Every finding on record at Regency Manor Nursing & Rehabilitation Center

Based on interview and record review, the facility failed to ensure adequate supervision for one (R700) out of ten residents reviewed for accident hazards, resulting in hospitalization with a hematoma (pooling of blood after damage to the blood vessels) of the right forearm. Findings include:Review of an incident report dated 6/5/2026 revealed at approximately 8:25pm, Registered Nurse (RN) B was notified by another resident (R701) that R700 had left the facility. A search was conducted, and after approximately 15 minutes of searching the facility staff was notified by a neighbor that R700 had been found. R700 was subsequently returned to the facility via Emergency Medical Services (EMS). The incident report documented R700 told facility staff they had fallen, and that an assessment was performed on R700 with findings of a bruised right arm with intact skin and a small knot above their right eye. The physician was contacted and ordered R700 sent out to the hospital.Review of R700's electronic medical record (EMR) revealed they were admitted into the facility on 3/12/2026 with diagnoses of unspecified dementia and age-related physical debility. Review of R700's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating impaired cognition.On 7/2/2026 at 9:22AM, an interview was conducted with R701. R701 stated they had seen R700 trying to enter the door code to exit the building for a couple of minutes, and that after an unsuccessful attempt, R700 then entered in the correct number and left the building. R701 said they did not see any staff members nearby when this occurred.On 7/2/2026 at 10:06AM, an interview was conducted with the facility administrator. The administrator said R700 and R701 had been near the front door together, and R701 reported to the nurse R700 had left the building. The administrator confirmed after R700 was found, they were assessed and then sent to the hospital.Review of a nursing progress note dated 6/7/2026 revealed R700 was admitted to the hospital and had a hematoma to right forearm.Review of R700's care plan for falls initiated 3/26/26 and last revised 6/13/2026 revealed R700 is at risk for falls due to deconditioning, gait/balance problems, and vision/hearing problems, and noted they had a fall on 6/3/2026 and 6/5/2026.Review of a Fall Risk Evaluation progress note dated 6/3/2026 revealed R700 had a history of 3 or more falls within the last 3 months, as well as intermittent confusion and balance problems.Review of a facility policy titled Fall Prevention Program, implemented 11/1/2022 and last revised 6/5/2026, revealed Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

Based on observation, interview, and record review, the facility failed to ensure safe water temperatures to reduce the risk of severe burns, having the likelihood of affecting all 35 residents in the facility. Findings include: On 05/20/2026 at 8:56 a.m., hot water temperature was observed and recorded at 159 degrees Fahrenheit at the hand sink located in the physical therapy/conference room. The hand sink did not have a mixing valve installed. On 5/20/26 at 9:51 a.m., Unit Manager E was interviewed on the usage in the physical therapy/conference room, and she stated residents receive therapy and are weighed in there. On 5/20/26 at 10:42 a.m., interviewed Maintenance Manager F on what the hot water temperatures are set to, and he stated it's set to 135 degrees Fahrenheit. Maintenance Manager F returned to the conference/physical therapy room a few minutes later and stated the hot water temperatures are set to 120 degrees Fahrenheit. On 5/20/26 at 11:02 a.m., hot water tanks observed in the basement were set to level B, on a range from Hot, A, B, C, very hot. On 5/20/26 at 11:12 a.m., interviewed Maintenance Manager F on the hot water temperature ranges, and he said they should be around 115-120 degrees Fahrenheit. On 5/20/26 at 11:24 a.m. hot water temperature was recorded at 145 degrees Fahrenheit in room [ROOM NUMBER] at the bathroom hand sink. On 5/20/26 at 11:45 a.m. hot water temperature was recorded at 149 degrees Fahrenheit at the hand sink in physical therapy/conference room. On 5/20/26 at 11:59 a.m. upon record review it was revealed that Resident #16 who resides in room [ROOM NUMBER] is ambulatory, has a BIMS of 5, and has a diagnosis of dementia. On 5/20/26 at 12:30 p.m., interviewed Assistant Regional Director of Therapy G on how often residents have physical therapy. She stated usually 3 times a week in either the mornings or afternoons. When asked if R16 received physical therapy, she stated the resident just started therapy. A review of the facility's policy on safe water temperatures revealed the following, Water temperatures will be set to a temperature of no more than 120 degrees F (48.88 degrees C), or the state's allowable maximum water temperature . Record review of census data report found that R16 is one of four residents who receives therapy three times a week daily for eight weeks. Record review of R16's occupational therapy treatment states therapy may include therapeutic exercises, neuromuscular reeducation, occupational therapy evaluation therapeutic activities, self-care management training and wheelchair management training. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Install thermostatic mixing valves as close as possible to fixtures. This will prevent scalding while permitting circulating hot water temperatures above 120 degrees F (49 degrees C). The immediate jeopardy began on 5/20/2026 when the facility failed to ensure safe hot water temperatures. Acting Director of Nursing (DON) was notified of the immediate jeopardy on 5/20/26 at 3:02 PM. The surveyor confirmed by observation, interview, and record review that the immediate jeopardy was removed on 5/21/2026, but noncompliance remains at no actual harm with potential for more than minimal harm that is not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. The immediate jeopardy that began on 5/20/2026 was removed on 5/21/2026 when the facility took the following actions to remove the immediacy. The water temperatures were immediately tested and adjusted in rooms [ROOM NUMBER]. All the resident's rooms, showers, bathrooms and all running water were tested and adjusted. The water temperatures ranged from 108-115 degrees. Nursing staff immediately did skin assessments on all the residents inside the facility. Maintenance shut the water off to sinks in rooms 15, 16, 17, 18, and 19. On 5/20/26 at 9:20 a.m., hot water temperature was recorded at 140 degrees Fahrenheit in room [ROOM NUMBER], then gradually lowered to 128 degrees Fahrenheit. On 5/20/26 at 9:29 a.m., hot water temperatures were recorded at 130 degrees Fahrenheit, then gradually decreased to 122 degrees Fahrenheit at the hand sink located in the shower room in the main hall. On 5/20/26 at 11:12 a.m., hot water temperature was recorded at 124 degrees Fahrenheit in room [ROOM NUMBER] at the hand sink. On 5/20/26 at 12:58 a.m., hot water temperature was recorded at 130 degrees Fahrenheit at the hand sink in room [ROOM NUMBER]. On 05/21/26 at 6:00 AM, the water temperature in the central/main hall bath maxed out at 128.0 degrees Fahrenheit after three minutes, then went down to 120.0 degrees Fahrenheit. On 5/21/26 at 6:15 AM, the water temperature at the sink in the shared bathroom between rooms 15/16 maxed out at 149.7 degrees Fahrenheit after one minute, then went down to 130.1 degrees Fahrenheit after three minutes and remained at 130.0 degrees Fahrenheit at five minutes. On 5/21/26 at 6:37 AM, a recheck of the shared bathroom for rooms 15/16, maxed out at 146 degrees Fahrenheit after two minutes and remained at 130.0 degrees Fahrenheit after three minutes. On 5/21/26 at 6:45 AM, the water temperature at the sink in the shared bathroom between rooms 17/18 maxed out at 150.1 degrees Fahrenheit after two minutes, and sustained 132.0 degrees Fahrenheit after three minutes, and 131.1 degrees Fahrenheit after five minutes. On 05/21/2026 at 6:57 AM, the acting Director of Nursing (DON) was notified of the high out of range water temperatures at water faucets in the shared bathrooms between rooms 15/16 and 17/18. On 5/21/26 at 9:30 AM, the hot water temperature in the bathroom hand sink in room [ROOM NUMBER] was measured to be 125 degrees Fahrenheit. On 5/21/26 at 9:40 AM, Maintenance Manager F was queried regarding how often the facility monitors the hot water temperatures in the building. Maintenance Manager F stated that the hot water temperatures are checked on a weekly basis. The hot water temperature logs were requested at that time. On 5/21/26 at 10:00 AM, review of the Weekly water temperature logs revealed that the last documented hot water temperatures had been done on 4/16/26. When queried at that time if there were any more recently documented hot water temperatures, Maintenance Manager F stated he did not know.

Based on interview and record review, the facility failed to have documented Registered Nurse (RN) coverage scheduled for at least eight consecutive hours, per day for seven days a week. Findings include:During the Staffing Task of the survey, a request was made to review six months of Daily Staffing Census/Postings. The daily postings that were provided revealed dates that did not indicate eight consecutive hours of RN coverage on the following dates 3/5, 3/6, 3/7, 3/8, 3/28, 3/29, 3/31, 4/14, 4/21, 4/24, and 4/28/2026.On 5/21/2026 at 3:12 PM, the Acting Nursing Home Administrator (ANHA) was asked if there were any other documentation that could be reviewed for RN coverage. The ANHA reported there were no other documents to provide.The facility did not provide a policy to address the above concern by the end of the survey.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 5/20/26 at 9:00 AM observed the following on a tour of the basement level kitchen with dietary supervisor (DS) B:The low temperature dish machine was operating with no chlorine detected by a test strip. DS B indicated that the chlorine supply was just changed but no chlorine was being dispensed. DS B indicated she was unsure of how to prime the pump and would follow up with a service technician by phone. DS B set up and tested quaternary sanitizer in the 3-compartment sink and indicated they would use that as a sanitize step for all cleaned equipment until the automatic dish machine was properly dispensing sanitizer. According to the 2022 FDA Food Code section 4-501.15 Warewashing Machines, Manufacturers' Operating Instructions. (A) A WAREWASHING machine and its auxiliary components shall be operated in accordance with the machine's data plate and other manufacturer's instructions.The dumbwaiter lift used to convey food carts between floors was soiled with an accumulation of debris and dirt build up. When asked about cleaning of this area, DS B said she was aware it needed more frequent cleaning. According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. Two clean equipment storage units were observed with shelves covered in aluminum foil. When queried, DS B said it was to provide a clean surface to store equipment because there is rust build up on the surfaces and they are no longer easily cleanable.According to the 2022 FDA Food Code section 4-202.16 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.On 5/20/26 at 11:45 AM, the ice machine in the main level hydration/supply room was observed with the water drip panel soiled with accumulation of a black mold-like substance. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch.A facility policy regarding kitchen/dietary equipment maintenance was requested but not provided for review by survey exit.

Based on observation and interview, the facility failed to properly dispose of waste and maintain the dumpster area to mitigate the presence of pests, potentially affecting all residents in the facility. Findings include:On 5/20/26 at 2:00 PM, the outdoor garbage enclosure was observed with the side door open, squirrels exited the dumpster on approach, and debris covered the ground throughout the enclosure (e.g. used gloves, food packaging, and bags of garbage). At the back side of the garbage enclosure a collapsing shed was full of debris.When queried at this time, the regional maintenance director (RMD) C and regional maintenance staff member D acknowledged the debris and need for removal and clean up. RMD C said the damaged shed was planned for demolition and removal. A facility policy regarding garbage removal was requested but not provided for review by survey exit.

Based on observation and interview, the facility failed to maintain cleanliness and ensure appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for the spread of pathogens and contamination to the water supply, affecting all 35 residents residing in the facility. Findings include: On 05/20/26 at 9:17 AM, in room [ROOM NUMBER], the sleeping area of the mattress for bed D was observed to be faded and worn with a tan and orange color verses the dark blue of the sides. The closet had three clear bags of clothes and more in a teal laundry basket on the floor. On 5/20/26 at 1:30 PM, a community bathroom used by the residents at the facility was observed with toilet paper on the floor which had a brownish substance on it. The toilet was observed to have urine in it and there were multiple sheets of damp paper towel on the floor. On 5/21/26 at 8:05 AM, an observation was made of the same bathroom having a brownish dirt-like substance on the floor in the shape of shoe prints. On 5/21/26 at 11:49 AM, an interview was conducted with Housekeeping Supervisor (HS) A and they were asked about observations made of the community bathroom used by the residents being dirty. HS A indicated that the housekeeper had probably not gotten to it. HS A indicated that the bathroom should be cleaned and remain clean on a consistent basis. HS A was asked about a housekeeping schedule and if a log was completed when things were cleaned. HS A indicated that they had no documentation related to that. On 5/21/26 at 1:34 PM, the Acting Director of Nursing (ADN) was interviewed regarding observations made of the community bathroom used by the residents being dirty. The ADN indicated that the bathroom should be monitored throughout the day and cleaned as needed. On 5/20/2026 at 11:45 AM, the main floor utility sink in the janitor closet was observed connected directly to the chemical dispensing system without a required backflow protection device installed at the faucet. On 5/21/26 at 10:51 AM, a facility policy regarding Cleaning and Environment was requested and not received by survey exit.

