Every finding on record at The Laurels of Bedford

This citation pertains to Intake 3096764Based on observation, interview, and record review, the facility failed to provide assistance with bathing/showering for one (R4) of three reviewed.Findings include:Review of the medical record revealed R4 was admitted to the facility on [DATE] with a diagnosis of quadriplegia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/2/26 revealed R4 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and required substantial/maximal assistance with personal hygiene and bathing/showering. Review of the care plans initiated 11/14/24 and revised on 6/1/26 revealed R4 refuses the shower bed and request bed bath due to her wounds [R4 had seven pressure ulcers] .prefers to have bed baths because the chair is too uncomfortable and she does not like the gurney. Staff washes her hair in the beauty shop. On 8/27/26 at 10:28 AM, R4 was observed lying in bed. R4 reported she preferred to have bed baths instead of showers because the shower bed was too uncomfortable for her. R4 reported she was supposed to receive bed baths three times per week on Monday, Wednesday, and Friday. R4 reported she never refused bed baths, but staff chart that I refuse so they don't have to do it. R4 reported she had not had a bed bath in at least a week. Review of the Shower/Bath task documentation for the past 30 days revealed R4 received a shower/bath/bed bath on 8/4/26, 8/13/26, and 8/15/26; did not receive bathing on 8/1/26, 8/11/26, and 8/18/26; and Not Applicable was documented on 8/6/26. Review of Documentation Survey Report revealed R4 was scheduled for a shower/bath during the evening shift (3:00 PM to 11:00 PM) on Tuesdays, Thursdays, and Saturdays. The documentation revealed R4 received showers/baths on 8/4/26, 8/13/26, and 8/15/26, and did not receive a shower/bath on 8/1/26, 8/6/26, 8/11/26, and 8/18/26. There was no documentation for 8/8/26, 8/20/26, 8/22/26, 8/25/26, and 8/27/26. R4's last documented bath/shower was on 8/15/26. Review of the Behavior Monitoring/Interventions 3: Patient will decline showers at times task documentation, revealed in the last 30 days, R4 displayed the behavior one time on 8/18/26. Review of the Progress Notes revealed R4 refused showers on 8/12/26 and 8/19/26. The Nurse Note dated 8/19/26 revealed Refused shower.will speak with guest as most times she receives a bedbath. There was no follow-up documentation on whether a bed bath was offered, received, or declined. In an interview on 8/28/26 at 9:53 AM, Director of Nursing (DON) B reported staff had a paper schedule for showers, but the documentation was in the tasks in the electronic medical record. DON B reported nurses should document refusals in progress notes and not applicable should be used only when it was not the resident's scheduled bath day or when the resident was out of the building for the entire shift. DON B confirmed R4 was scheduled for a shower/bath on Tuesdays, Thursdays, and Saturdays. DON B reported R4 sometimes accepted bed baths, and staff should document that. After reviewing the documentation, DON B agreed the last documented shower/bath was on 8/15/26 and documentation did not show why R4 did not receive a shower/bath on 8/18/26. DON B also confirmed there was no documentation on 8/20/26, 8/22/26, 8/25/26, and 8/27/26. DON B reported managers were auditing showers/bathing daily and reported the audits showed R4 refused a shower on 8/11/26. DON B reported R4 had not appeared on this week's audit.

This citation pertains to Intake: 2960508Based on observation, interview, and record review the facility failed to prevent the development of pressure ulcers for one resident (R2) out of three residents with pressure ulcers reviewed, resulting in the development of three facility acquired stage 3 pressure ulcers (full thickness tissue loss) and worsening of one stage 3 pressure ulcer present on admission to stage 4 (full thickness tissue loss with exposed bones and or tendons) that required hospital transfer for osteomyelitis (wound and bone infection), pain, and debridement. Findings: Review of the Face Sheet and Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/2/26 reflected R2 was a [AGE] year old female admitted to the facility on [DATE] with diagnosis that included stage 4(full thickness tissue loss with exposed muscle, tendon and or bone) pressure ulcer along with two facility acquired stage 3 (full thickness tissue loss that extends into subcutaneous fat), quadriplegic, Crohn's disease, depression and anxiety . The MDS reflected R2 had a BIM (assessment tool) score of 15 which indicated her ability to make daily decisions was cognitively intact, and she was dependent on staff for repositioning in bed, transfers, dressing, bathing, hygiene, and eating. Continued review of the MDS reflected R2 was at risk for pressure ulcer (PU) and had three stage 3 pressure wounds that was not present on admission, and one stage 4 pressure wound present on admission(worsening). The MDS reflected R2 was not on a turning/repositioning program.Review of the complaint received by the State Agency alleged the facility failed to provide care, consistent with professional standards of practice to prevent the development or worsening of avoidable pressure ulcers.During an observation and interview on 6/11/26 at 8:40 a.m. R2 was lying in bed and able to answer questions without difficulty. R2 had an air mattress with pump on foot of bed and wound vac in use. R2 reported wound vac had been used for long time for three open wounds on backside and the facility wound nurse changed the dressing every Tuesday and Friday. R2 reported admitted to facility in 2024 with one wound to bottom and reported wound had gotten worse and had developed new wounds since admission that developed at facility. R2 reported facility had wound doctor that rounded with wound nurse every Tuesday and new treatment orders were given to treat wound on left foot and staff had not yet completed them(two days later). Observed R2 had personal sock on left foot with no dressing in place and R2 verified did not use blue heel boots because caused too much heat. R2 reported does not go to wound clinic because facility talked her out of going. R2 reported requires staff assist with everything including repositioning and eating and reported staff do not always reposition her every two hours. Observed meal tray on foot of bed. R2 reported staff had delivered it about 8:20 a.m. and had not returned yet to assist resident with meal and verified weight loss. Facility staff entered room at 8:50 a.m.(30 minutes after tray delivered) and informed R2 plan to assist with breakfast.Review of the Electronic Medical Record (EMR), dated 11/13/24 through 6/11/26, reflected R2 admitted to the facility on [DATE] with the following wounds:-one stage 2 pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured blister);-one unstageable with slough pressure wound (Known but not stageable due to coverage of wound bed by slough and/or eschar);-2 unstageable pressure injuries presenting as deep tissue injury. Continued review of R2 EMR reflected R2 had current (6/2/26) wounds as follows:-Worsening stage 4 sacral wound (present on admission [DATE]);-New facility acquired rear left thigh stage 3 pressure ulcer with start date 1/9/26;-New facility acquired rear right thigh stage 3 pressure ulcer with start date 1/9/26;-New facility acquired left lateral foot, stage 3 pressure ulcer with start dated of 11/23/25; During an observation and interview on 6/12/26 at 8:40 a.m. R2 was laying in bed with no wound vac at this time. R2 reported Wound Nurse (WN) G had informed R2 of plan to complete wound treatments between 7:00 am and 8:00 am but had not completed yet. R2 granted surveyor permission to observe wound care. During an observation on 6/12/26 at 9:07 a.m. Wound Nurse G along with Registered Nurse Staff Educator (SE) H entered R2 room and informed R2 plan to complete wound treatments. WN G removed border foam dressings from R2 sacral and both right and left posterior thigh areas dated 6/12/26. WN G first cleansed R2 right thigh wound, then left thigh wound then sacral wound with gauze soaked with wound wash with no change of glove between wounds. Bilateral posterior thigh wounds appeared about golf ball size including depth and sacral wound appeared slightly larger. WN G again washed all three wounds and applied dry gauze in each wound and changed gloves. WN G applied skin prep around right posterior thigh wound, framed wound with thin duederm, removed dry gauze from wound and placed black wound vac foam inside wound, and covered with clear drape and changed gloves. WN G