Patient was discharged with a Foley catheter. Patient was seen by hematology oncology. Patient CT scan the abdomen did reveal pancreatic tail cystic mass highly suspicious for malignancy patient also had evidence of splenic vein thrombosis which is chronic in nature. Patient was treated medically for non-ST elevation microinfarction Patient stabilized and transferred to subacute rehab where he seen and examined. Admit Dx: Impaired mobility debility post hospitalization for metabolic [DIAGNOSES REDACTED] On the afternoon of 8 / 6 /17 while the guest was eating strawberry shortcake he began to forcefully cough and stating he was having a difficult time with swallowing. The nurse assessed and controlled the immediate situation than with a MD order to downgrade his diet was obtain with the permission of the guest until seen by the speech therapist. Later that night the guest started to have unstable vital and a mental status change. (HR 104; SP02 88%; TEMP 103) At this time the physician was immediately contacted and the decision was made to transfer the guest to Troy Beaumont Hospital for further evaluation. He was found to have sepsis secondary to healthcare associated pneumonia. He was started on IV antibiotic, IV fluid, he was stabilized and eventually transferred to subacute rehab to receive physical therapy and rehabilitation. On 8/11/2017 the guest was transferred back to the facility. A nursing comprehensive evaluation was conducted which included a mental assessment and an elopement risk assessment. He was noted to be alert and oriented to person, place, and time with a calm and cooperative demeanor. He was also noted not at risk for elopement. Physician orders were reviewed and the altered diet was continued until seen by a speech therapist. On the afternoon of 8/14/2017 at approximately 10:00 am our staff went to the guest room to take his lunch order. The facility orders are received starting at 10:00am. Lunch services starts at 11:30 am. At around approximately 11:30 am the guest began to complain to the nursing assistant that he has not received his meal. She than assisted him to the cafe. At approximately 12:00 pm the guest went to the cafe and received his meal. which was the mechanical soft. The guest became upset not wanting to eat this type of a diet. The culinary aide explained she needed to see the nurse to get a new diet plan. At this time he went to see the nurse regarding his diet. The nurse educated him she could not give the order to the culinary department until she spoken to the physician and the speech therapist for his safety. The nurse attempted to encourage him to wait while she verified the situation with the physician. The guest then stated he was going to leave the facility and go to a restaurant. The nurse encouraged the guest to allow her to help assist with ordering a delivery place. The guest continued to refuse and stated he was leaving. As the guest was approaching the front door in his motorized wheel chair, the administrator was passing by and he asked a direct question where the front door was located. The administrator did inform him of the location as she would to anyone asking a general question. At no time did the administered witness the guest exiting throw the front door. Approximately 10 minutes later the nurse instructed the nursing assistant to see if the guest left the facility. At that time it was verified with the receptionist that he did go on a LOA in his motorized wheel chair. The nurse than went to the facility administrator to report the LOA. The administrator than completed a brief chart review and identified he was alert and oriented and was in own responsible party. The administrator informed the nursing assistant to sign him out on the LOA form. Approximately 20 minutes later the administrator received a phone call from the police department informing her guest had his motorized wheelchair stuck in a crack in the side walk and that they were going to follow him back to the facility. Upon the guest return, the administrator spoke to the guest whom reported while on his LOA his wheel did get stuck in a crack in the side walk and he did not have our facility phone number to contact for help so he called 911. He reported the police came and freed his wheel and he returned. The nurse assessed him and did not find any harm or injury to the guest. He then proceeded to the cafe for lunch and his diet orders were clarified and adjusted. The therapy department assessed the safety of the motorized wheel chair including the ability to maneuver. All was deem appropriate.At approximately 5:00 pm the administrator followed up with the guest and the risk versus benefits of leaving without signing out was discussed. The resident agreed he would not leave again without signing out. At that time he was eating dinner calm stable mood with no negative outcomes observed or reported. The guest was asked to sign the LOA book both in and out. A further chart review was conducted and it was identified that the guest did have two conflicting orders for LOA. The physician was contacted for the nursing staff and orders were verified and updated. The social worker conducted a BIM's assessment (15); social service evaluation, and the social service history for the guest. On 8/15/2017 staff involved with his care on the dayshift of 8/14/2017 were interviewed. It was concluded he did inform both the nurse and the nursing assistant that he was going to out of the building to get something to eat. It was determined that he himself did not sign the LOA book and it was not offered for him to sign himself out. The Director of Nursing contacted the physician to reconfirm the guest was assessed on 8/11/2017 and was fully competent to make decision and was medically safe to leave the facility on a LOA. An incident and accident report was completed in regard to the wheel of the motorized wheel chair getting stuck in a crack in the sidewalk while on a LOA. The Medical Director was contacted in regards to the incident via phone. The facility conducted a QA meeting in relation to the occurrence. The Director of Nursing and the Regional Director of Operations met with the guest and received a verbal statement related to the incident on 8/14/17. The guest confirmed he did leave the facility to go to a restaurant. He did confirm he notified the nurse and the nursing assistant. He confirmed he did not sustain any injuries and there was no damage to his motorized chair. The motorized chair was inspected and determined to be functioning properly. The guest reports he has been using a motorized wheelchair for the last 8 years and frequently uses it in the community to get around. The guest stated I am only [AGE] years old and I can do what I want to do. Based on the chart review, interviews, observation, and policy review resident #711 did not elope from the facility but rather the LOA policy was not followed to its full intent. Element 2: Residents are those who are in the facility who require a proper leave of absence order in order to determine their status in relation to leaving the facility and proper signature for signing out and in or those who require wander guard placement based on the score of their elopement risk assessment. 1. Resident's physician orders were reviewed and updated if needed for LOA. 2. Residents at risk for elopement have been reviewed and ensured all necessary interventions are in place. Element 3: 1. The facility policy on Leave of Absence was reviewed and deemed appropriate on 8/15/17. 2. The facility policy on Elopement was reviewed and deemed appropriate on 8/15/17. 3. RN/LPN/CENA were reeducated on the Leave of Absence policy, including, but not limited to having an order for [REDACTED]. Facility staff were reeducated on verification of residents leaving the facility to ensure they signed out on the LOA book. The education began at approximately 3:00 pm on 8/15/17. Upon completion of the reeducation of the PM shift the education was ongoing and completed prior to the start of the employee shift. 4. The Administrator was reeducated on the LOA policy. 5. A poster was applied to the front entrance door reminding guest and visitors to sign in and out in the Leave of Absence book located at the nursing station. Element 4: Quality Assessment and Assurance 1. The DON/designee will conduct audits weekly x 4 and monthly x3 to ensure that residents have appropriate orders for LOA and have signed out/in in the LOA book. Results of the audits will be taken to the QA committee for review and recommendation. Any areas of non-compliance will be addressed immediately. The Administrator is responsible for attaining and sustaining compliance Date of compliant: 8/15/17