Based on observation, interview and record review the facility failed to develop a care plan that addressed the complete care needs and behaviors of the residents for three residents (R13, R15, R34) of 12 sampled residents whose care plans were reviewed. Findings include:R13 On 05/20/26 at 9:30 AM, R13 was observed lying on their back with their eyes closed in the bed. A review of R13's medical record revealed that they were admitted into the facility on 2/12/26 with diagnoses of Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side; Dysphagia; and Hypertension. A review of 13's Brief Interview for Mental Status assessment score was a 00 indicating severely cognitively impaired cognition. Further review of the medical record revealed that R13 had been referred to restorative therapy for three times a week for twelve weeks on 2/18/26. There was no care plan or records found for restorative treatments. On 05/21/2026 at 11:20 AM, Social Worker J was asked about the care plans not being available in the chart for R13. SW J stated there was a recent transition in systems and the care plan may not have been carried over. On 05/21/26 at 2:30 PM, the Acting Director of Nursing reported they were unaware R13 was receiving restorative services. R15 On 05/20/26 at 9:45 AM, R15 was observed lying in bed looking at a magazine. R15 stated they were concerned about their care and wanted to go home. On 05/21/26 at 9:25 AM, R15 was observed refusing medication from nurse in their room staying the medications do not help them anymore. A review of R15's medical record revealed they were admitted into the facility on 2/05/25 with diagnoses of Cerebral infarction; Benign prostatic hyperplasia; and adjustment disorder with mixed disturbance of emotions and conduct. Further review revealed R15 was cognitively intact. Further review of the medical record revealed R15 refused medications daily for several months. A review of R15's care plans did not reveal a care plan with a focus on refusal of care. A policy related to care planning for residents was requested on 05/21/26 at 2:30 PM but not provided prior to survey exit. R34 On 05/20/2026 at 3:16 PM, a review of the facility provided list of smokers identified R34 as a resident who smoked. On 05/21/2026 at 8:26 AM, the Social Worker reported R34 as a resident who they had seen smoking. On 05/21/26 at 1:05 PM, R34 was observed on the patio outside the dining room smoking. A review of the electronic medical record for R34 revealed R34 was admitted into the facility on [DATE] and readmitted on [DATE]. R34's diagnoses included Diabetes and High Blood Pressure. A review of the active care plan revealed no care plan related to R34's smoking. On 05/21/26 at 3:24 PM, the acting Director of Nursing reported a smoking care plan should be in R34's plan of care. A copy of the smoking care plan was requested but not received prior to survey exit.

Based on observation, interview, and record review, the facility failed to ensure, medication and biologicals were discarded when expired and dated when opened in two of two medication carts and one of one medication rooms remained locked when not in use. Findings include: On [DATE] at 5:50 AM, in the high medication cart, a bottle of vitamin D was found with an expiration date of 05/2025. A container of glucose strips was not dated when opened. On [DATE] at 9:10 AM, in the low medication cart an umeclidinium 0.0625 mg (milligram) dry powder inhaler was not dated when opened on the box nor on the inhaler. On [DATE] at 9:42 AM, in the medication room refrigerator a tuberculin vial was dated opened [DATE] and expired. The door to the medication room was not latched and opened without the need to turn the handle or use a key. Licensed Practical Nurse (LPN) H reported the door to the medication room was supposed to be closed. At 12:50 PM and 2:24 PM the door to the medication room was not latched and closed. On [DATE] at 1:49 PM, tuberculin vial storage was reviewed on the World Health Organization (WHO) website and revealed, An opened tuberculin (PPD) vial must be discarded 30 days after opening, or by the manufacturer's expiration date, whichever comes first. Key Guidelines for Opened Tuberculin Discard Timeline: Once a tuberculin vial is punctured or opened, it should be used within 30 days. If the vial fluid changes color or the manufacturer's expiration date is reached before 30 days, it must be discarded immediately.On [DATE] at 3:08 PM, the identified medication storage concerns were reviewed with the Acting Director of Nursing (DON). The DON reported the tuberculin vial was good for thirty days after opening; The inhaler should have been dated when opened and the door to the medication room should be latched and locked.A policy related to medication storage and labeling was requested on [DATE] at 2:28 PM but not received prior to survey exit.

This citation pertains to Intake 2966095. Based on observation, interview, and record review, the facility failed to implement and document a restorative exercise program for two residents (R13, R31) of three residents reviewed for restorative needs. Findings include: R13 On 05/20/26 at 9:30 AM, R13 was observed lying on their back with their eyes closed in the bed. A review of R13's medical record revealed that they were admitted into the facility on 2/12/26 with diagnoses of Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side and Hypertension. A review of 13's Brief Interview for Mental Status assessment score was a 00 indicating severely cognitively impaired cognition. Further review of the medical record revealed R13 had been referred to restorative therapy for three times a week for twelve weeks on 2/18/26. There was no documentation found for restorative treatments. On 05/21/2026 at 11:30 AM, Restorative Aide I reported R13 had not been on their caseload nor received restorative services. On 05/21/26 at 2:30 PM, the Acting Director of Nursing reported they were unaware R13 was supposed to be on restorative caseload. R31 On 05/20/2026 at 9:17 AM, R31 was observed to be in bed. R31 was leaned over at the left edge of the bed. R31 reported they had a stroke about two years ago with the right side affected. The resident reported they had therapy but was not currently on therapy case load and was not on a restorative program. At 1:03 PM, R31 continued to lean toward the left side of bed as before. The resident was feeding themself from a tray at the left side of the bed. A review of the physical therapy evaluation dated 02/17/26 documented the right and left upper extremity strength as impaired' recommend (Restorative Nursing Program) RNP to maintain (Range of Motion) ROM and ms (muscle) strength. An occupational therapy evaluation dated 02/18/26 documented the right and left lower extremity strength as impaired, sitting during activities of daily living as poor and in need of assistance to feed themself. A review of the document titled Restorative Care Program dated 02/18/26 revealed Goals for Restorative Program: To maintain (Range of Motion) ROM and (Muscle) MS strength on (bilateral) B (lower extremity) LE and (upper extremity) UE. Approach/Recommendations for implementation for above goals: (Active) AAROM exercise and AROM exercise on B LE and UE for 15 reps (repetitions) times two (sets). Frequency - Three times a week times twelve weeks. A review of the electronic medical record (EMR) for R31 under the tasks tab revealed no current or cancelled restorative program or notes. A review of the EMR revealed R31 was admitted in the facility 02/13/26. R31's diagnoses include Right Side Paralysis, High Blood Pressure and Depression. The Minimum Data Set (MDS) dated [DATE] indicated intact cognition and the need for substantial/maximal assistance for bed mobility, rolling left to right in bed and dependent for most Activities of Daily Living (ADLs) except eating. A review of the active care plan and the stroke care plan initiated 02/23/26 and revised 05/20/26 revealed no interventions or revisions for restorative services or range of motion exercises. On 05/21/2026 at 2:18 PM, Restorative Aide I reported they were not able to do much restorative lately because they have been short staffed and work in many roles. The aide further reported they had not documented the restorative services provided to residents and had not spoken with the DON or Administrator about it. On 05/21/26 at 3:08 PM, the Acting Director of Nursing reported restorative services should be provided as recommended by the therapy department and documented. The Acting DON reported they had only the one restorative aide who performed multiple tasks and roles which included supply. A policy related to the positioning of dependent residents was requested on 05/21/26 at 2:28 PM but not provided prior to survey exit. A restorative policy was not provided.

This citation pertains to Intake number 3008091. Based on observation and interview, the facility failed to ensure an adequate supply of towels potentially affecting all 35 residents residing in the facility. Findings include: A complaint submitted to the State Agency (SA) revealed the following, No linens (towels) until late afternoon to change (the residents) .only one washing machine works .they expect the workers to use rags .to clean patients .hospice nurse could not care for patient due to lack of linens . On 05/20/2026 at 10:51 AM, Certified Nursing Assistant (CNA) K reported the supply of towels had run short off and on. At 10:53 AM, two towels were observed in the high side unit linen cart. On 5/21/26 at 11:00 AM, the facility linen closet was observed to be empty of towels. On 5/21/26 at 11:10 AM, Housekeeping Supervisor (HS) A was asked about the lack of towels in the linen closet and proceeded to accompany the surveyor up to the second floor of the facility into one of the offices and indicated extra towels and other linen were stored in that room. Observation was made of five towels available. HS A indicated the facility was waiting on additional clean towels from a laundry drop off from a sister facility. At 11:26 AM, HS A further indicated both washers at the facility were not operating and laundry was sent out approximately three times per week to a sister facility to be washed. HS A confirmed they were unsure of the number of towels (and other linens) sent out and returned when laundered. On 5/21/26 at 1:34 PM, the Acting Director of Nursing (ADN) was interviewed and asked about the lack of towels and confirmed both facility washing machines were offline. The ADN indicated their expectation was for all residents to have towels as needed. On 5/21/26 at 8:29 AM, a laundry policy was requested but not received by survey exit.

Based on interview and record review, the facility failed to provide Advance Beneficiary Notice of Non-coverage (SNF ABN) and Notice of Medicare Non-coverage (NOMNC), at least 48 hours (two days) before the end of coverage for one resident (R34) of three reviewed for Beneficiary notice, Findings include: A review of the facility's list of residents that had been discharged in the last 60 days from Medicare coverage revealed one resident (R34).A review of R34's NOMNC coverage form noted, therapy services to end on 4/4/26. The form revealed, R34 signed the form on 4/3/26, one day prior to therapy services to end. A review of R34's SNF/ABN form was also noted to be signed on 4/3/26 for the cost to continue therapy services at the facility.On 5/21/2026 at 2:27 PM, R34 was asked if they were aware the form was supposed to be given at least two days ahead of the coverage ending and said they had been signing a lot of papers, and their memory is not as good as it used to be.A review of R34's medical record noted R34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Osteomyelitis, Left Ankle and Foot. A review of R34's Minimum Data Set (MDS) assessment noted R34 with intact cognition. On 5/21/2026 at 3:30 PM, the Business Office Staff (Staff L) was asked about the delivery of the coverage forms. Staff L reported they were notified on 4/2/26 via email by the corporate office that R34's coverage was ending. Staff L continued and explained they then delivered the forms to R34 on 4/3/26 confirming they understood the notice to be done at least two days ahead of the coverage ending. At that time a verbal request was made for Staff L to provide a facility policy to address the above concern regarding delivery notice of the Medicare coverage ending. A policy was not provided by the end of the survey.

Based on observation, interview, and record review, the facility failed to maintain a home-like environment free of offensive odors. This deficient practice had the potential to affect all residents, staff, and visitors. Findings include:On 7/15/25 at 9:00 AM, there was a strong odor of urine upon entry into the facility. The urine odor persisted on the ramp leading to the upper level and was evident in the hallway leading to the resident rooms. All hallways throughout the facility were observed to be carpeted. On 7/15/25 at 11:00 AM, the urine odor was still present throughout the facility. On 7/16/25 at 10:00 AM, pervasive urine odors remained throughout facility. On 7/16/25 at11:20 AM, Maintenance Supervisor F was queried regarding the schedule for cleaning the carpets. Maintenance Supervisor F stated he was unsure, but that he would ask his boss. After speaking with corporate staff, Maintenance Supervisor F stated that carpets are cleaned every 6 months by an outside company, and that they are probably about due to be done again. When asked for documentation or an invoice for the last carpet cleaning, Maintenance Supervisor F stated there was no documentation of when it was last done. A policy for cleaning the carpets and maintaining a home-like environment was requested but was not provided by the end of the survey.