then applied skin prep around sacral wound, framed wound with thin duederm, removed dry gauze and placed black wound vac foam inside wound, and covered with clear drape and changed gloves. WN G then applied skin prep around left posterior thigh wound, framed wound with this duederm, removed dry gauze, placed black wound vac foam inside wound, and covered with clear drape and changed gloves. WN G place clear drape over intact skin with plan to bridge to wound vac tubing away from pressure areas. WN G cut three holes in clear drape over each wound and bridged (connected by black foam) right thigh wound to sacral wound then bridged left thigh wound to sacral wound followed by bridge from sacral wound to right hip area where WN G placed [NAME] pad, connected tubing and wound vac set at 150. R2 was repositioned with pillows and WN G exited room at 10:00 a.m. R2 appeared to tolerate treatment with some reported muscle spasms observed and reported pain with spasms. R2 reported wound vac came off yesterday before lunch, nurse placed dressings then night staff changed dressings last night. Observed dressing in place on left foot and R2 verified nurse completed left foot dressing change yesterday afternoon, first time since doctor ordered on Tuesday. Review of R2, Skin Issue assessment, dated 1/6/26, reflected, Location: Sacrum. Issue type: Pressure ulcer / injury. Progress: Deteriorating: wound characteristics deteriorated. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound was present on admission. Exact date: 11/13/2024.Length (cm): 2.79 Width (cm): 3.1 Depth (cm): 1 Area (cm2): 6.5 Undermining: No. Tunneling: No. Epithelial: 0%. Granulation: 100%. Slough: 0%. Eschar: 0%. Exudate amount: Moderate. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery.Surrounding tissue: Maceration.#002: Skin issue has been evaluated. Location: Left lateral foot.Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. Exact date: 11/23/2025.Length (cm): 1.23 Width (cm): 0.82 Depth (cm): 0 Area (cm2): 0.81 Undermining: No. Tunneling: No. Epithelial: 0%. Granulation: 0%. Slough: 0%. Eschar: 100% .Review of R2 Resident At Risk Progress Note, dated 1/9/26, reflected, Reviewed Clinical Indicator: Skin Action Taken: New DTI [deep tissue injury] to the right and left gluteus. Response to Previous Actions Taken: Wound MD [medical doctor] and RD [registered dietician] to follow. Tx[treatment] initiated.Review of R2, Skin Issue assessment, dated 1/12/26, reflected, Skin Issue: #001: Skin issue has been evaluated. Location: Rear left thigh. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. Exact date: 01/09/2026 Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 3.02 Width (cm): 2.22 Depth (cm): 0 Area (cm2): 5.57 Undermining: No. Tunneling: No. Epithelial: 0%. Granulation: 0%. Slough: 0%. Eschar: 0%. Exudate amount: None. Exudate type: None. Odor after cleansing: None.#002: Skin issue has been evaluated. Location: Rear right thigh. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. Exact date: 01/09/2026 Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 1.42 Width (cm): 1.15 Depth (cm): 0 Area (cm2): 1.62.#003: Skin issue has been evaluated. Location: Sacrum. Issue type: Pressure ulcer / injury. Progress: Deteriorating: wound characteristics deteriorated. Pressure ulcer staging: Stage 4 Pressure ulcer / injury - full thickness skin and tissue loss. Wound was present on admission. Exact date: 11/13/2024 Signs and symptoms of infection: None. Painful: No. Staged by: Health care provider. Length (cm): 2.95 Width (cm): 1.85 Depth (cm): 1 Area (cm2): 3.9 Undermining: No. Tunneling: No. Epithelial: 0%. Granulation: 100%. Slough: 0%. Eschar: 0%. Exudate amount: Moderate. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery.Review of R2 Physician wound note, dated 1/13/26, reflected R2 complained of 7 out of 10 pain on pain scale and wound treatment was changed to Negative Pressure Wound Vac.Review of R2, Skin Issue assessment, dated 1/20/26, reflected, Skin Issue: #001: Skin issue has been evaluated. Location: Rear right thigh. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Progress: Deteriorating: wound characteristics deteriorated. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound acquired in-house. Exact date: 01/09/2026.Length (cm): 3.28 Width (cm): 1.44 Depth (cm): 0.1 Area (cm2): 3.25 Undermining: No. Tunneling: No. Epithelial: 0%. Granulation: 40%. Slough: 0%. Eschar: 60%. Exudate amount: Moderate. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery. #002: Skin issue has been evaluated. Location: Rear left thigh. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Progress: Deteriorating: wound characteristics deteriorated. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound acquired in-house. Exact date: 01/09/2026 Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 2.18 Width (cm): 1.14 Depth (cm): 0 Area (cm2): 2.12 Undermining: No. Tunneling: No. Epithelial: 0%. Granulation: 100%. Slough: 0%. Eschar: 0%. Exudate amount: Moderate. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery.Review of R2 Physician wound note, dated 1/20/26, reflected R2 complained of 8 out of 10 pain on pain scale and wound treatment was Negative Pressure Wound Vac.Review of R2 Physician wound note, dated 2/3/26, reflected R2 wounds declined including Right thigh stage 3 pressure ulcer measured 1.99 cm x 1.45cm x. 0.1 cm Treatment changed to santyl. Left thigh stage 3 2.23 cm x 1.49 cm x 0.1 cm.Review of R2 Skin Issue assessment, dated 2/17/26, reflected, #001.Location: Sacrum. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Stage 4 Pressure ulcer / injury - full thickness skin and tissue loss. Wound was present on admission. Exact date: 11/13/2024 Painful: No. Staged by: Health care provider. Length (cm): 2.56 Width (cm): 2.4 Depth (cm): 4 Area (cm2): 4.8 Undermining: No. Tunneling: No. Granulation: 80%. Slough: 20%. Exudate amount: Heavy. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery. #002: Skin issue has been evaluated. Location: Rear left thigh. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Progress: Deteriorating: wound characteristics deteriorated. Pressure ulcer staging: Stage 3 Pressure ulcer / injury -full thickness skin loss. Wound acquired in-house. Exact date: 01/09/2026 Signs and symptoms of infection: Smell increased. Signs and symptoms of infection: Size has increased. Staged by: In-house nursing. Length (cm): 4.13 Width (cm): 3.23 Depth (cm): 0.5 Area (cm2): 10.04 Undermining: No. Tunneling: No. Slough: 30%. Eschar: 20%. Exudate amount: Moderate. Exudate type: Purulent: indication of pus, typically thick, yellow, green, tan or brown. Odor after cleansing: Faint. #004: Skin issue has been evaluated. Location: Rear right thigh. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Progress: Deteriorating: wound characteristics deteriorated. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house. Exact date: 01/09/2026 Signs and symptoms of infection: Smell increased. Signs and symptoms of infection: Size has increased. Staged by: In-house nursing. Length (cm): 3.09 Width (cm): 3.27 Depth (cm): 0.8 Area (cm2): 7.79 Undermining: No. Tunneling: No. Granulation: 50%. Slough: 50%. Exudate amount: Moderate. Exudate type: Purulent: indication of pus, typically thick, yellow, green, tan or brown. Odor after cleansing: Faint.Review of R2 Physician wound note, dated 2/17/26, reflected R2 wounds declined, including R2 Right thigh was documented as Stage 4 and R2 complained of 8/10 pain and provider performed sharp debridement.Review of R2 Physician wound note, dated 2/24/26, reflected R2 wounds declined with signs of infection noted and culture and sensitivity (C&S) sample collected and sent related to infection.Review of Braden Scale for Predicting Pressure Ulcer Risk Evaluation, dated 2/24/2026, reflected, Sensory Perception: Slightly limited. Moisture: Occasionally moist. Activity: Chairfast. Resident is Completely Immobile: does not make even slight changes in body or extremity position without assistance. Nutrition: Adequate. Friction and shear: Problem. SW - BRADEN Score: 13.0.Review of R2 Nurse progress Note, dated 3/2/2026 wound C&S resulted and discussed with [named wound physician] Orders for clindamycin 300mg qid[4 times daily] x 14 days given and entered. Guest notified.Review of R2 Skin Issue assessment, dated 3/3/26, reflected, . #001: Skin issue has been evaluated. Location: Sacrum. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Stage 4 Pressure ulcer / injury - full thickness skin and tissue loss. Wound was present on admission. Exact date: 11/13/2024 Signs and symptoms of infection: Smell increased. Signs and symptoms of infection: Non-healing. Painful: No. Staged by: Health care provider. Length (cm): 3.38 Width (cm): 1.94 Depth (cm): 3 Area (cm2): 5.22 Undermining: No. Tunneling: Yes. Number of tunnels: 2. Tunnel length (cm): 4 Tunnel location 1: 5 o'clock. Tunnel length (cm): 4 Tunnel location 2: 7 o'clock. Granulation: 80%. Slough: 20%. Exudate amount: Heavy. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery. Odor after cleansing: Faint.Dressing appearance: Saturated.#002: Skin issue has been evaluated. Location: Left lateral foot. Laterality / Orientation: Lateral. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. Exact date: 11/23/2025.Length (cm): 1.34 Width (cm): 1.12 Depth (cm): 0 Area (cm2): 1.16 . Eschar: 100% .#003: Skin issue has been evaluated. Location: Rear right thigh. Laterality / Orientation: Medial. Issue type: Pressure ulcer/ injury. Progress: Improving: overall wound characteristics improved. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house. Exact date: 01/09/2026 Signs and symptoms of infection: Non-healing. Signs and symptoms of infection: Smell increased. Signs and symptoms of infection: Increased exudate. Signs and symptoms of infection: Size has increased. Painful: No. Staged by: In-house nursing. Length (cm): 3.61 Width (cm): 4.3 Depth (cm): 2 Area (cm2): 11.53 Undermining: No. Tunneling: No. Slough: 80%. Eschar: 20%. Exudate amount: Moderate. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery. Odor after cleansing: Faint.#004: Skin issue has been evaluated. Location: Rear left thigh. Laterality / Orientation: Medial. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house. Exact date: 01/09/2026 Signs and symptoms of infection: Size has increased. Signs and symptoms of infection: Non-healing. Signs and symptoms of infection: Smell increased. Signs and symptoms of infection: Increased exudate. Painful: No. Staged by: In-house nursing. Length (cm): 4.55 Width (cm): 3.11 Depth (cm): 1.5 Area (cm2): 11.02 Undermining: No. Tunneling: No. Granulation: 20%. Slough: 10%. Eschar: 70%. Exudate amount: Moderate. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery. Odor after cleansing: Faint.Review of R2 Physician wound note, dated 3/2/26, reflected R2 wounds declined including Right thigh wound stage 4 pressure wound with signs of infection noted and R2 complaint of 9/10 pain.Review of R2 Physician wound note, dated 3/10/26, reflected R2 wound decline and R2 reported 9/10 pain.Review of R2 Nurse Progress Note, dated 3/17/2026, reflected, Wound MD in to see guest this shift. After assessment of sacral wound, an order to extend clindamycin x 14 days was given and entered. guest notified.Review of R2 Physician wound note, dated 3/24/26, reflected R2 wound decline and plan to start IV antibiotics for wound infection.Review of Physician orders, dated 3/25/26, reflected R2 was ordered Vancomycin Intravenous every 12 hours for osteomyelitis for six weeks.Review of Provider Progress Note, dated 3/25/26, reflected, [named R2] is a [AGE] year-old woman seen today for chronic disease management and evaluation of her ER[emergency room] visit. She was sent to ER because she is starting antibiotics for osteomyelitis. They were unable to have it placed in the facility due to difficult insertion. Therefore she was sent to ER for placement and returned with a left arm PICC[peripheral inserted central catheter] line. She will begin antibiotics today. Pain Level: 10.Other osteomyelitis, multiple sites:1. PICC line placed into left arm2. Start Vancomycin every 12 hours today through 5/6 - dosed per pharmacy3. Start Meropenem 1 gram every 8 hours through 5/64. Start Flagyl 500 mg every 6 hours through 5/6.Review of R2 History and Physical, dated 4/8/26, reflected, [AGE] year-old female is seen for an admission visit. She was previous at our facility for long-term care and continued wound treatments. She has a history of quadriplegia and has non-healing sacral decubitus ulcers. She underwent a colostomy to help with care of her wound and frequent infections.Pain level 8.Review of R2 Change of Condition assessment, dated 4/9/26, reflected, Nursing observations, evaluation, and recommendations are: Patient was c/o[complaint of] pain r/t[related to] sacral wound. Patient rated pain 10/10 and refused scheduled and PRN[as needed] pain medications stating she just wants to go to the ER for pain medication.Review of R2 Skin Issue assessments, dated 4/14/26 to 6/8/26 reflected facility acquired stage 3 bilateral thigh pressure wounds were present on admission 4/6/26 as well as left lateral foot stage 3 facility acquired pressure wound and sacrum stage 4 pressure wound.Review of R2 Nurse Progress Note, dated 4/30/26, reflected, Call placed to [wound provider] related to PICC malfunction. Due to antibiotics scheduled to end on 5/4 [named wound provider] gave orders to discontinue abx[antibiotics] now and begin negative pressure wound therapy. Abx orders d/c. wound vac ordered. order to remove PICC entered. Plan discussed with guest and they are in agreement.Review of R2 Skin Issue assessment, dated 6/2/26, reflected, #001: Skin issue has been evaluated. Location: Left lateral foot. Issue type: Pressure ulcer / injury. Progress: Stalled: previously improving wound characteristics plateaued. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Length (cm): 1.75 Width (cm): 1.2 Depth (cm): 0.5 Area (cm2): 1.63 Undermining: No. Tunneling: No. Granulation: 50%. Slough: 50%. Exudate amount: Light.Debridement: Sharp. Other primary dressing: thera honey, collagen Secondary dressing: Foam.#002: Skin issue has been evaluated. Location: Rear right thigh. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin Loss. Length (cm): 3.93 Width (cm): 2.38 Depth (cm): 2 Area (cm2): 7.48 Undermining: No. Tunneling: Yes. Number of tunnels: 1. Tunnel length (cm): 4.5 Tunnel location 1: 12 o'clock. Granulation: 100%. Exudate amount: Moderate. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery.Debridement: Mechanical. Debridement: Sharp. Primary dressing: Negative pressure wound therapy.#003: Skin issue has been evaluated. Location: Sacrum. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Stage 4 Pressure ulcer / injury - full thickness skin and tissue loss.Length (cm): 4.11 Width (cm): 3.25 Depth (cm): 2 Area (cm2): 9.35 Undermining: No. Tunneling: Yes. Number of tunnels: 2. Tunnel length (cm): 4.5 Tunnel location 1: 2 o'clock. Tunnel length (cm): 4.5 Tunnel location 2: 9 o'clock. Granulation: 100%. Exudate amount: Moderate. Exudate type: Serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery. Debridement: Sharp. Debridement: Autolytic. Debridement: Mechanical. Primary dressing: Negative pressure wound therapy.#004: Skin issue has been evaluated. Location: Rear left thigh. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin Loss.Length (cm): 6.01 Width (cm): 4.1 Depth (cm): 1.5 Area (cm2): 16.8 Undermining: No. Tunneling: Yes. Number of tunnels: 1. Tunnel length (cm): 3 Tunnel location 1: 12 o'clock. Granulation: 90. Slough: 10%. Exudate amount: Moderate. Primary dressing: Negative pressure wound therapy.Review of R2 Skin Care Plans, dated 11/14/25 with last revision 6/10/26, reflected R2 included, [named R2] has an actual impaired skin integrity r/t: Stage 4 Sacrum, stage 3 left lateral foot, Left rear thigh stage 3, Right rear thigh stage 3, DTI right heel DTI left heel.[named R2] refuses to be repositioned while in bed. [named R2] refuses dressing changes [named R2] has a wound vac bridged from sacrum to bilateral thighs [named R2] prefers wound vac application be completed by wound nurse. Date Initiated: 11/14/2024.Revision on: 06/10/2026. Continued review of R2 care planned interventions included, Air mattress Date Initiated: 12/05/2025. Encourage [named R2] to allow repositioning to alleviate pressure areas Date Initiated: 01/07/2025 .