Based on interview and record review, the facility failed to maintain monthly medication regimen review (MRR) documentation (Pharmacy reviews) for nine residents (R6, R7, R11, R14, R25, R26, R32, R33 and R37) of nine reviewed for pharmacy medication review. Findings include: R37 A review of the record for R37 revealed R37 was admitted into the facility on [DATE]. Diagnoses included Anxiety, Depression, Diabetes, and Stroke. A review of the electronic medical record revealed no documentation of Medication Regimen Reviews by the pharmacist in the last 12 months. A review of the active Medication Administration Record (MAR) for July 2025 revealed 13 medications were administered daily. R37’s medications included daily antiseizure and antipsychotic medication. R33 A review of the record for R33 revealed R33 was admitted into the facility on [DATE]. Diagnoses included Schizoaffective disorder, Bipolar, Depression, and Hypertension. A review of the electronic medical records revealed no documentation of Medication Regimen Reviews by the pharmacist in the last 12 months. A review of the active Medication Administration Review (MAR) for July 2025 revealed that 12 medications were administered daily. R33's medications included daily high blood pressure and antipsychotic medication. R 6 A review of the record for R6 revealed R6 was admitted into the facility on [DATE]. Diagnoses included Schizophrenia, Anxiety, Depression, Bipolar, and Diabetes. A review of the electronic medical record revealed no documentation of Medication Regimen Reviews by the pharmacist in the last 12 months. A review of the active medication Administration Record (MAR) for July 2025 revealed nine medications were administered daily. R6's medications included daily antipsychotic and high blood pressure medication. R25 A review of the record for R25 revealed R25 was admitted into the facility on [DATE]. Diagnoses included Schizoaffective, Bipolar, Parkinsonism, and Diabetes. A review of the electronic medical record revealed no documentation of Medication Regimen Reviews by the pharmacist in the last 12 months. A review of the active Medication Administration Record (MAR) for July revealed thirteen medications were administered daily. R25's medications included daily antiseizure and antipsychotic medications. On 07/16/2025 at 12:02 PM, the MRR's for R6, R7, R11, R14, R33, R25, and R37 were requested from Staff E identified as the Infection Control preventionist and corporate consultant. Staff E reported they may have not been scanned into the medical record and would look into it. No MRR's had been uploaded into the electronic medical record or received prior to survey exit. R7 A review of the record for R7 revealed R7 was admitted into the facility on [DATE]. Diagnoses included Dementia, Irregular Heartbeat and Lung Disease. A review of the electronic medical record revealed no documentation of Medication Regimen Reviews by the pharmacist in the last 12 months. A review of the active Medication Administration Record (MAR) for July 2025 revealed six medications were administered daily. R7's medications included daily opioids and antiseizure medication. R11 A review of the record for R11 revealed R11 was admitted into the facility on [DATE]. Diagnoses included Anxiety, Heart Disease, Lung Disease and High Blood Pressure. A review of the electronic medical record revealed no documentation of Medication Regimen Reviews by the pharmacist in the last 12 months. A review of the active Medication Administration Record (MAR) for July 2025 revealed eighteen medications were administered daily. R11 also received an opioid 16 times and a muscle relaxant four times. R14 A review of the record for R14 revealed R14 was admitted into the facility on [DATE]. Diagnoses included Dementia, Anxiety, Diabetes and High Blood Pressure. A review of the electronic medical record revealed no documentation of Medication Regimen Reviews by the pharmacist since admission. A review of the active Medication Administration Record (MAR) for July 2025 revealed eleven medications were administered daily. R14's medication included antipsychotics and insulin. R32 A review of R32's electronic medical record (EMR) revealed that R32 was admitted to the facility on [DATE] with diagnoses that included Schizophrenia and Generalized Anxiety Disorder. R32's most recent minimum data set assessment (MDS) dated [DATE] revealed that R32 had an intact cognition and required assistance with all activities of daily living (ADLs) other than eating. Further review of R32's EMR revealed that the resident was prescribed the following psychotropic medications, Mirtazapine 7.5 mg. (milligrams), Olanzapine 7.5 mg, and Buspirone 15 mg twice daily. No medication MRR documentation was located in R32's EMR. A review of R32's care plan revealed the following, Problem: Start Date: 12/31/2024. Category: Psychotropic Drug Use. Problem: I receive antianxiety medication R/T (Related to) generalized anxiety disorder. Target Date: 06/20/2025. Goal: I will not exhibit drowsiness/oversedation, delayed reaction, imp (Impaired) cognition/behavior .Approach: Monitor for drug use effectiveness and adverse consequences. On 7/16/25 at 12:14 PM, R32’s MRR documentation for the past 12 months was requested and not received by the end of the survey. On 7/16/25 at 1:00 PM, the Administrator (NHA) was interviewed regarding their expectations for the implementation of the MRR process. The NHA indicated that MRRs should be received from the pharmacy, nurses are to scan it and enter it into the EMR, nurses are to contact the physician, following the physician signature, they should be faxed to the pharmacy. R26 A review of R26's medical record revealed they were admitted into the facility on 4/17/25 with diagnoses of dementia, mood disorder due to known physiological condition with mixed features, adjustment disorder with mixed anxiety and depressed mood. Further review revealed the resident had a severe cognitive impairment and required extensive assistance for Activities of Daily Living. Further review of R26's medical record revealed the resident was prescribed the following psychotropic medications, Escitalopram Oxalate (Lexapro) 20 mg (milligrams), Olanzapine (Zyprexa) 15mg, Xanax 0.5 mg, and Trazadone 5mg. A review of R26’s care plan revealed the following, “Problem: Problem Start Date: 04/28/2022. Category: Psychotropic Drug Use. [R26] is at risk for adverse consequence R/T (related to) receiving antipsychotic medication for treatment of schizoaffective disorder, bipolar type… Approach. Approach Start Date: 04/28/2022…Pharmacy consultant review….” On 7/16/25 at 9:31 AM, a request for R26’s medication regimen reviews were requested for the last 12 months and were not received by the end of the survey. A review of the facility policy titled, Pharmacy Services revised 03/04/25, revealed It is the policy of this facility to ensure that pharmaceutical services whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice.

Based on observation, interview, and record review, the facility failed to ensure resident food items brought in from outside were dated and failed to monitor the temperature of the resident refrigerator. This deficient practice had the potential to affect all residents that consume food. Findings include:On 7/15/25 at 10:00 AM, the resident refrigerator located in the break room was observed. There was no thermometer observed inside the refrigerator, and the temperature log located on the side of the refrigerator was last updated on 6/26/25. In addition, there were 3 undated food containers in the refrigerator. On 7/16/25 at 11:00 AM, Dietary Manager G was queried about the resident refrigerator and stated that she used to be responsible for monitoring that refrigerator, but that housekeeping is now responsible. On 7/16/25 at 11:15 AM, Dietary Manager G stated that she found the refrigerator thermometer buried underneath some food containers and confirmed that the temperature log was not up to date. According to the policy Use and Storage of Food Brought in by Family or Visitors revised 1/5/25 noted: 2. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated.

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP) and failed to ensure nursing staff used appropriate Personal Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all 37 the residents in the facility. Findings include: On 7/16/25 at 10:00 AM, the facility's Water Management Plan (WMP) was requested from the Administrator. The Administrator provided the following policies for the WMP: Legionella Surveillance revised 1/5/25 which noted: It is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections .2. In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies. A second undated document provided labeled Water Management Program, was noted to be a template. There were numerous places in the policy which noted List name of facility. The template had not been revised to be specific to the facility. The facility was missing the following components of a water management plan: There was no diagram of the building water system, and no text description of the water system. There was no risk assessment. There were no identified areas where Legionella could grow and spread. There were no listed control points, measures and limits. There was no evidence of control point monitoring. There was no evidence that the water management team was meeting routinely. On 7/16/25 at 8:45 AM, the Administrator was queried about the provided Water Management Program which was a template and not specific to this facility and stated, We can fill that out and give you the correct copy. On 7/16/25 at 9:15 AM, the Maintenance Supervisor F was queried about his involvement in the water management program. Maintenance Supervisor F stated that he has been in this building for a month, and that no one has talked to him about the WMP. On 7/16/25 at 9:30 AM, the Infection Preventionist (IP) E was queried about her involvement in the WMP. IP E stated she has been the Infection Preventionist for about 2 months. IP E stated they did review the policy for WMP last month during QA but couldn't provide any further information. When queried about the primary prevention strategies listed in the Legionella Surveillance policy, IP E stated she was unsure of what that means. On 7/16/2025 at 11:30 AM, Licensed Practical Nurse (LPN) “A” entered R7’s room to check the placement of a feeding tube. An EBP warning sign was located on the wall to the right of the door which indicated a gown, gloves and mask were required for high contact activities including tube feeding. A caddy with gown, gloves and masks were hanging next to the sign. LPN “A” did not put on a gown, mask, or protective eye wear. An inquiry to LPN “A” regarding what PPE was required for EBP, LPN “A” acknowledged they did not know there was a sign which indicated R7 was on EBP. LPN “A” indicated PPE should be worn when changing briefs. An inquiry was made to LPN A was asked if tube feeding placement checks required a gown and gloves. LPN “A” answered, I guess I am not sure. On 7/16/2025 at 11:45 AM, an interview with Unit Manager (UM) “A” reported upon the expectation is staff will know where the precaution signs are and be able to identify which PPE should be worn. On 7/16/25 at 1:30 PM, Nursing Home Administrator/Director of Nursing (NHA/DON) revealed that PPE should be worn when providing high-contact activities to protect staff and residents from infection control issues.

Based on interview and record review the facility failed to provide eight hours of Registered Nurse (RN) coverage potentially affecting all 37 residents residing in the facility. Findings include:Review of the Daily Staff Postings for May 27 through May 30th, 2025, revealed May 27 did not have 8 hours of 24 hours of Registered Nurse (RN) coverage. Review of the Daily Staff Postings for June 1st through June 30th, 2025, RN coverage was missing 13 days of 30 days for that month. Review of Daily Staff Postings for July 1st through July 10th, 2025, RN coverage was missing two of 10 days for that month. On 7/16/25 at 1:20 PM, Timecard Reports were requested, but no other information was provided by the end of the survey.On 7/16/2025 at 1:30 PM, the Director of Nursing (DON) who was also the Nursing Home Administrator (DON/NHA) revealed they shared responsibility for ensuring there was 8 hours in 24 hours of RN coverage with Unit Manager (UM) Registered Nurse A. The NHA/DON further revealed there was difficulty filling and maintaining stable staffing and there were many call-ins. Documentation of staffing policies and RN coverage by the DON and UM A was requested but not received prior to survey exit.

Based on observation, interview and record review the facility failed to ensure that two of eight multi-use, single resident medications were labeled with an open date in one of two medication carts. Findings Include:On 7/16/2025 at 11:30 AM, the South medication cart was reviewed with Licensed Practical Nurse (LPN) B and revealed two ophthalmic (eye) preparations (Restasis and Atropine Sulfate) that were opened without open dates. LPN B revealed any medications for single patient use should include the resident name and date opened.At 11:45 AM, Unit Manager (UM) A was queried regarding the expectations regarding when medications should be date and confirmed, labeled medications for a single resident, should be dated when opened.At 1:30 PM, The Director of Nursing (DON) confirmed multi-use medications for single patient use should be dated when opened.On 7/16/2025 at 1:30 PM, a policy regarding medication storage and labeling was requested and was not received by the end of survey.

This citation pertains to Intake MI00152611. Based on observation, interview, and record review, the facility failed to provide adequate monitoring and supervision for one resident (R700) out of 14 reviewed for supervision. Findings include: A review of a Facility Reported Incident (FRI) noted the following, .On April 21,2025, one of the neighbors came to the door to let staff know that one of our residents was walking down the street. The staff immediately ran outside and saw that it was [R700]. The CNA (Certified Nursing Assistant) ran up the street to walk [R700] back and the nurse ran back to get her car to bring [R700] back to the facility. Staff noted the dining room alarm was not working properly so door alarm did not sound when [R700] went out the dining room. A review of the medical record revealed R700 admitted into the facility on [DATE] with the following medical diagnoses, Dementia and Insomnia. A review of the most recent Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 99, indicating an impaired cognition. R700 also required minimum staff assistance with bed mobility and transfers and was at risk for elopement. On 5/5/2025 at 9:39 AM, A tour of the facility was conducted with the Nursing Home Administrator (NHA). The door in the dining room was observed where R700 exited the facility. The area was partially fenced, with an open area that led to the sidewalk. The door was noted to not have a lock on it. The NHA reported R700 eloped and made it about a block away before staff were alerted and they went and brought them back to the facility. On 5/5/2025 at 10:03 AM, an interview was conducted with CNA A. CNA A reported they were working day shift when R700 eloped. CNA A reported they were aware R700 was an elopement risk and was sitting with them in the dining are where the door is located, along with other day shift staff. CNA A indicated they got up around 7:00PM when it was shift change to round and give report to the oncoming shift. CNA A reported during report a man came banging on the door and stated one of the resident's were walking down the street. CNA A reported they all ran outside and saw R700 down the street. CNA A reported when they got R700 back in the facility. On 5/5/2025 at 11:27 AM, an interview was conducted with Maintenance D. Maintenance D reported they were unaware that the door alarm was not functioning properly, or they would have had a vendor come in and fix it immediately. Maintenance D indicated the door has a loud alarm when functioning. A review of the monthly maintenance checklist revealed that the door was last checked on 4/18/2025. On 5/5/2025 at 12:14 PM, an interview was conducted with the Director of Nursing (DON). The DON reported they have been giving R700 a lot more activities and taking him outside more with supervision, as well as frequent observation and positive redirection. The DON reported that R700 was placed on a 1:1 until the door was fixed. On 5/5/2025 at 12:30 PM, R700 was observed sitting in the dining room with the activities staff. R700 was unable to complete an interview. A review of a facility policy titled, Elopements and Wandering Residents noted the following, This facility ensures that residents who exhibit wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing [NAME] wandering or elopement risk.

This citation pertains to Intake MI00150065. Based on observation, interview, and record review, the facility failed to maintain a homelike environment in the resident showers and ensure the ice machine on the first floor was backflow protected. This deficient practice had the potential to affect all 39 residents in the facility. Findings include: On 2/12/25 at 9:50 AM, the ice machine drain line on the first floor was observed to extend down approximately 2 inches into the floor drain which was observed to have a buildup of black mold. Further observations of the sink located inside the room where the ice machine was located, revealed lime build-up around the faucet aerator. On 2/12/25 at 9:55 AM and 12:30 PM, observations of the facility's two shower rooms were observed with black mold, and an unknown brown substance around the perimeter of the shower, in addition to the shower walls. On 2/12/25 at 4:00 PM, findings of the ice machine and showers were brought to the attention of the Nursing Home Administrator (NHA), and she acknowledged she would look into the concerns. According to the Food & Drug Administration (FDA) 2017 Model Food Code, Section 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. A review of the facility's Safe and Homelike Environment policy revealed the following, .3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment .

Based on observation, interview, and record review, the facility failed to transport a resident from a doctors appointment in a respectful manner for one sampled resident (R901) of one reviewed for resident rights. Findings include: On 2/12/25 at 9:32 AM, R901 was observed lying in bed. Certified Nursing Assistant (CNA A) reported that R901 went out yesterday for a medical appointment for their feet. On 2/12/25 at 10:54 AM, R901's Interested Party (IP) reported that R901 had a doctor's appointment for R901's foot, the van was an hour and a half late to pick R901 up for the appointment and late for the return to the facility. The IP also explained that when the van arrived at the doctor's office the driver had two children without car seats inside the van, and was observed cursing and hitting the children in the van. The doctor's office manager approached the driver, and she then began to curse at the office manager. After the exchange the office manager called the facility to report the driver and eventually, decided to allow the resident to ride back to the facility, with the children in the van. The IP explained that she followed behind the van and arrived back to the facility around 5:30 PM. The IP reported that R901 reported that they were hit by the children during the ride back to the facility. On 2/12/25 at 11:30 AM, R901 was asked about their ride back to the facility when the children were in the van. The resident was asked if their were kids on the van, and R901 stated, Yes. R901 was asked if anything happened during the ride with the kids, and R901 stated, They hit me. R901 was asked what they hit them with and stated, A book. R901 was asked did anything else happen, and explained that they were cursing. A review of R901's progress notes revealed: 2/11/2025 02:35 PM Resident left the facility for Infectious Disease appointment by wheelchair in company van . Resident is alert and oriented times 3 (alert and oriented to person, place and time) . 2/11/2025 05:18 PM Resident returned from doctor's appointment with sister. Further review of R901's medical record revealed, R901 was admitted to the facility on [DATE], with diagnoses that included osteomyelitis, right ankle and foot Pressure ulcer of right heel, unstageable, Type II diabetes mellitus with foot ulcer. A review of R901's Minimum Data Set (MDS) five-day admission review dated 2/5/2024 noted, R901 with an intact cognition and dependent of staff to complete ADLs (activities of daily living). On 2/12/25 at 3:47 PM, Nursing Home Administrator (NHA) was asked if they were aware of the incident that occurred at the doctor's office. The NHA reported they were called around 6:30 PM regarding the van's driver with the children and how she was behaving. The NHA explained she then called the sister facility's administrator to report the information to them, because that was it was their driver/van. The NHA was asked if they had followed up with the sister or R901 regarding the drive to the facility, after the driver was observed to hit the two children that were in the van. The NHA explained they did not follow up with R901 or the sister. A review of the facility's policy titled, Transportation Policy dated 1/8/2025 noted, Policy: To provide guidelines for the safe and comfortable transportation of residents to medical appointments and other locations. Policy Explanation and Compliance Guidelines: General Guidelines: . 3. Facility vehicles must not be used for personal use 8. Unsafe Conduct is any act which creates the potential for injury or other risk to any passenger, or driver. 9. Abusive Conduct is any disruptive act toward any passenger, or driver a. This includes, but is not limited to, any acts that are generally offensive, invading the private rights of others, or touching another person in a rude, insolent, or angry manner. The driver may request the rider discontinue the behavior. Riders who continue with the behavior may be asked to leave the vehicle . General Safety 2. Ensure resident dignity is preserved .

This citation pertains in part to Intake MI00133877. Based on observation, interview, and record review, the facility failed to coordinate transportation for dental services, for one (R903) reviewed for dental care, resulting in delayed dental services and treatment, on-going tooth pain, and the potential for oral infections. Findings include: A review of a State Agency Intake summary noted, Resident has multiple carious (loss of tooth enamel) teeth which causes [R903] pain and several infections it has been recommended that [903] have all his teeth surgically removed. Administrator has failed to obtain transportation for this resident to go to [their] appointment. This has been an issues for over a year. For [R903's] December appointment it would cost $275 dollars for transportation to (name of local hospital) and the administrator choose not to pay the cost so the resident missed [R903's] appointment. On 2/1/23 at 10:00 AM, R903 was lying in bed sleeping. On 2/1/23 at 2:20 PM, R903 was observed in bed watching television. R903 was asked about their teeth. R903 was only able to answer with yes and no questions. R903 was asked if they still had pain with their teeth and stated, Yes. R903 was explained that their medical records had been reviewed and saw that the facility did not arrange transportation for the most recent appointment. R903 was asked is the pain bad and R903 stated, Yes. R903 was asked how long have they been waiting for the dental appointment, R903 gestured with their hand in the air, indicating I don't know. As R903 opened their mouth, R903's teeth were observed with enlarged red gums, missing teeth, and teeth that were different shades of brown. R903 was asked the pain level from one to ten with ten being the worse pain, R903 was observed with a look of frustration on their face and to shoot their hand/finger to the ceiling of the room. R903 was asked if that meant a high level of pain and R903 stated, Yes. A review of R903's progress notes revealed: Progress notes: 03/14/2022 03:45 PM, Resident alert, calm, cooperative with care and treatment. Meds given as ordered, continue on PO (oral) ABT (Antibiotics)for oral abscess . pain # 7 at left jaw. Oral cavity has chronic gingivitis, all teethes have cavity, gums beefy-red-black color . 03/15/2022 08:02 AM, Resident continues on oral abt, no adverse reactions noted, resident displayed relief in oral area, oral care given. 03/31/2022 04:38 PM [Recorded as Late Entry on 04/06/2022 05:02 PM] Nutrition follow up/weight note: 49 y/o (year old) . receiving a regular mech (mechanical) soft diet. PO (by mouth) intake is poor to fair r/t (related to) facility foods consuming 25-50% . PEG (Percutaneous Endoscopic Gastrostomy-tube inserted into stomach for foods and fluids) tube dependent with orders for Bolus Jevity 1.5 2 can tid (three times per day) . Bolus TID (three times a day) . [R903] has a documented hx (history) of refusing bolus feedings despite max encouragement from writer . indicating a 8.6% wt loss. He has dental concern r/t missing and infected teeth dental consult in place . 11/28/2022 03:53 PM, Resident returned from dentist appointment with a note that read that the MD (medical doctor) must provide a risk stratification for extractions under general anesthesia, full H&P (history and physical), medications and any recent CBC (Complete blood count)/BMP (basic metabolic panel)/other pertinent labs. Extractions may also be staged under local however more beneficial for the patient to undergo extractions under anesthesia in one apt (appointment). No new appointment made at this time until all is done to email . MD aware. 04/07/2022 03:57 PM, Monthly/Weight Loss: . Nutritional status WNL (BMI 22): Significant weight loss x (times) 180days with gradual trending downward since December 2022. Weight loss is unplanned, unavoidable and likely r/t (related to) refusal of TF (tube feed), Supplements, most meals, decaying teeth and gum pain, with periods of self-feeding difficulties . 06/23/2022 12:12 AM, Resident continues to be monitored for acceptance of bolus tube feeding and flushes, resident has refused this shift not accepting any bolus feedings nor flushes. Resident has a PO diet and has eaten 100% of the meals offered and accepts regular fluids at bedside. No s/s (signs or symptoms) of dehydration or malnourishment observed. Resident c/o (complained of) pain to [R903's] teeth causing [R903's] head to hurt nurse checked with regular asking about any upcoming dental appointments to fix the tooth pain. Prns (as needed) given for pain with minimal effectiveness. 06/23/2022 03:46 AM, message written and provided to social worker (SW) to reply to nursing about resident if [R903] has an upcoming dental appointment or not, if one can be scheduled to remove teeth that are causing pain to resident. 06/28/2022 11:50 AM, SW called and left voicemail for resident's guardian to get update on the resident's financial situation so he can proceed with his oral surgery. Resident was set to get surgery last month but due to his benefits being suspended due to the the guardian not having up to date documentation. Guardian reported will get it fixed and update the facility when the resident's money is back active to get surgery. Resident still complains of pain and discomfort. SW will follow up tomorrow as well. 12/06/2022 12:08 AM, Res (resident) received in bed alert and responsive. C/O pain to mouth, scheduled pain medication given and effective . 12/06/2022 10:14 AM, Recorded as Late Entry on 12/09/2022 10:15 AM] This writer emailed the oral surgeon at . the information that they requested on 11/28/22 to reschedule the appointment. 12/06/2022 02:52 PM, Monthly follow up: . [R903] has poor dentation, orders for oral surgery in place. PO intake varies based in mouth discomfort . 12/12/2022 01:58 PM, This writer call [local hospital] Oral and Maxillofacial Surgery Center . to schedule an appointment after the requested email paperwork was emailed and no response has been received. On hold at the clinic for over 25 minutes finally got voicemail and left a message to call . 12/12/2022 04:37 PM, Received email from [local hospital] oral surgery team. Thank you for your email. We will submit this to our clinical manager and plan for removal of teeth in the operating room. We will call once it has been approved. 12/13/2022 05:11 PM, Oral surgeon called appointment set for December 20, 2022 at noon. The receptionist stated, The resident will have to be there 2 hours before and the operating room will call with further instructions .Director of Nursing (DON) and Administrator aware of appointment. 12/19/2022 03:23 PM, NPO (nothing by mouth) at midnight oral surgery 10 AM 12/20/22 [local hospital]. Administrator notified. 12/20/2022 04:25 PM, Oral surgery for today canceled related to no transportation. Awaiting calendar from [name of sister facility] to reschedule appointment. Administrator aware. 01/03/2023 10:54 AM, Resident is alert and oriented and able to make needs known. Resident refused all medications this shift. Resident complained about teeth hurting. MD aware no new orders. DON aware. 01/03/2023 12:43 PM, this writer attempted to reschedule resident's oral maxillary surgery by calling the clinic. Writer was on hold for 25 minutes. Spoke with the receptionist, the receptionist stated, 'The clinic does not schedule the appointments but the hospital does. She is going to send an email to the OR (operating room) to schedule the appointment and will call the facility.' DON and administrator aware. 01/03/2023 03:53 PM, this writer was called by the OR receptionist. The OR is closed until Thursday for oral surgery. The receptionist will call back on Thursday morning to schedule the appointment. The OR is only open on Tuesday in the AM for oral surgery. The direct phone number to the receptionist is . DON aware. 01/05/2023 03:36 PM, Follow up call for appointment for OR r/t dental surgery. Spoke with . (office supervisor) who stated 12/20/2022 appointment was missed a no show states she got an appointment for resident full mouth extraction for OR on 02/14/2022 and resident has to be there by 10:00 am. Will ensure transportation for that date. 01/22/2023 05:33 PM [Recorded as Late Entry on 01/25/2023 05:33 PM] Annual Nutritional Summery: . [R903] is receiving a regular/mech soft diet. PO intake is variable consuming 25-100% of [R903's] foods, food preferences updated [R903] has a tablet for communication. Meal alternatives and snacks provided which [R903] consumes. [R903] has poor dentition and intermitted teeth and gum pain medication in place for pain management; [R903] is scheduled for oral surgery of [DATE]th. R903 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Hemiplegia following cerebral infarction affecting right dominant side. A review of R903's Minimum Data Set (MDS) assessment dated [DATE] noted, R903 with an impaired cognition and required extensive assistance from staff with activities of daily living. Further review of R903's medical record revealed, a care plan that noted, Problem: Start Date: 12/17/2021. [R903] has difficulty making self understood R/T HX of CVA (cerebral vascular accident ). Goal: Long Term Goal Target Date: 01/26/2023. [R903] will establish a reliable means of communication as evidenced by: answering simple yes or no questions. Approach: Ask yes or no questions whenever possible. Problem: Pain. [R903] has complaints of acute pain R/T poor dentition Pain site(s): mouth. Goal: Resident will verbalize relief of pain. Approach: Encourage resident to request pain medication before pain becomes unbearable. Schedule dental consult r/t poor dentition. 3/1/22. On 2/1/23 at 12:55 PM, the DON was asked about the issue with transportation for R903. The DON explained, when the nurse has the appointment, they will let the Business office set up the transportation. The DON further explained that the Business office would review the calendar that they share with sister facility to set up transportation. On 2/1/23 at 1:15 PM, the Nursing Home Administrator (NHA) was asked why the reason transportation was not provided for R903's oral surgery appointment and stated, I will check. I'm not sure. On 2/1/23 at 1:52 PM, the NHA reported, that she remembered what happened with this transportation, the nurse did not set up transportation at the time the appointment was made. The NHA stated, We have to collaborate with another facility (sister facility). The NHA was asked for clarification if R903 had transportation set up for the appointment on 12/20/22 and stated, No. On 2/1/23 at 2:34 PM, the Social Services staff was asked about R903's dental appointment history and stated, This is my fourth day here, I am not sure. I can look. At this time a request was made for the history of R903's dental services. The information was not provided by the end of this survey. A review of the facility's policy/procedure titled, Ancillary Department dated, 3/17/2022, noted, Policy Statement: Routine and Emergency Dental care is available to all residents of this facility. Policy Interpretation and Implementation 1. Emergency dental services includes services needed to treat an episode of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity that required immediate attention by a dentist. 2. Promptly means within 3 business days or less from the time the loss or damage to dentures is identified unless the facility can provide documentation of extenuating circumstances that resulted in the delay .