(revised 6/6/25 to read as follows) Encourage [named R2] to allow repositioning in bed and wheelchair to alleviate pressure areas. Roho cushion Date Initiated: 08/11/2025. Supplement as ordered Date Initiated: 12/17/2024. Provide _1:1___ assistance with eating or drinking as needed. Date Initiated: 07/16/2025.Review of Treatment Administration Records(TAR), dated 1/1/26 through 6/12/26 reflected several holes(missing documentation indicating treatments not completed) on record.During a telephone interview on 6/12/26 at 11:26 a.m., Licensed Practical Nurse (LPN) I reported R2 had wound vac ordered prior to recent room change then changed to wet to dry then changed again and had not cared for R2 recently. LPN I reported R2 preferred to be up in chair all day and verified motor chair was able to position back for position changes and offloading. LPN I reported R2 would occasionally refuse to have dressings changed when up in chair and reported if residents refused staff expected to document on TAR and then complete progress note. During an interview on 6/12/26 at 11:50 a.m., LPN J reported completed R2 left later foot dress on 6/11/26 evening and verified no dressing was in place prior to completing physician ordered treatment including kling wrap.During an interview on 6/12/26 at 1:55 p.m. WN G reported had been facility wound nurse for five months and as not currently wound care certified. WN G reported R2 admitted with sacral wound on 11/13/24 and verified had declined and was currently a stage 4 pressure wound. WN G reported R2 also currently had both right and left posterior thigh stage 3 pressure wounds that were facility acquired that presented as deep tissue injuries on 1/9/26. WN G verified R2 also had a current stage 3 facility acquired left later foot pressure wound that was identified on 11/23/25. WN G was quired, What led to R2 facility acquired bilateral posterior thigh pressure ulcers on 1/9/26. WN G stated, the wheelchair she is in. WN G reported R2 does not allow staff to lay her down and report R2 up until 3:00am to 4am at times. WN G verified R2 had motor chair that was able to recline to offload and verified had observed R2 in that position. WN G reported had educated R2 of importance of offloading including when up in motor chair. Requested evidence of resident education be provided. WN G verified R2 had specialized cushion in motor chair. WN G reported R2 refused to have any other staff except WN G complete wound vac treatment and reported that is why R2 is only scheduled for every Tuesday and Friday wound vac dressing changes. WN G reported R2 recently had colostomy to aid in wound healing related to frequent wound infections and wound decline including osteomyelitis in sacral wound. WN G was last treated for osteomyelitis in May 2026 with intravenous (IV) antibiotic treatments. WN G' reported facility wound physician rounds weekly and provides treatment orders including R2 current wound vac orders. WN G reported R2 wound vac removed when signs of infection and then resumed after antibiotic treatment complete and reported wound physician and not ever had three wounds bridged prior to R2. WN G reported had prior experience with wound vac treatment prior to facility including bridging wounds. Requested supporting evidence that all three wounds could be bridged together, pulling wound drainage directly over other wounds including stage 4 pressure wound with history of osteomyelitis. WN G verified R2 was high risk for skin breakdown on admission and continued to be high risk and verified would expect staff to follow care plans including assistance with turning and repositioning, and assistance with feeding. WN G verified forgets to document treatments completed on TAR during wound rounds and verified holes on TAR included more areas than just treatment days and reported staff should always document on TAR including if resident refuse and progress note should be linked. WN G verified R2 lateral foot dressing change was not completed as ordered on 6/9/26 or on 6/10/26 according to R2 EMR and verified hole on R2 TAR and reported was related to timing of order transcription. During an interview on 6/13/26 at 3:30 p.m., Director of Nursing (DON) B' reported would expect staff to follow physician orders and document on Treatment Administration Record (TAR) if treatments completed or refused and verified would not expect holes on TAR. DON B' reported would expect Certified Nurse Aids to follow Kardex and staff to educate residents if they refuse Care Planned interventions or physician orders and document. DON B reported facility Wound Physician notes not available after 5/26/26 related to physician under review and auditing purposes. DON B reported acceptable practice to bridge wounds with wound vac directly from one wound over another and wound. Requested supporting documentation along with facility wound Policy.Review of the facility provided, Negative Pressure Wound Therapy (NPWT) Procedure, revised 4/21/26, reviewed by Academy of Medical-Surgical Nurses, reflected, Special Considerations *If the patient has multiple wounds of a wound smaller than 1.6 (4 cm) that requires NPWT, specific techniques may be indicated. (See Strategies for multiple and smaller wounds.) STRATEGIES FOR MULTIPLE AND SMALLER WOUNDS Depending on the size of wound or the number of wounds, you may use the bridging or picture framing technique for negative pressure wound therapy (NPWT). Bridging. When a patient has [NAME] than one wound of similar origin and the wounds are positioned in close proximity, one NPWT unit can be used to treat them. Wounds that are infected shouldn't be bridged with noninfected wounds.After the foam dressing is placed inside the wounds, connect the wounds using another piece of foam (a bridge piece). Ensure that all the foam pieces directly touch. Place the vacuum pad in a central area in a manner that prevents one wounds drainage from being pulled across another. (observed each of R2 posterior thigh wounds bridged directly over R2 stage 4 sacrum pressure wound.)Prior to completion of survey and survey exit the facility failed to provide supporting evidence that all three of R2 pressure wounds could be directly bridged together. No supporting evidence regarding pulling wound drainage directly over other wounds including stage 4 pressure wounds. The facility failed to provide requested supporting documentation that R2 had been educated on refusal of care planned interventions to support wound healing.

This citation Pertains to Intake 2989698. Based on interview and record review the facility failed to follow a physician order to administer an anti-seizure medication for one resident (Resident #4) of one resident reviewed for seizure medication. Findings include: Review of the clinical record, including the Minimum Data Set (MDS) 3/25/26 reflected Resident 4 (R4) was a [AGE] year-old female admitted to the facility with diagnoses that included epilepsy and seizure disorder on 06/02/21 with a readmission date of 4/14/26. R4 was scored 14 out of 15 on the Brief Interview for Mental Status (BIMS). Further review of R4's electronic medical record (EMR) revealed R4 had a seizure on 4/11/2026 that lasted approximately 30 minutes and resulted in a hospitalization. Review of R4's April 2026, monthly Physician orders for revealed a Physician order for Midazolam solution 5 Milligram/0.1 Milliliter 1 spray in nostril every 24 hours as needed for active seizure. May give additional spray in opposite nostril after 10 minutes if no response from the first dose the patient does not have difficulty breathing or is not excessively sedated. Review of the medication administration audit revealed one dose of Midazolam was administered by Registered Nurse (RN) F on 4/11/26 at 11:46 pm. There was no documentation that R4 was given the second dose of Midazolam, nor was there any documentation that the medication was held due to R4 having difficulty breathing or being excessively sedated. On 6/10/2026 at 3:00 PM, during an interview with Director of Nursing (DON) B, she reported RN F was no longer employed at the facility, an attempt to interview RN F was made via telephone, voice mail requesting return call was made with no response on 6/10 and 6/11. DON B offered no explanation why RN B did not administer the second dose of Midazolam. It was discussed that Midazolam comes from pharmacy in a two pack of single use doses. Review of Physician progress note dated 4/11/2026 revealed they received a call from a nurse at the facility who reported R4 was having a seizure and the nurse requested Inter Muscular (IM) Ativan. A Verbal order for 2mg/ml give 1mg (0.5ml) IM one time dose was given. Nurse then reported all IM Ativan had been pulled from out of back up. Verbal order was then given to transfer R4 to hospital. Review of the controlled substance log for R4 reflected one dose of Midazolam was administered to R4 on 6/26/25, leaving one dose, thus after the 4/11/26 dose was administered that left the count at 0, thus the second dose of Midazolam that was to be administered on 4/11/2026 was not available, along with the IM Ativan that was not available. On 6/12/26 at 11:40 am during an interview with DON B she reported the Midazolam was not administered to R4 because the Midazolam was not available, DON B acknowledged according to the Physician Orders two doses of Midazolam should be available at all times and should have been reordered on 6/26/25 after the nurse administered the initial dose.