This citation pertains to intake #MI 545. Based on observation, interview, and record review, the facility failed to ensure adequate supervision to prevent elopement and ensure the safety for one sampled resident (901) who had impaired decision making and with a known elopement risk. Resulting in an Immediate Jeopardy (IJ) on Saturday 11/17/18 at 8:34 PM when, Resident #901 exited the unit through an unalarmed door to the employee break room, that lead to another unalarmed door to a vestibule, and then exited the facility through a third unalarmed door. This elopement was unbeknown to facility staff until approximately 9:00 PM. Resident (901) was located by the local fire department at approximately 9:55 PM and then taken to the emergency room . This deficient practice resulted in Resident 901 exposed to 30-degree weather, hand abrasions, wet clothes, and the likelihood of causing serious harm, injury, and/or death. Findings include: The IJ was started on 12/07/18 and identified on 11/17/18. The Administrator was notified of the Immediate Jeopardy on 12/07/18 at 11:30 a.m. The Administrator was asked for a plan to remove the immediacy. The IJ was removed on 12/7/18 based on the facility's implementation plan and verified onsite on 12/7/18. Although the IJ was removed, the facility's deficient practice remains at isolated, actual harm that is not immediate jeopardy. On 12/07/18 at 9:19 AM during an interview, the Director of Nursing (DON) was interviewed regarding Resident 901's elopement from the building. The DON stated, It happened on (MONTH) 17th. I received a call at 9pm. Upon investigation we found out (R901) left out of the building at 8:34pm, it was confirmed by cameras. (R901) left through the employee break room, which has three doors. The employee door was observed with the DON. The door to the hallway lead to a small break room, the room had another door that lead to stairs and another door that lead to the outside. The DON was asked were the doors alarmed as they are now. The DON stated, No. None of the three doors had alarms. The DON continued and explained, After (R901) exited the building the cameras did not pick up anything else. The DON was asked for the staff that were assigned to (R901). The DON reviewed the facility's investigation and stated, According to my statement (Nurse A) called me at 9:07 PM saying that she could not find (R901). I asked how long has (R901) been missing and she said that the last time anyone had seen (R901) was about 30 minutes ago. I told them to search the building again and have someone to call the police. (R901) was not found. I got here around 9:20 PM the Police was already here when I showed up. Around 9:55 PM the Police Officer got a call that the resident was found. They found (R901) about a mile away from here. The DON was asked what was Resident 901's condition when found. The DON stated, (R901's) condition was reported that (they) had abrasions on (their) hands, (they) were cold and a little wet. The DON was asked if they reported how Resident #901 got wet. The DON stated, I'm not sure, it wasn't raining. The Local Fire department took (them) to the emergency room . The DON was asked if Resident #901 returned to the facility. The DON stated, No. (Resident #901) was discharged to another facility that had a locked unit. On 12/7/18 at 9:40 AM, an observation of the facility's camera footage was reviewed with the DON, from her cell phone. The video footage was not time stamped with the incident actual time. The video revealed, Resident #901 walking in the hallway. Resident #901 was wearing a blue sweat shirt, jogging pants, socks, and slide in shoes (sandal that left toes and heels exposed). Resident #901 opened the door and went into the room (employee break room) and was out of view. Resident #901 was not observed to return back into the hallway from that door. On 12/7/18 at 11:30 AM a review of the Police Report revealed, On 11/17/18 at 2115 (9:15 PM) Officer E and I (Officer F) were dispatched to (facility) for a resident who was missing. (Officer E) started searching the immediate area and I (Officer F) made the nursing home. I made contact with one of the nurses at (facility) . were the nurses/employees that were working during the time that (R901) became missing. I was advised that (R901) was last seen at (YEAR) hours (9:15 PM). Initial thought was that (R901) had possibly been missing for an hour. The last time that (R901) was last seen by each nurse was estimated to be between 2000 (hours) hrs and 2100 hrs (8:00 PM - 9:00 PM). Around 2045 hrs (8:45 PM) after realizing that (R901) was missing they started looking for (them) throughout the building. When (they) could not be located they called the Police . The nurses advised me that almost every exit door is alarmed when someone exits them and that no alarm had gone off . On video, I can see (R901) making several attempts to exit out the main door starting around 1900 hrs (7:00 PM). (R901) would walk to the door, pull on it several times and then walk back into the dining area. I also observed at times some of the nurses would put a clothes hanger in the main door when people would step outside. This would bypass the alarm if someone were to leave out the door. The last observed time I seen (R901) inside (facility) was at (YEAR) hrs (9:15 PM). Prior to going further in the video (Officer E) had radioed that he had found (R901) behind the gate in the Department of Public Works (DPW) lot. (R901) was walking by the front gate inside the DPW lot. The gate was closed and locked . We could see that (R901) was cold and wet had some blood on (their) hands from small cuts. (R901) had no shoes on and was wearing slipper socks . (Hospital) treated (R901) and stated that (R901's) core temperature was 34.5 degrees Celsius (94.1 degrees Fahrenheit) . Person of interest) had contacted the station to give an update on (R901). Interested Party stated that (R901) sustained minor cuts to (their) hands and was in the process of warming up (their) core. Interested party stated, that (R901) possibly has frost bite on one of (their) big toes . On 11/20/18 I (Officer F) followed up with the home . the video showed the male subject was able to exit an employee door located off Macmillan St. stated they have since alarmed the door . Case closed. On 12/7/18 at 1:56 PM during an interview, the Administrator was asked about the employee door that Resident #901 exited out of. The Administrator stated, The doors sound when open and stop when closed. The Administrator was asked what is supposed to happen when the alarm sounds. The Administrator stated, It is to alert a staff person to come and check the door. On 12/7/18 at 2:00 PM, during an interview, Nurse A was interviewed regarding Resident #901's elopement. Nurse A stated, I was doing my rounds for blood sugars. Went to my med cart to prepare (R901's) medication, when I did not find (them) in the room that is when the search started. Had to be around 8 PM no later than 9 PM. Called the DON and the Police, some staff went outside to look for the resident. Around 10:30 PM (R901) was found by the stadium around Hall road. I was told he was wet and had bare feet. Nurse A was asked if this was the first time Resident #901 had left the building. Nurse A stated, Yes. That is normal for him to wander, he has tried before, but the doors have alarms on them so we are able to stop residents fast. Nurse A was asked if the door that Resident #901 left out had alarms. Nurse A stated, No. On 12/7/18 at 2:18 PM, during an interview, Nurse B was interviewed regarding Resident #901's elopement. Nurse B stated, (R901) was wandering around the facility. (Nurse A) came to me around 8:15 PM and asked if I had seen (R901). I said yes (R901) just walked passed me. That's when she told me that (R901) could not be found. We started the search . They found (R901) down near the Clinton River. Nurse B was asked if they said he was in the river. Nurse B stated, They didn't say he was in the river. On 12/7/18 at 2:23 PM, during an interview, Certified Nursing Assistant (CNA D) was interviewed regarding Resident #901's elopement. CNA D stated, (R901) was one of my residents. Around 8:15 PM I assisted (them) to the restroom. During that time I helped (their) roommate and (R901) walked out the room. I went to the nurses desk and CNA C came and asked where (R901) was, that is when we started looking for (R901). CNA D was asked to describe Resident #901's behavior prior to the elopement. CNA C stated, He was going to the front door a lot, but that was normal for (R901). On 12/7/18 at 11:00 AM a review of the facility incident statements revealed the following: (Nurse A) Date of Incident: 11/17/18. Resident involved: (R901) . Where were you immediately prior to the incident? 'In another resident room taking a blood sugar' . Where was the resident immediately prior to the incident? 'By the nurses station wandering around attempting to leave, staff had to redirect resident numerous times.' Describe the incident in your own words. 'I was preparing the resident medications, once I finished I went to look for the resident once resident was not found I immediately notified staff and we looked throughout the facility and the neighborhood we called the DON then I called the police .' (Nurse B) Date of Incident: 11/17/18. Resident involved: (R901) . Where were you immediately prior to the incident? 'Passing medications on back hall at 8 PM.' What were you doing immediately prior to the incident? 'Passing medication.' Where was the resident immediately prior to the incident? In hall way walking around .' (CNA C) Date of Incident: 11/17/18. Resident involved: (R901) . Where were you immediately prior to the incident? Behind the desk at the nurse station. What were you doing immediately prior to the incident? Walking around the building on the lower level. Where was the resident immediately prior to the incident? Walking around the building. Describe the incident in your own words. (R901) got out of the building .' (CNA D) Date of Incident: 11/17/18. Resident involved: (R901) . Where were you immediately prior to the incident? In resident room then immediately at front desk. What were you doing immediately prior to the incident? 'Looking through paperwork.' Where was the resident immediately prior to the incident? In hall way walking around .' DON's written statement revealed, At 9:10 PM, Writer received a call from Nurse A stating resident (R901) was missing and staff was unable to locate (them). Writer asked how long resident had been missing and nurse responded, 'about 30 minutes.' . Officer received calls that resident had been located at 9:59 PM. Officer exited building to retrieve resident from location . Upon return to the building at approximately 10:20 PM, officer was accompanied by personnel from (Local Fire Department) that stated (R901) had been located approximately one mile away from facility and (R901) had cuts and abrasions on (their) hands and was cold and wet but expected to recover . A review of Resident #901's Minimum Data Set (MDS) assessment dated [DATE] revealed the following: Resident #901 was admitted into the facility on [DATE] and with medical [DIAGNOSES REDACTED]. Further review revealed the resident's cognitive skills for daily decision making were severely impaired, and required limited assistance from staff for activities of daily living (ADLs). Hospital Discharge records. Progress Note: Date of Service 9/24/18. Psychiatry. Subjective: The patient is doing better. (R901) remains intrusive. (R901) walks into other people's rooms. (R901) has been checking doors . Elopement Assessment 9/28/18. Resident Elopement Assessment: Mobility Ambulatory . Mental status Cognitively impaired (Decreased safety awareness/disturbance in judgement) . Total Score: Elopement Risk 11.0 Level. At Risk. Care Plan: Problem Start date 9/29/18. Category: Behavioral Symptoms Wandering. Goal Maintain safety for resident. Approach: redirect resident approaching doors and fire doors to prevent elopement. Redirect resident from wandering into other resident room. Monitoring resident whereabouts for safety. Progress notes: 09/30/2018 12:48 AM. New Admission Day 2. Resident alert with confusion. Requires constant redirection and 1:1 supervision. Resident ambulates freely with steady gait. Resident very restless and wanders continuously from room to room. 09/30/2018 12:58 AM. Resident continually attempting to go out fire door in activity room. Very difficult to redirect. Diversional activities unsuccessful. Resident has very short attention span and requires 1:1 monitoring. Becomes highly agitated when you attempt to redirect him. Raises (their) hand with a closed fist as if he is going to hit you. Will continue to monitor. 10/01/2018 02:54 AM. New admit Day 4. Resident is alert with confusion. Able to make needs known. Ambulating freely throughout the facility. Continues to require 1:1 supervision and continual redirection. No behaviors noted this evening. Cooperative with care. Constantly on the move requiring diversional type activities to keep him busy. Elopement precautions maintained secondary to poor impulse control and poor safety awareness. Will continue to monitor. 10/01/2018 11:13 AM. activity admission note-resident admitted [DATE]. alert with confusion. has short attention span and can be difficult to re-direct. wanders throughout day-elopement risk. will monitor when attending/participating in activities. 10/05/2018 01:51 AM. Resident alert with confusion (related to) r/t dementia. Wanders and on the move continually. Requires 1:1 supervision. Elopement precautions maintained secondary to poor impulse control and poor safety awareness. Ambulates freely. 10/05/2018 01:56 AM. Resident assisted to bed by CNA but was up within 5 minutes. Resident pacing back and forth continually going in and out of other residents room. Resident observed going up the ramp and then stepped up and climbed over the railing Fall and safety precautions maintained. Will continue to monitor. 10/08/2018 03:17 AM. resident alert with confusion awake most of night wandering in and out of other residents rooms redirected several times in hall disrobing re directed to room nurse assist with putting underwear and pants back on found dirty underwear in hallway. in bed resting at this time will continue to monitor. 10/09/2018 05:02 AM. resident started wandering at start of shift, appeared to be confused and not knowing what he was supposed to be doing. at one point, resident grabbed the hallway grab bar, lowered himself to the ground, put (their) head against the wall and was content just sitting on floor in common area. assisted resident into dining room on chair to watch television. resident got up and began wandering, redirected resident into (their) room, turned television on and resident slept in (their) bed remainder of night. woke up twice and both times urinated on floor in (their) room. reeducated resident to use the toilet when needing to urinate or call for assistance as needed. resident went back to sleep. resting quietly and comfortable at this time. no issues or complaints. call light within reach. safety maintained. (will continue to monitor) wctm. 10/20/2018 12:48 PM. Resident doing well with recent medication change. No adverse reactions noted. Resident up wandering facility thru out the day. Constant re direction needed, but nothing abnormal for resident. Will continue to monitor. 11/09/2018 10:34 PM. Resident up and ambulates with steady gait throughout facility attempts to go out emergency exits redirected numerous times in bed resting at this time will continue to monitor. 11/16/2018 05:22 AM. Resident was resting and awoke wandering to nursing station. Resident had (bowel movement) BM tracking from bedroom and down (their) leg. Nurse assisted the resident to the bathroom and directed to the toilet. A review of the facility's policies revealed the following: Wandering Behaviors undated, . 3. To properly transition residents to the appropriate level of safety in regards to elopement risk, the provider should consider the level of elopement prevention hardware in place . b. Alarmed: The doors are alarmed to alert the egress but do not delay egress. c. Wanderguard Type devices: Sensor alarms as a resident with a bracelet approaches the door. Sensor causes the door to lock as a resident approaches . Wandering Unsafe Residents dated 6/1/16, Policy Statement. The facility will strive to prevent unsafe wandering while maintain the least restrictive environment for residents who are at risk for elopement. Policy Interpretation and implementing . 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues . 6. Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behaviors . The facility's Plan of Correction Element #1 Resident #901 left the faciity on [DATE] but is no longer a resident of this facility. A search of the building and grounds both inside and out on (MONTH) 17, (YEAR) was conducted by facility staff, consisting of nurses, certified nursing assistants, Director of Nurses and Administrator. The facility enlisted the assistance of the local Police Department. The resident was found approximately 10 minutes or less away from the facility at 9:59 p.m. and was taken to a local Hospital for assessment and observation to evaluate (their) wellbeing. Resident never returned to the facility. The resident's family was notified by the Director of Nurses of the resident's location at the hospital. Review of the facility's interior revealed all alarms present working therefore the incident was not due to defective equipment. A need for another interior alarm was identified. Completion: 11/17/2018 Element #2 All residents are at risk for leaving the building unattended. The facility reviewed all facility residents to assess those at risk for wandering/elopement and only four residents are at risked. All residents Elopement risk assessments and care plans have been reviewed and/or updated. The Elopement Book has been updated and placed at the nursing station. There is only 1 nursing station. Elopement risk assessments will be done for every resident on admission, quarterly, annually and as needed. Elopement risk assessment will also be completed when any exit seeking behaviors occur. Element #3 Facility staff education was initiated on 11/17/2018 and is ongoing date of completion is 12/9/18. All staff in-serviced begin on 11/17/18 on at risk residents and elopements. For any employee who was not present during this in-service on elopement/at risk residents will be arranged immediately upon their return to work. The Director of nursing/Nurse Managers reviewed the current elopement risk assessment form that is being use at the facility with the interdisciplinary team (ID) during the Quality Assurance meeting held on Element # 3 on 11/19/18. An Alternative Elopement risk assessment is being sought to replace the current assessment versus the current form in use. Both the elopement policy, Wandering/Unsafe resident policy were reviewed and deemed appropriate. In order to ensure the safety and supervision of facility residents, the following interventions and systemic changes have been immediately put into place by the Quality Assurance Committee on (MONTH) 19, (YEAR). The Employee Break room exit door will be closed off at 11:00 pm to 7:00 am and a second audible alarm has been added to the door on 12/7/18. When the alarm sounds the staff will responsible and go to the door and ensure that no residents has exit/enter the door. Element #4 Staff will document (every) q -15 minutes on each resident determined to be at high risk for elopement daily X 4 weeks or until sustained compliance. An audit will be completed by the Director of Nurses and Nursing Administration Team daily (times) X 4 weeks to ensure staff is documenting on each resident that scored high on elopement risk assessment to ensure compliance. A door alarm audit will be checked daily by the Maintenance Director/Designee X 4 weeks to ensure compliance that door alarms are working and Audible. Results will be reported to the Quality Assurance Committee monthly for review and documentation. The Medical Director also has been informed and involved in the plan of correction for this corrective measure. Element #5 The Administrator will be responsible for sustained compliance. Date of Completion: (MONTH) 7, (YEAR).