This citation pertains to intake: 2685213Based on observation and interview, the facility failed to maintain infection control practices for two resident shower rooms out of three resident shower room observations. Findings Included:On 01/27/2026 at 09:35 a.m. during observation of shower room (across form room [ROOM NUMBER]) the following was observed: soiled linen was on the floor, next to a cabinet, 3 empty bottles of shampoo on the assist bar of the shower and not labeled for any resident, an unused brief on the back of the sink, a black comb with hair present and not labeled with any resident name on top of the paper dispenser. On 01/27/2026 at 11:55 a.m. during observation of shower room (across from coffee shop) the following was observed: a hand size pile of dark colored hair on the shower floor near the drain, corner tile was missing on the corner of the shower, and tile missing near the toilet paper dispenser. On 01/28/2026 at 12:42 p.m. during observation with Director of Nursing (DON) B of shower room (across from room [ROOM NUMBER]) the following was observed: soiled resident clothing on the floor, soiled towels on the floor, soiled towel on shower stretcher, unused brief on the back of the sink, and a black comb with hair present and not labeled with any resident name on top of the paper dispenser. During this observation DON B explained that resident clothing and soiled linen should not be placed on the floor. DON B also explained that resident personal items should be labeled accordingly. DON B explained that this observation did not meet infection control standards of practices. On 01/28/2026 at 12:52 p.m. during observation with Director of Nursing (DON) B of shower room (across from the coffee shop) the following was observed: one used bottle of shampoo without residents name on assist bar, bottle of body cleanser without residents name, toilet bowel plunger beside the toilet not covered and resting on the floor, corner tile was missing on the corner of the shower, and tile missing near the toilet paper dispenser. During this observation DON B explained that the missing tile prevented the shower and near the toilet to have a cleanable surface. DON B also explained that toilet plunger should have been placed in a bag and should not have been just setting on the floor.

This citation pertains to intact 2685213Based on observation, interview, and record review, the facility failed to provide showers/baths for two Residents (#1, #5) of three Residents reviewed.Findings Included:Resident #1 (R1):Review of the medical record demonstrated that R1 was admitted to the facility on [DATE] with diagnoses that included aortic valve stenosis, dry eye syndrome of bilateral lacrimal glands (lack of tears), hyperlipidemia (high fat content in blood), rectal prolapse (a condition where the rectum protrudes from the anus), osteoarthritis (degenerative joint disease) right ankle and foot, repeated fails, osteoporosis (weak and brittle bones), right foot drop, depression, peripheral venous insufficiency, hypothyroidism (low thyroid hormone), borderline personality disorder, anxiety, and dementia. Review of R1's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/20/2025, revealed R1 had a Brief Interview for Mental Status (BIMS) of 11 (moderate cognitive impairment) out of 15. Review of Section GG- Functional Abilities of the MDS, with the same ARD, revealed R1 required partial/moderate assistance with shower/bathing of self. On 01/27/2026 at 09:53 a.m. R1's family member C explained that R1 was not receiving her showers/baths twice per week.On 01/28/2026 at 09:44 a.m. during observation and interview R1 was observed lying down in bed and appeared well groomed. R1 explained that she does not always receive a bath/shower twice a week. R1 could not verbalize what days or times she was to receive a bath/shower each week.Review of document entitled North Hall Showers revealed 318-2 (R1's room location) was to receive a shower/bath every Monday and Thursday during the day shift.Review of R'1s point of care task (PCT-documentation that demonstrates completed task performed for residents by direct care staff) for shower/bathing revealed that the task was scheduled on Mondays and Thursdays during the day shift. Review of R1's PCT documentation for shower/bathing for November 2025 revealed R1 only received one shower/bathing during the week of November 16th, which was completed on 11/19/2025. Review of R1's PCT documentation for shower/bathing for December 2025 revealed R1only received one shower/bathing during the week of December 14th, December 21st, and December 28th. Review of R1's PCT documentation for shower/bathing for January 2026 revealed R1 only received one shower/bathing during the week of January 4th and January 11th. Resident #5 (R5)Review of the medical record demonstrated that R5 was admitted to the facility on [DATE] with diagnoses that included paralysis of right side following cerebrovascular disease (stroke), bilateral osteoarthritis (degenerative joint disease) of knee, depression, abnormal posture, right hand contracture, hypertension, hyperlipidemia (high fat content in blood), cocaine abuse, nicotine dependence, and chronic kidney disease. Review of R5's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/05/2026, revealed R5 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. Review of Section GG- Functional Abilities of the MDS, with the same ARD, revealed R1 required substantial/maximal assistance with shower/bathing of self. On 01/27/2026 at 11:43 a.m. during observation and interview R5 was observed lying down in bed and appeared to be well groomed. R5 explained that he does not always receive a bath/shower twice per week. Review of document entitled Skilled Hall Showers revealed 118-2 (R5's room location) was to receive a shower/bath every Monday and Thursday during the evening Review of R5's point of care task (PCT-documentation that demonstrates completed task performed for residents by direct care staff) for shower/bathing revealed that the task was scheduled on Mondays and Thursdays during the evening shift. Review of R5's PCT documentation for shower/bathing for November 2025 revealed R5 did not receive shower/bathing during the week of November 16th (refused once but no other documentation present for 2nd shower). Review of R5's PCT documentation for shower/bathing for December 2025 revealed R5 had not received shower/bathing during the week of December 1st and December 21st. Review of R5's PCT documentation for shower/bathing for January 2026 revealed R5 only received one shower/bathing during the week of January 11th and R5 had not received any shower/bathing during the week of January 18th.In an interview on 01/28/2026 at 10:07 a.m. Director of Nursing (DON) B explained that it is her expectation that residents are to receive shower/bathing according to their plan of care. DON B explained that shower schedules are maintained at each nurse's station which informs staff when shower/bathing is to be completed. DON B explained that documentation of shower/bathing is completed in point of care task (PCT-documentation that demonstrates completed task performed for residents by direct care staff). DON B was asked to review R1's PCT shower/bathing documentation and R5's PCT shower/bathing documentation. DON B confirmed that R1 and R5 had not received showers as identified on their PCT documentation. DON B could not explain shower/bathing had not been completed twice a week for R1 and R5.

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). 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 the residents in the facility.Findings include:On 9/16/25 at 1:56 PM, Observation of the 300 hall Tub room found that discolored water came from the tub and sink of the room. An interview with Maintenance Director (MD) H found that staff do not regularly use this room, but he uses the tub to help clean maintenance items sometimes. The hot water ran at the tub for a few minutes and slowly started to clear up over time. When asked if he sees the water this color anywhere else in the facility, MD H stated no, and that even the spa tub the facility has clear water when filled up. When asked about flushing of stagnant lines in the facility, MD H stated that he has a monthly work order to flush the hot water tank, but not specific fixtures.On 9/16/25 at 3:01 PM, AN interview with MD H found that he takes free chlorine samples to ensure a level of disinfection in the facilities water supply. A review of samples taken shows a range of concentrations above .2 parts per million (ppm), which is stated as the facilities control limit. When asked how these tests are performed, MD H demonstrated a test using the facilities digital colorimeter. A review of the test performed found that phenyl red reagents were being used to help determine chlorine concentration, and these reagents are only for finding the pH of the water and not for determining the concentration of free chlorine. Upon following the manufactures directions for finding free chlorine, the free chlorine level from the hot water out of the men's locker room sink was found to be .04 ppm. A review of the facility provided documents for the Water Management Plan, found no updated risk assessment that showed a facility description of water flow and building design. A record review of the facility provided document entitled, Water Management Program, last revised 2/1/2024, found that, Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key activities are routinely performed in a Legionella water management program. B. Describe the building water systems using flow diagrams and a written description. Further review of the document found that, The general principles of an effective water management program include.Preventing water stagnation.Ensuring adequate disinfection.