Based on observation, interview and record review, the facility failed to operationalize and implement a Restorative Nursing Program and failed to perform and document Range of Motion (ROM) activities for 1 (# 708) of 3 Residents reviewed for Restorative Nursing and (ROM), from a total sample of 10, resulting lack of monitoring and documentation of Resident ROM abilities and development of contractures (foot drop- contracture of the ankle). Findings include: Record review on 10/10/17 at 10:00 AM revealed Resident #708 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had severely impaired cognitive skills for daily decision making, had impaired ROM in their bilateral upper and lower extremities, and required total assistance to perform Activities of Daily Living (ADL's). The MDS further revealed the Resident was not receiving Restorative Nursing services. On 10/10/17 at 10:25 AM, Resident #708 was observed lying in bed in their room. The Resident's feet were observed to be pointed down (toes were pointed away from the Resident's head) while in bed. On 10/10/17 at 10:30 AM, wound care treatment for [REDACTED]. During wound care treatment, the Resident was rolled in the bed from side to side. The Resident's feet were observed to be pointed down (toes were pointed away from the Resident's head), at a 30 to 40 degree angle, at all times during the care observation. When queried regarding Resident #708's heels, Nurse C lifted Resident #708's foot from the bed. When the Resident's feet was lifted, the Resident's toes remained pointed downward (away from the Resident's head) and the Resident displayed facial grimacing and moaned. The Resident's ankles remained at a 30 to 40 degree angle when lifted from the bed by Nurse C. On 10/10/17 at 11:10 AM, review of Resident #708's medical record revealed documentation of Restorative Nursing entitled, Restorative Care Flow Record. The documentation indicated Resident #708's most recent Restorative Nursing treatment occurred on 4/17/17. On 10/10/17 at 12:05 PM, an interview was conducted with Restorative Nursing Staff A. When queried regarding the facilities Restorative Nursing Program, Staff A stated, We usually have them (Residents) for 12 weeks after they are done with therapy. With further inquiry regarding what occurs after the 12 weeks is completed, Staff A stated, They (Residents) are done with Restorative so none. We don't see them after that. I was told it is because of insurance. When queried how the facility prevents and ensures that Resident's functional status does not decline after Restorative Nursing is no longer seeing a Resident, Staff A replied, I've always wondered that myself. Staff A then stated, If the staff notice a change, they can try to get PT (Physical Therapy) to evaluate them again. With inquiry regarding Resident #708 and their last documented Restorative treatment occurring on 4/17/17, Staff A stated, Yeah, that is when they were done with their 12 weeks. I don't see Residents unless there is an order. When asked about Resident #708's feet and contractures, Staff A stated, They didn't have any contractures before. At this time, observation of Resident #708's feet and ankles occurred with Staff A. The Resident's feet were observed to be pointed down (toes were pointed away from the Resident's head) at a 30 to 40 degree angle. Staff A was observed asking Resident #708 to point their toes toward the ceiling. The Resident was unable to point their toes toward the ceiling. Staff A then asked Resident #708 to wiggle their toes. Slight movement was observed in toes on both of the Resident's feet. With further inquiry, Staff A stated, I would say they (Resident #708's feet/ankles) are at a 30 degree angle. Staff A then attempted to move the Resident's feet upward to point their toes toward the ceiling. The Resident's feet were observed with minimal movement but their toes did not point toward the ceiling and the Resident displayed facial grimacing and made a moan sound. Staff A then stated, (Resident #708) definitely has lost ROM in both ankles. On 10/10/17 at 12:15 PM, an interview and observation was completed with Nurse B and Staff A. When queried regarding Resident #708, Nurse B stated, (The Resident) used to have boots a long time ago but they don't anymore. (The Resident) had a pressure ulcer before. Staff A asked Nurse B if the boots were discontinued because of the pressure ulcer and Staff A replied, No. They (boots) didn't have anything to do with that. They were discontinued after the pressure ulcer healed. When queried if the boots were to decrease pressure, Nurse B replied, They were the pressure boots that have the metal on the side. When queried further, Nurse B stated, I'm not aware of them (Resident #708) having any contractures. Observation of Resident #708's feet occurred with Nurse B and Staff A at this time. The Resident's feet were observed to be pointed downward (toes pointed away from the Resident's head) at a 30 to 40 degree angle. Nurse B asked the Resident to move their feet and point their toes towards the ceiling. No movement was observed in the Resident's feet and ankles. Nurse B placed their hands on the Resident's feet to point the Resident's toes toward the ceiling. The Resident's feet and toes did not reach a 90 degree angle with pressure applied by Nurse B. When Nurse B moved the Resident's feet, Resident #708 displayed facial grimacing. Nurse B proceeded to state, (Resident #708) is stiff, the right (ankle) is worse than the left (ankle). (Resident #708) would probably qualify for Restorative. When queried if staff complete passive ROM activities with Resident #708, Nurse B replied, No. Nurse B then stated, I will check into it and see if we can get Therapy to see (the Resident). On 10/10/17 at 12:35 PM, Resident #708's facility provided active care plans were reviewed. Review revealed care plans entitled: ADL Functional/Rehabilitation Potential (Start Date: 9/28/16, Edited 2/9/17),Nutritional Status (Start Date: 2/17/17, Continue: 7/19/17), Psychosocial Well-Being (Start Date: 8/8/17), Pain (Start Date: 9/28/16, Continue: 8/1/17), Falls (Start Date: 4/4/16, Continue: 8/1/17), and Mood State (Start Date: 8/3/17, Edited: 8/8/17). The care plans did not include any interventions related to ROM. On 10/10/17 at 12:50 PM, an interview was conducted with the facility Administrator/Director of Nursing (DON). When queried regarding Restorative Nursing, the Administrator/DON stated, If someone gets therapy, they can get Restorative afterwards. When asked how the facility monitors Residents to ensure Residents with limited ROM do not experience a further decline in ability, the Administrator/DON stated, Staff let someone know if they notice a concern. When asked if staff perform active or passive ROM with Residents that are not receiving Restorative services the Administrator/DON replied, No, When queried regarding Resident # 708's decreased ROM in both ankles, the Resident not being able to point their toes toward the ceiling, and contractures, the Administrator/DON did not provide an explanation. When queried regarding Residents not receiving Restorative services for longer that 12 weeks due to insurance, the Administrator/DON replied, It is usually for 12 weeks after therapy. A policy pertaining to Restorative Nursing and ROM was requested but not received by the conclusion of the survey.

Based on observation, interview and record review, the facility failed to ensure 1 (# 703) of 2 Residents reviewed for facility acquired pressure ulcers (wounds caused by pressure), out of a total sample of 10, did not develop multiple, avoidable pressure ulcers and failed to ensure adequate monitoring, documentation, and timely modification of interventions, equipment competency, and documentation of functioning interventions, resulting in pressure ulcer development, pain, and the potential for infection and delayed healing. Findings include: On 10/9/17 at 9:00 AM, during the initial tour of the facility, Resident #703 was observed in their room. The Resident was lying in bed, positioned on their back. Facility Staff D was present in the room. When queried regarding Resident # 703, Staff D stated, (The Resident) has a pressure ulcer. I don't know what is going on but I don't think this bed (air mattress) is helping. It is so hard. Staff D then pressed on the Resident's bed with their hand. The mattress did not squish or give when pressure was applied. The air mattress control device was observed on the end of Resident #703's bed. The settings on the air mattress control device indicated the mattress was set to static, normal pressure. The air mattress control device included a circular shaped dial that ranged from soft to firm. The dial was positioned toward the firm side of the control, at the eight o'clock position. Staff D then stated, I told the nurses about it a couple weeks ago but nothing happened. Record review on 10/9/17 at 9:30 AM revealed Resident #703 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired, required extensive assistance to perform Activities of Daily Living (ADL's), and was always incontinent of bowel and bladder. The MDS further indicated Resident #703 was at risk of developing pressure ulcers but did not have a pressure ulcer and experienced communication difficulties including rarely/never understood and sometimes understands. On 10/9/17 at 11:35 AM, Resident #703 was observed in their room. The Resident was lying on their back. The Resident make eye contact when spoken to but verbal responses to questions were garbled and unable to be understood. An air mattress control device was observed on the end of Resident #703's bed. The settings on the air mattress control device indicated the mattress was set to static, normal pressure. The air mattress control device dial was positioned toward the firm side of the control, at the eight o'clock position. Additional review of Resident #703's medical record on 10/9/17 at 11:45 AM revealed the Resident spoke German, did not speak English, had two facility acquired pressure ulcers, and was admitted to Hospice services on 7/12/17. On 10/9/17 at 11:50 AM, an interview was conducted with Nurse G. When queried regarding Resident #703, Nurse G stated, (The Resident) has two wounds. One is on their coccyx and one on their buttocks. When queried regarding wound care treatments, Nurse G replied, It is daily. When queried regarding the onset date of the pressure ulcers, Nurse G replied, I don't know. Resident #703's treatment log for October 2017 was reviewed at this time. The following was included on the treatment log: -Bilat heel protectors at all times -Turn and reposition frequently both in bed and chair. On 10/1/17 and 10/12/17, the 7 PM to 7 AM, the task was not marked as completed by staff. -[MEDICATION NAME] ointment topically to dry skin q (each) shift and PRN (as needed). On 10/1/17 and 10/12/17, the 7 PM to 7 AM, the task was not marked as completed by staff. -Mediplex border to coccyx q 72 hours and PRN -Cleanse right hip with normal saline, apply [MEDICATION NAME] and cove with 4 X 4 gauze daily. Additional review of Resident #703's medical record at this time revealed the Resident's last documented weight was 98 pounds in September 2017. Review of the care plan entitled, Pressure Ulcer: Resident is at risk for pressure ulcers R/T (related to) hx (history) of pressure ulcers, incontinence, and impaired mobility (Start Date: 10/4/17, Edited: 10/4/17) revealed the following interventions: -Bilateral heel protectors on at all times. (Start Date: 10/4/17, Edited: 10/4/17) -Pressure relief mattress to bed. (Start Date: 10/4/17, Edited: 10/4/17) -Reposition at frequent intervals. (Start Date: 10/4/17, Edited: 10/4/17) -Treatment as ordered per doctor. (Start Date: 10/4/17, Edited: 10/4/17) -Wound care N.P. to see Resident per order. (Start Date: 10/4/17, Edited: 10/4/17) No documentation was noted within Resident #703's medical record of documentation of frequent repositioning and/or the date the specialty mattress was applied to the Resident's bed. On 10/9/17 at 2:25 PM, an interview was completed with Nurse C. When queried regarding Resident #703's pressure ulcers, Nurse C stated, I know when I charted but I'm not sure when the date of onset was. On 10/9/17 at 2:35 PM, record review of Resident #703's medical record revealed the following nursing documentation that indicated the Resident's right ischium pressure ulcer was first observed by facility staff on 9/11/17. Additional review of nursing documentation indicated the pressure ulcer on Resident #703's coccyx was first discovered on 7/15/17. Review of wound care consultation documentation, authored by Healthcare Provider K revealed Resident was last seen on 9/17/17 for treatment of [REDACTED]. No notation of coccyx pressure ulcer was present on documentation dated 9/17/17. Weekly wound measurements were not noted in the medical record. On 10/10/17 at 6:15 AM, Resident #703 was observed lying in their bed, positioned on their back with their eyes closed. The air mattress control device setting were changed. The mattress settings indicated the mattress was set to normal pressure. The air mattress control device dial was positioned toward the soft side of the control, at the five o'clock position. On 10/10/17 at 6:45 AM, an interview was conducted with Staff D. When queried regarding Resident #703's air mattress, Staff D stated, Yeah, I asked again yesterday why it was so hard. (Nurse C) and another person went into (Resident #703's) room but they didn't know how to change it. They said it was to hard too. They must have figured it out. On 10/10/17 at 10:00 AM, an interview and observation was completed with Nurse B and Nurse C. When queried regarding the air mattress settings, Nurse C stated, Hospice does it. Nurse C then stated, I turned the static off but I couldn't get the low pressure to turn on. I don't know. At this time Nurse C pressed the button on the air mattress control, turning the static control back on. When queried further, Nurse B stated, It was really hard before too. It has been for quite a while. Nurse C stated, I unplugged the connections a while ago and re-plugged them in. That seemed to help for a while. When queried regarding the onset date and stage of the pressure ulcers, Nurse C stated, I don't think (Healthcare Provider K) has faxed over their notes from the last time they were here but they said (Resident #703) has two stage two pressure ulcers now. With further inquiry, Nurse C stated, I try to make sure we get the (wound care) documentation right away but it doesn't always happen. When queried about wound measurements and staging of pressure ulcers, Nurse C replied Healthcare Provider K does all the measurements staging now. When asked how facility staff are aware of the status of Resident #703's pressure ulcer without the documentation, no explanation was provided. On 10/10/17 at 10:15 AM, observation of wound care treatment for [REDACTED]. Resident #703's coccyx pressure ulcer dressing was removed by Nurse B. A small amount of light pink and yellow colored drainage was observed on the removed dressing. Nurse C washed the wound bed with normal saline. The coccyx pressure ulcer was irregularly shaped and approximately the size of a quarter. The wound bed was bright red in color with a scant amount of white colored tissue noted in the wound bed. The skin surrounding the pressure ulcer was red in color with areas of peeling skin. When queried regarding the skin surrounding the open area, Nurse C stated, That is from the tape. It really bothers (Resident #703's) skin. Nurse C then changed their gloves and applied a new dressing. After application of a new dressing to the Resident's coccyx pressure ulcer, Nurse C changed their gloves. Nurse B then removed the dressing on Resident #703's right ischium (hip). The pressure ulcer was irregularly shaped and approximately the size of a dime. A small amount of yellow colored drainage was observed on the removed dressing. Nurse C proceeded to cleanse the wound bed with wound cleanser. The wound was irregularly shaped and approximately the size of a dime. The wound bed was red and white in color. Nurse C then applied a new bandage to the wound. Resident #703 made moaning sounds during the dressing change and made noticeably louder moans when the wounds were cleansed. On 10/10/17 at 12:25 PM, an interview was completed with Nurse C. When queried regarding not washing their hands after cleansing Resident #703's pressure ulcers and applying a new dressing and between dressing changes for the two pressure ulcers, Nurse C stated, But I changed my gloves. On 10/10/17 at 12:50 PM, an interview was conducted with the facility Administrator/Director of Nursing (DON). When queried regarding when hand hygiene should be performed per facility policy during wound care, the Administrator/DON stated, Hands should be washed each time you change gloves. When queried regarding documentation by staff of repositioning, the Administration/DON stated, We don't document that. When queried regarding Resident #703's air mattress settings, the Administrator/DON stated, We changed the settings because the mattress was really hard. With further inquiry regarding how facility staff know what the air mattress controller settings should be at, the Administrator/DON stated, We usually go by weight but that one (air mattress) doesn't have a weight setting. I downloaded the manufacturer guide yesterday. When asked how they were aware that that the Resident was receiving pressure relief with the mattress, without knowing if the settings were appropriate and that the air mattress was functioning properly, the Administrator/DON stated, I guess we don't. With further inquiry regarding how the facility monitors air mattresses to ensure the equipment is functioning appropriately, the Administrator/DON replied, We don't have checks (documented) on them. When asked how staff are aware of what the mattress settings need to be in order to provide pressure relief for Residents, the Administrator/DON did not provide an explanation. The Administrator/DON then stated, We need to have a uniform one (air mattress) throughout the building. Record review on 10/10/17 at 3:30 PM of facility policy entitled, Prevention of Pressure Ulcers (Dated: 8/1/16) revealed, The following information should be recorded in the Resident's Medical Record: The type of skin care given, The date and time skin care was given, The position in which the Resident was placed, The name and title of the individual who gave the care, . The condition of the Resident's skin . Record review on 10/10/17 at 3:40 PM of facility policy entitled, Support Surface Guidelines (Dated: 6/1/16) revealed, The following information should be documented in the Resident's medical record: That specialty bed settings are appropriate and correspond with care plan and physician orders, the date and time device placement occurred or when the specialty bed settings were checked, . The effectiveness of the pressure relief regime and steps taken if ineffective.