Based on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living. Findings Include:On 9/16/25 at 9:50 AM, Observation of the kitchen main exhaust ventilation for the cook line found four ventilation filters ajar from position as well as having gaps between some of the filters. Filters should be placed snug and tight together to effectively filter out grease. On 9/16/25 at 11:14 AM, Observation of the 100 Hall shower room found dried brown and black smudges on the privacy curtain for the commode. On 9/16/25 at 11:17 AM, Observation of the 100 Hall Mr. Slim rooftop unit found an accumulation of black spotted debris on the surface of the plastic guard and grates where air is expelled. On 9/16/25 at 11:23 AM, Observation of the 400 Hall linen closet found that blankets and pillows were stored on the bottom of the open wire rack shelving, with no bottom barrier to protect clean linens from contamination due to cleaning. On 9/16/25 at 11:26 AM, Observation of the 200 Hall Shower room found hair a debris on the flower of the shower area and drain of the shower. Further observation found a used washcloth in the sink. On 9/16/25 at 1:30 PM, Observation of the laundry room, with Maintenance Director (MD) H, found that two carts used to help move clean linen through the washing and drying process were found with an increased accumulation of paper and plastic trash along with dirt debris under their bottom support floor (used to help bring linen to the top of the cart). On 9/16/25 at 1:54 PM, Observation of the 300 Hall Mr. Slim rooftop unit found an accumulation of black spotted debris on the surface of the plastic guard and grates where air is expelled. On 9/16/25 at 2:03 PM, Observation of the 300 Hall shower room found a strong odor upon entry and a yellowish puddle near the front of the commode. Further observation of the room found that the underside of the shower bed was heavily discolored in a black accumulation. On 9/16/25 at 2:20 PM, Observation of resident room [ROOM NUMBER] found a broken tile on the windowsill that developed sharp edges. Further review of the window sill found an accumulation of dust and dead insects. On 9/16/25 at 2:28 PM, Observation of the main dining room sitting area found a brown love seat with heavy orange and pink staining underneath the cushion. Further observation found an accumulation of dirt debris in the side and back crevices of the couch. On 9/16/25 at 2:32 PM, Observation of the 200 Hall Mechanical room found a mop sink faucet with and warm handle to the cold-water supply indicating hot water is bleeding into the cold-water supply from this fixture. On 9/16/25 at 2:38 PM, Observation of the 100 Hall shower room found both shower curtains with discoloration on a large portion of the bottom sections of the curtains as well as an accumulation of black spotted debris. On 9/16/25 at 3:32 PM, An interview with Housekeeping Manger J, found that staff try to get to each privacy curtain once and month or as needed.

Based on observation and interview, the facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120 F. This resulted in an increased risk of injury among residents in the facility. Findings Include:On 9/16/25 at 1:42 PM, with Maintenance Director (MD) H, Observation of the boiler room in the service hall found that the outgoing water temperature to resident care areas was showing 133F. An interview with MD H found that water temperatures for domestic use usually run around 110F as they are tempered with point of use mixing valves at each faucet. On 9/16/25 at 2:01 PM, Observation of the 300 Hall shower room found that both showers reached 130F and the sink was 112F when tested with a rapid read thermometer. When asked about how often water temperatures are taken, MD H stated that he does about 15 fixtures each week, which puts him at a frequency to test each fixture about once every two months. When asked if the showers themselves are part of the temperature checks, MD H stated that his focus has been on resident room fixtures, and the showers have not been part of the regular testing. On 9/16/25 at 2:42 PM, Observation of the 100 Hall shower room found that one of the two showers reached 130.8F when tested with a rapid read thermometer. An interview with MD H found that he would start adding the showers to temperature checks and make sure the mixing valves inside the shower fixtures were adjusted to lower the temperature.

Based on interview, and record review the facility failed to ensure accurate advance directive (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for one resident (#110) of one resident reviewed for advance directives from a total sample of 23 residents.Findings include:Review of the clinical record, including the Minimum Data Set, dated [DATE] revealed Resident #110 (R110) was admitted to the facility on [DATE] with diagnosis that included chronic kidney disease. R110 scored 13 out of 15 (cognitively intact) on the Brief Interview Mental Status (BIMS). Further review of R110's electronic medical record reflected R110 signed an advanced directive for Do Not resuscitate (DNR), meaning if the heart and breathing should stop, no attempts were to be made to resuscitate R110. R110 signed the Advance Directive form on June 11, 2025. R110's signature was no be witnessed by two persons. The form did have one witness signature and was dated June 11, 2025, the other witness signature was dated June 12, 2025. On 09/17/2025 4:04 PM during an interview with Licensed Practical Nurse [NAME] LPN G she offered no explanation for signing as a witness to a signature after the fact.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one (R30) of 23 reviewed.Findings include:Review of the medical record reflected R30 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included left hand contracture, bipolar type schizoaffective disorder, depressive type schizoaffective disorder and major depressive disorder. The Quarterly MDS, with an Assessment Reference Date (ARD) of 8/9/25, reflected R30 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had upper extremity impairments on both sides. R30's medical record included a document, dated 11/27/24, which reflected an OBRA Level II evaluation was completed. The Annual MDS, with an ARD of 2/6/25, reflected a response of No for question, A1500. Preadmission Screening and Resident Review (PASRR) .Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?. During an interview on 09/18/25 at 2:16 PM, MDS Nurse H reported they coded the response to MDS question A1500 and reviewed the medical record for an OBRA letter to do so. MDS Nurse H reported R30's OBRA letter was dated 11/27/24, but it did not state that R30 had a serious mental illness. According to MDS Nurse H, schizophrenia did not qualify as a serious mental illness for the MDS, and they were looking for things such as epilepsy and developmental delay. R30's Comprehensive Level II Evaluation for 11/2024 was marked for mental illness and reflected Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnoses of, Schizoaffective disorder, unspecified-Primary and Unspecified neurocognitive disorder-Secondary. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024 reflected, .A1500: Preadmission Screening and Resident Review (PASRR) .Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD [intellectual disability/developmental disability] or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions .

Based on interview and record review, the facility failed to ensure coordination of care with Community Mental Health (CMH) for one (R30) of one reviewed.Findings include: Review of the medical record reflected R30 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included left hand contracture, bipolar type schizoaffective disorder, depressive type schizoaffective disorder and major depressive disorder. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/9/25, reflected R30 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had upper extremity impairments on both sides. R30's medical record included a document, dated 11/27/24, which reflected an OBRA Level II Evaluation was completed. A Level II Evaluation was not noted in R30's medical record. During an interview with Social Worker (SW) C and SW D on 09/17/25 at 11:49 AM, it was reported that CMH provided the facility with copies of their Level II Evaluations, which were reviewed to determine if anything from CMH needed to be added to the Care Plan. The Level II was then given to the Medical Records department to scan into the medical record. When asked if they had received R30's Level II Evaluation (from 11/2024), they reported they would find out. On 09/18/25 at 1:28 PM, SW D reported CMH had emailed a copy of R30's Level II Evaluation (since the interview on 9/17/25), which he would scan into the medical record. SW D acknowledged he had not yet read/reviewed the Level II Evaluation. R30's Level II Evaluation for 11/2024 reflected 15 items listed under the section for PROPOSED PROGRAMS/OBJECTIVES FOR TREATMENT PLANNING, which included but were not limited to recommendations that R30 be assessed by the therapy department to determine if they could utilize a cup with a handle or another option for independent fluid consumption and that R30 undergo further evaluation for a neurocognitive disorder.

Based on observation, interview and record review, the facility failed to implement the Care Plan for one (R30) of 23 reviewed.Findings include:Review of the medical record reflected R30 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included left hand contracture, bipolar type schizoaffective disorder, depressive type schizoaffective disorder and major depressive disorder. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/9/25, reflected R30 scored three out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had upper extremity impairments on both sides. R30's Care Plan reflected they were to wear palm protectors to both hands during the day, as they would allow. The palm protectors were Care Planned that they could be removed for hygiene, meals and at night. On 09/16/25 at 12:03 PM, R30 was observed in a broda chair, in the dining room. R30's left hand was noted to be flexed into a fist. Their right hand was flexed, but their index finger was observed to be extended. Palm protectors were not observed to be in place. On 09/18/25 at 1:31 PM, R30 was observed in bed, with their eyes closed. Palm protectors were not observed to be in place. In an interview on 09/18/25 at 1:50 PM, Certified Nurse Aide (CNA) F reported they did not routinely care for R30 and were not aware of any orthotic devices they were to wear. CNA F reported they reviewed R30's Kardex (CNA care guide) that morning and did not recall seeing palm protectors listed. Review of R30's Kardex reflected they were to wear bilateral palm protectors during the day, as they would allow.