This citation pertains to MI Based on interview and record review, the facility failed to implement appropriate safety interventions in a timely manner for one (#701) of one residents sampled for falls, out of a total of three sampled residents resulting in an actual fall with a head injury. Findings include: On 1/10/17 at 9:30 a.m., a record review of Resident #701's Minimum Data Set assessment dated [DATE] revealed the following: Resident #701 was admitted to the facility on [DATE], and then readmitted on [DATE]. Resident #701 had severe cognitive impairment and needed hands on extensive assist with transfers, eating, toileting, personal hygiene, bed mobility and bathing. Resident #701 was diagnosed with [REDACTED]. On 1/30/17 at 9:40 a.m., a record review of the daily medicare nursing notes revealed the following: 1/6/17: Resident had repeatedly tried getting out of bed and wheelchair. Resident #701 had tried to be redirected but could not be because of a language barrier. No fall interventions were put into place. On 1/7/17: Resident #701 Will not stay in bed and as soon as staff would leave she would attempt to get out of the bed. No fall interventions were put into place. On 1/8/17: Resident #701 was very agitated, moving around and brought to the dining room near the nurses station to monitor for safety. Patient had crawled out of the gerichair to the floor. Constant talking. Given a mat to sleep on as she would not stay in a gerichair or wheelchair. On 1/9/17: Resident #701 was sitting in the dining room, redness on shoulder and down right arm, Doctor notified and ordered to sent out to the hospital. On 1/30/17 at 10:25 a.m., an interview was completed with the Assistant Director of Nursing (Nurse A) regarding the investigation of Resident #701 having crawled out of her chair and been placed on a mat on the floor for safety on 1/8/17. Nurse A had said that she had reviewed the video tape of the incident and that Resident #701 did indeed fall face first onto the floor, hitting her head and right arm. Nurse A stated, It was very sad to watch. Nurse A was asked if the video tape was still available, however it was not. Nurse A further explained that there were no further fall or safety interventions attempted on Resident #701 (toileting, walking, snacks, alarms, one in one supervision, activities or pain assessments) before placing Resident #701 on the floor in the dining room. Nurse A also explained that the resident had fallen on the floor on 1/8/17 at 4:11 a.m. and then again at 4:16 a.m. and had been placed on a black fall mat in the dining room on the floor at 4:22 a.m. by the nurse in charge and Resident #701 had been laid on the floor until the next shift came in and moved her back into a chair at 7:19 a.m. Nurse A further explained that the nurse did not notify the family or the doctor of either of the falls. On 1/30/17 at 10:35 a.m., a record review was completed. On 1/9/17 Resident #701 was returned back to the facility with the [DIAGNOSES REDACTED]. The Admission assessment revealed a right temporal bruise, right elbow and right biceps bruise along with a right hand bruise. Nurse A was interviewed at this time in regards to the bruising. Nurse A stated, Yeah, I did the initial skin assessment when she came back. She was pretty badly bruised from the fall and she had a big goose egg on her forehead. Review of the doctors orders revealed that the resident was ordered a pad alarm to the right and left side of the bed and a lap buddy to the wheelchair. These were ordered after the resident had fallen and placed on the floor in the dining room. On 1/30/17 at 1:00 p.m. an interview was completed with the Director of Nursing (DON) who also was the Administrator. The DON stated that the nurse involved with the incident involving Resident #701 was suspended upon investigation and eventually terminated from employment. The DON also said she had reported the nurse to the state board of nursing. The DON stated, The care was not at all what it should have been. On 1/30/17 at 3:35 p.m., a review of the policy titled, Falls-Clinical Protocol revised 06/01/2016 revealed the following: Cause Identification 9. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified . Treatment/Management 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling . A call was placed to the nurse involved in the incident, however no call back was received. ( )

This citation pertains to MI Based on interview and record review, the facility failed to maintain dignity for one (#701) of three residents sampled for dignity and abuse by placing resident # 701 on a mat on the floor in a public dining area for several hours resulting in a potential for emotional harm and humiliation. Findings include: On 1/30/17 at 9:30 a.m., a review of Resident #701's Minimum Data Set assessment dated [DATE] revealed that the resident was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #701 required extensive assist with transfers, toileting needs, personal hygiene, bed mobility, bathing and was severely cognitively impaired. On 1/30/17 at 9:40 a.m., review of the daily medicare nursing notes revealed that on 1/8/17; Resident #701 was very agitated, moving around and brought to the dining room near the nurses station to monitor for safety. Patient had crawled out of the gerichair to the floor. Constant talking. Given a mat to sleep on as she would not stay in gerichair or wheelchair. On 1/30/17 at 10:25 a.m., an interview was completed with the Assistant Director of Nursing (Nurse A) regarding the investigation of Resident #701 having crawled out of her chair and been placed on a mat on the floor for safety on 1/8/17. Nurse A said that she had reviewed the video tape of the incident and that Resident #701 did fall face first onto the floor, hitting her head and right arm. Nurse A stated, It was very sad to watch. Nurse A was asked if the video tape was still available, however it was not. Nurse A further explained that there were no further fall or safety interventions attempted on Resident #701 (toileting, walking, snacks, alarms, one in one supervision, activities or pain assessments) before placing Resident #701 on the floor in the dining room. Nurse A also explained that the resident had been placed on a black fall mat in the dining room on the floor at 4:22 a.m. by the nurse in charge and that Resident #701 had laid on the floor until the next shift came in and moved her back into a chair at 7:19 a.m. On 1/30/17 at 1:00 p.m. an interview was completed with the Director of Nursing (DON) who also was the Administrator. The DON stated that the nurse involved with the incident involving Resident #701 was suspended upon investigation and eventually terminated from employment. The DON also said she had reported the nurse to the state board of nursing. The DON stated, The care was not at all what it should have been. On 1/30/17 at 1:15 p.m., an interview was completed with Dietary Aide C. Dietary Aide C said that she had come in on the morning of 1/8/17. When she went to punch in, she seen Resident #701 lying on the floor in the dining room on a mat with a blanket over her. Dietary Aide C stated, I thought, if that were my mom .no, it's not right! When asked if she had reported it to a supervisor is she felt it was wrong, she said she did not. On 1/30/17 at 1:40 p.m., an interview was completed with Certified Nursing Assistant (CNA) B. CNA B stated that she had come in the morning of 1/8/17 and seen Resident #701 on the floor in the dining room on a mat. CNA B stated that the resident was awake and moving around on the mat. CNA B had denied reporting the incident to a supervisor. On 1/30/17 at 2:00 p.m., an interview with the Nurse A and the DON was completed. Nurse A had stated that the incident happened over the weekend and that they (she and the DON) had not known about it until the following Monday during their morning meeting. Nurse A stated that none of the staff had called or reported the incident to her or the DON. The DON confirmed this and said that she was individually reviewing the abuse and reporting protocol with all of the staff. She also stated she reprimanded the staff that worked that day that did not report the incident. On 1/30/17 at 3:15 p.m., a record review of the policy titled, Resident Rights revised 7/1/2016 revealed the following: Policy Statement-Employees shall treat all residents with kindness, respect, and dignity. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. On 1/30/17 at 3:30 p.m. a review of the policy titled, Abuse Prevention Program revised 7/1/2016 revealed the following: 1. Our facility is committed to protecting our residents from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. b. Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, etc. c. Identification of occurrences and patterns of potential mistreatment/abuse; g. The reporting and filing or accurate documents relative to incidents of abuse; ( )

Based on observation, interview and record review, the facility failed to assist 1 ( # 703) of 1 sampled resident to elevate legs to reduce swelling in her left lower leg and foot to promote wound healing from a total sample of 10 residents, resulting in swelling and discoloration of the resident's left lower leg and foot that decreased the ability of the resident's left ankle wound to heal. Findings include: On 12/20/16 at 1100 record review revealed that resident #703 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] (MDS), provided a Brief Interview for Mental Status(BIMS) score of 0/15 indicating severe cognitive impairment, supervision with eating, and extensive assistance with 2 staff members for transfers, dressing, toileting and bathing. The Skin Conditions section of the MDS indicated the resident was at risk for pressure ulcers and currently had 1 Stage 3 pressure ulcer with dimensions 0.7 centimeters (cm) length by 1.0 centimeters, width and 0.3 centimeters depth. It indicates 0 (meaning none) venous or arterial ulcers present. In the Skin and Ulcer Treatments section of the MDS the facility chose Pressure reducing device for Chair, Pressure reducing device for Bed, Pressure ulcer care and application of ointments/medications. Turning and repositioning was not chosen. Review of the MDS dated [DATE] indicated the resident was at risk for pressure ulcers and had 1 stage 3 pressure ulcer and also had 1 venous or arterial ulcer. In the Skin and Ulcer treatment section of the MDS the facility marked the following: Pressure ulcer care and applications of ointments/medications to the feet. Turning repositioning program was not chosen. The MDS dated [DATE] indicated the resident was at risk for pressure ulcers and had no ulcers present of any type. On 12/20/16 at 1430, review of the the care plan for resident 703 revealed a Care Plan for Pressure Ulcers, . has an arterial tissue injury to left lateral malleolus dated 12/9/16: Goal, Residents tissue injury will heal without complication while providing interventions to prevent further breakdown. Approaches included Assessment, use of heel protectors/offloaders, Boost supplement, a treatment that was changed 12/21/16 to a daily dressing change with [MEDICATION NAME]. There was no intervention for repositioning or relief of dependent swelling ([MEDICAL CONDITION]) in the resident's lower legs and feet. On 12/20/16 at 1345, the resident was observed sitting in a wheelchair sleeping, in the dining room with a left heel boot in place and food from lunch on her shirt and pants. At 1445 on 12/20/16 Certified Nurse Assistant (CNA) T was asked if she was assigned to Resident 703 and said no and then stated, Oh wait, I do have that room, yes. When asked if CNA T assisted the resident with care that morning, CNA T stated, No, night shift got her up. CNA T was queried if the resident had been back to their room at anytime that day, CNA T stated, No. When asked if the resident had been out of her wheelchair and layed down the CNA Tsaid no. On 12/20/16 at 1450 Resident #703 was observed sitting in the dining room with food on her clothes. At 1500 on 12/20/16 the resident was assisted to her room by CNA T and her brief and clothes were changed. On 12/21/16 at 1005 Resident #703 was observed in the dining room sitting in a wheelchair. The heelboot was not on her left foot. At 1105, 1215 and 1330 the resident was in the dining room and had not been back to her room. An observation and interview with Nurse Manager J and Wound Nurse U at 1415 on 12/21/16 revealed the resident was in the dining room and they assisted her to her room to change the dressing on her left ankle. The heel boot was not in place. When queried where the heel boot was, they replied they did not know, Probably in the wash. When asked if the resident was supposed to have it on, Nurse Manager J responded, Yes. Nurse Manager J removed the residents sock's and dressing from the left ankle. Wound Nurse U stated, Her wound looks punched out. It would heal better if there wasn't so much [MEDICAL CONDITION]. It just starts to heal and then opens up again. It started in August. Nurse Manager J and Wound Nurse U were asked if the resident had a plan for reducing the swelling in the resident's leg and foot, they did not respond. When asked why the resident sat in the wheelchair all day without her leg elevated to reduce swelling, Wound Nurse U stated, She can't have a foot pedal because her leg won't bend. When Wound Nurse U was queried as to what type of wound it was, she stated, I haven't had consistent documentation on it, but it is arterial. When asked why the physician stated it was from [MEDICAL CONDITIONS] at his visit on September 8, 2016 (the last physician progress notes [REDACTED]. At 1425 on 12/21 /16 CNA L entered the resident's room and was asked if Resident #703 had layed down in bed that day and stated, No, we can't lay her down because she will try and get up and fall. A review of the policy, Prevention of Pressure Ulcers, dated 8/1/16 reveals the following: General Preventive Measures, Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or decreased circulation (blood flow) to that area and subsequent destruction of tissue, 8. For a person in a wheelchair, change position at least every hour. An interview with the DON/Administrator on 12/21/16 at 1435 provided No? when informed the resident had not layed down during the day on 12/20/16 or 12/21/16, because staff say she will try and get out of bed and fall. ( )