Based on observation, interview and record review, the facility failed to provide an effective bowel management program for one (Resident #64) of one reviewed, resulting in the potential for constipation.Review of the clinical record revealed R64 was admitted into the facility on 7/1/25 with diagnoses that included: muscle weakness and difficulty walking. According to the Minimum Data Set (MDS) assessment dated [DATE], R64 scored 11/15 on the Brief Interview for Mental Status exam (which indicated moderately impaired cognition).On 9/16/25 at 12:41 PM R64 was observed lying on his side in bed. R64's lunch tray was observed on his tray table with only a few bites gone. R64 reported that he didn't want to eat more because the food made him constipated. He further reported that he had suffered from constipation for about a month. When asked if he was receiving medication to help, he reported not to his knowledge.A review of R64's task log (documentation of residents' bowel movements) for the past 30 days, revealed no bowel movement documented during the following date spans:8/22/25-8/25/25 (4 days)8/27/25-8/28/25 (2 days)9/7/25-9/8/25 (2 days)9/10/25-9/12/25 (3 days)A review of R64's physician orders revealed the following prn (as needed) orders for constipation:Miralax 17gm every 24 hours prn constipationMOM (Milk of Magnesia) 30mls prn constipation dailyA review of R64's Medication Administration Record for August and September revealed:Miralax given on 8/25 and 8/26 onlyMOM had not been administered in August or SeptemberA review of R64's progress notes and MAR revealed no additional documentation that resident was offered medication or other interventions for constipation.On 9/18/25 at 1:53 PM, during an interview with Director of Nursing (DON) B, she reported that her expectation for monitoring for constipation would be if no bowel movement for 3 days that they would offer an intervention and review/document the resident's normal bowel pattern. DON B reported that the facility does not have a structured bowel management program or any associated facility policy. DON B reviewed R64's electronic health record and reported the things she hoped would be there were not (documentation).

This citation pertains to Intake #MI00149504 Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act 42CFR483.12(c) Findings include Resident #1 (R1) Review of the medical record reflected R1 was an initial admission to the facility on [DATE]. Diagnoses of unspecified fracture of upper end of left humerus, subsequent encounter for fracture with routine healing, difficulty with walking, Type 2 Diabetes Mellitus, and history of falling. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/2024, revealed R1 had a Brief Interview of Mental Status (BIMS) of 11 out of 0 to 15 being (moderate cognitive impairment). Under section G0100, Activities of Daily Living (ADL) Assistance reveals R1 needs set up assistance for meals and oral hygiene. R1 requires substantial to maximum assistance with showers, toileting, and getting dressed. During an interview and observation on 01/22/25 at 8:24 AM, R1 was eating breakfast in her room. R1 was sitting in her wheelchair with the over the bed table in front of her. R1 stated that R9 hit her and added that he hit her on the left arm that was broken. R1 stated she was sitting in her wheelchair, out in the hallway. R1 then stated R9 moves around the facility in his wheelchair. R1 then stated R9 rolled his wheelchair up to hers and purposefully hit her a couple of times in the left arm. R1 stated that it startled her, and it hurt where R9 hit her. During an interview on 01/22/25 at 11:30 AM with LNA A, writer asked for the incident report and investigation on the resident-to-resident incident on 01/09/25 between R1 and R 9. LNA A stated he had started one yesterday as writer entered the building and would go get it. Upon reading the incident report, it was as followed: Incident Description reads, another resident made contact with this resident left shoulder. Doctor notified and a shoulder Xray was ordered due to it being the shoulder that was post-op. Under section was this incident witnessed: Patient stated that she was experiencing no increased pain in shoulder. Stated that she does not feel the other resident hit her on purpose. Incident report completed by Licensed Practical Nurse (LPN) G. Writer asked LNA A if he reported this incident of resident to resident to the state, and he stated no. During an interview on 01/22/25 at 12:08PM, LPN G stated that R9 had come up to R1 and purposefully hit her a couple of times in the left shoulder. LPN G stated R1 complained of pain, and the Nurse Practitioner (NP) L was still in the building, and she came over to assess R1. LPN G stated the process is to make sure both residents are safe, contact LNA A then go through the incident report. LPN G stated, they look at new interventions to prevent it from happening again. LPN G stated R1 was sitting in her wheelchair up by the nurse's station because she was a fall risk. LPN G also stated they changed R1's room so she would not be close to R9, however R9's room was not changed. LPN G stated she re-assessed R1 and it should be documented in the nursing progress notes. LPN G also stated they usually assess residents for 3 days and they were assessing that area due to R1 still having staples in arm. LPN G also stated that R1 did have left arm/shoulder pain following the incident, but by the time she started to fill out the incident report, R1 was no longer having pain in the left arm/shoulder. Record review did not reveal a nursing progress note on this incident from LPN G. No nursing progress notes on this incident from any nursing staff caring for R1. NP L documented R1's . This is a [AGE] year-old female patient being seen today at the request of nursing staff for an altercation involving another resident. The other resident (R9) approached the patient (R1) and then struck the patient on her left injured arm. The patient was very upset and painful. Vital signs were completed, all within range. Her left arm is in a sling. She has staples on her left shoulder from her surgery. The staples are intact and no redness or oozing and no visible edema or ecchymosis. Reevaluated patient prior to leaving for the day and no changes. Pain is managed. Her vital signs are stable . Continue to monitor for increased pain. May need to perform an x-ray after altercation with other residents . During an interview on 01/23/25 at 12:06 PM, LNA A stated R9 goes all over the place in the facility. LNA A stated he was told R9 hit R1 in the shoulder, nurse asked LNA A to come down to the unit. LNA A stated R1 was startled, she told LNA A she was hit, it scared her. LNA A stated that it seemed like it was more of R9 seeking attention kind of thing verses being harmful on the other residents (R1) end. LNA A stated he let the doctor know, didn't see any bruising on her, so they moved her off that hall, to get her closer to the nursing station and away from him (R9). LNA A then stated, this specific incident, no injury, or intent. Writer asked LNA A if the incident was investigated, he stated yes, stated they put interventions in place. Writer asked to see the investigation. Record review revealed R1 had an X-Ray since this was a fresh surgical left arm that was hit.FINDINGS: There is postoperative change with a side plate and screws at the proximal humerus. Fracture alignment maintained. CONCLUSION: Postoperative changes . During an interview on 01/23/25 at 12:30 PM, Unit Manager/RN F stated her and other nurse in her office, Minimum Data Set (MDS) Nurse K stated the changes to interventions would not be on R1's care plan as she didn't do anything wrong, it would be on R9's care plan. During this same interview, MDS Nurse K also stated that R9 cannot go off his unit without supervision. MDS Nurse K added that they cannot stop him from going where he wants to go within the facility, but he would have a supervision with him. Record review of the incident report on the resident-to-resident incident was not completed, areas were left blank and unanswered. It did not mention the fact that R1 had an x-ray ordered for the left shoulder due to the incident and pain in that area. The report did not reflect the results of the X-rays. Writer request for the investigation that went along with the incident report was never provided before the exit of the survey. This resident to resident incident was not investigated or reported to the state. Resident #9 (R9) Review of the medical record reflected R9 was an initial admission to the facility on [DATE]. Diagnoses of Pericardial Effusion, Difficulty walking, Unspecified lack of expected normal Physiological Development in Childhood, Brief Psychotic Disorder, Anxiety, Unspecified Speech Disturbances. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/ 23 /2024, revealed R9 functions at a 9-year-old child. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R9 is dependent of all care. During an interview and observation on 01/22/25 at 8:24 AM, R1 was eating breakfast in her room. R1 was sitting in her wheelchair with the over the bed table in front of her. R1 stated that R9 hit her and added that he hit her on the left arm that was broken. R1 stated she was sitting in her wheelchair and sitting out in the hallway. R1 then stated R9 rolled his wheelchair up to hers and purposefully hit her a couple of times in the left arm. R1 stated that it startled her, and it hurt where R9 hit her. During an interview on 01/22/25 at 11:30 AM with LNA A, writer asked for the incident report and investigation on the resident-to-resident incident on 01/09/25 between R1 and R 9. LNA A stated he had started one yesterday as writer entered the building and would go get it. Upon reading the incident report, it was as followed: Incident Description reads, another resident made contact with this resident left shoulder. Doctor notified and a shoulder Xray was ordered due to it being the shoulder that was post-op. Under section was this incident witnessed: Patient stated that she was experiencing no increased pain in shoulder. Stated that she does not feel the other resident hit her on purpose. Incident report completed by Licensed Practical Nurse (LPN) G. Writer asked LNA A if he reported this incident of resident to resident to the state, and he stated no. During an interview on 01/22/25 at 12:08PM, LPN G stated that R9 had come up to R1 and hit her a couple of times in the left shoulder. LPN G stated R1 complained of pain, and the Nurse Practitioner (NP) L was still in the building, and she came over to assess R1. LPN G stated the process is to make sure both residents are safe, contact LNA A then go through the incident report. LPN G stated R1 did have pain from the hitting of her left shoulder. LPN G stated they look for new interventions, to prevent it from happening again. LPN G stated R1 was sitting up by the nurse's station because she was a fall risk. LPN G also stated they changed R1's room so she would not be close to R9, however R9's room was not changed. LPN G stated she re-assessed R1 and it should be documented in the nursing progress notes. LPN G also stated they usually assess residents for 3 days and they were assessing that area due to R1 still having staples in arm. Record review did not reveal a nursing progress note on this incident from LPN G. No nursing progress notes on this incident from any nursing staff caring for R1. NP L documented R1's . This is a [AGE] year-old female patient being seen today at the request of nursing staff for an altercation involving another resident. The other resident (R9) approached the patient (R1) and then struck the patient on her left injured arm. The patient was very upset and painful. Vital signs were completed, all within range. Her left arm is in a sling. She has staples on her left shoulder from her surgery. The staples are intact and no redness or oozing and no visible edema or ecchymosis. Reevaluated patient prior to leaving for the day and no changes. Pain is managed. Her vital signs are stable . Continue to monitor for increased pain. May need to perform an x-ray after altercation with other residents . During an interview on 01/23/25 at 12:06 PM, LNA A stated R9 goes down all the halls in the facility. LNA A stated he was told R9 hit R1 in the shoulder, nurse asked LNA A to come down to the unit. LNA A stated R1 was startled, she told LNA A she was hit, it scared her. LNA A stated that it seemed like it was more of R9 seeking attention kind of thing verses being harmful on the other residents (R1) end. LNA A stated he let the doctor know, didn't see any bruising on her, so they moved her off that hall, to get her closer to the nursing station and away from him. LNA A then stated, this specific incident, no injury, or intent. Writer asked LNA A if the incident was investigated, he stated yes, stated they put interventions in place. Writer asked to see the investigation. During an interview on 01/23/25 at 12:30 PM, Unit Manager/RN F stated. Her and other nurse in her office, Minimum Data Set (MDS) Nurse K stated the changes to interventions would not be on R1's care plan as she didn't do anything wrong, it would be on R9's care plan. During this same interview, (MDS) Nurse K also stated that R9 cannot go off his unit without supervision. MDS Nurse K added that they cannot stop him from going where he wants to go within the facility, but he would have a supervision with him. Record review of R9's care plan revealed under Need: R9 had an actual behavior problem R/T: Patient will pinch, hit and kick. Patient will throw items such as remote and silverware during mealtimes. Patient will put self onto floor. Per guardian, patient will sit on the floor per preference. Guest will lay down on the floor when he is tired Date Initiated: 12/26/2024, Revision on: 01/04/2025. Under Goal: Patient will have fewer episodes of behaviors by review date. 12/26/2024, Target Date: 02/06/2025. Under Interventions: Guest needs plastic silverware no knives, 2-person care for ADL's. If patient get combative, ensure patient is safe and reapproach. Patient likes to hug and expresses emotion through hands. Will sometimes touch without meaning harm. Redirect resident. Document behaviors, and resident response to interventions. Ensure resident doesn't get in reach of other residents during increased supervision during waking hours. Move guest to lower stimulus environment when guest becomes agitated. Offer to wheel resident around facility as this is calming to him. Set firm boundaries and let patient know this is not appropriate behavior. Record review of a nursing progress note reported dated 12/29/2024 at 5:29PM, Behavior Note Text . Throughout the day resident was sitting at nurses' station and staff was watching his iPad with him. He was happy and calm and cooperative at this time of watching it with him. While in the middle of his show he became upset and started to grab this nurse's arm scratching her, hitting her, and attempting to bite her. Staff offered toys/games/movies in his room. He again was cooperative with nurse playing with his toys with him when he again lashed out and took the toy and struck the nurse in the head/shoulder. He then proceeded to run up the hallway knocking off papers, phones, med cups, gloves, iso carts, chairs down. He was not able to be redirected, and all interventions were exhausted. Staff administered compound medication of Ativan, Benadryl and Haldol (ABH) cream. This was only mildly effective. He has had outburst throughout the entire day of this caliber. Staff had notified on call manager and administrator of his behaviors. He does calm with time but will repeat this behavior . Record review of a nursing progress note reported dated 12/30/2024 at 3:23 PM, Resident left to go to [NAME] Battle Creek (BBC) emergency room (ER) for evaluation/treatment related to behavioral symptoms and aggression towards staff. Patient left facility on stretcher with Emergency Medical System (EMS). Record review of a social work progress note reported dated 12/30/2024 at 4:27 PM, Guardian informed patient petition for inpatient psych sent to BBC for behaviors and aggression towards others. Guardian would like for patient to go to inpatient psych. Rapport with BBC social worker given. Record review of a nursing progress note reported dated 12/30/2024 at 6:06 PM, Resident arrived back to facility. No new orders at this time. Record review of a nursing progress note reported dated 1/4/2025 at10:39 PM, Guest walking around the unit and upset because his tablet is not charged, however staff has been plugging it in and he will immediately unplug it and use it until the battery dies. Guest throwing stuff on the unit pulling things off the wall, grabbing and pinching staff attempts to redirect unsuccessful, ABHR cream applied, and guest settled down laying on the floor trying to sleep, staff attempted to get guest to bed and guest declined, guest made safe on the floor per his preference and continued to encourage guest to lay down in bed. Record review of a nursing progress note reported dated on 1/9/2025 at 4:01AM, Guest was aggressive with staff at the beginning of the shift this evening. He was choosing to throw items around the nurse's station, throw pens at the nurse, and hit the nurse with closed hands. After multiple attempts by staff, he eventually calmed himself with the help of his tablet and sat on his bed watching television. He has been up periodically throughout the night with no further issues. Record review of a nursing progress note reported dated 1/19/2025 00:00 Telehealth - Nurse states that guest is still not sleeping, he does have anxiety and is having a rough night. He is pacing and running up and down the hallways, hitting the wall, and just unable to be calmed. He is already on melatonin 10mg and 0.5mg of Ativan and neither are helping. Advised to give trazodone 50mg x1. Update: nurse reports that script was effective. Record review of a nursing progress note reported dated 1/19/2025 at 02:00 AM, Behavior Note: Guest has struggled this shift to regulate his emotions. He has been anxious and running about the facility with staff close behind. He is expressing desire to go home but is not seeking exit. This nurse gave his PRN dose of Ativan without relief and was able to obtain a one-time order for trazodone 50mg which was effective and allowed him to rest. Phone call was placed to guardian with no answer. Administrator and on call nurse notified. Record review of a nursing progress note dated 1/20/2025 at 4:11pm, Patient has been extremely agitated and physically & verbally aggressive this shift. He has been screaming, running through hallway, throwing things off the nurse's desk, knocking things over, slamming his room and other patient's room doors. He bit this nurse on the breast, abdomen, and arm. Several attempts were made to redirect patient and were ineffective. PRN ABH gel was administered and unsuccessful. Patient then began to hit himself in head and bang head against wall. No injuries were noted. Patient hit, bit, and pinched several other staff members. Management was notified of this. Patient was eventually calmed down and given different options to keep him entertained such as coloring pages, a blow-up set of dice, and playing catch with staff. Record review of a nursing progress note reported dated 1/22/2025 at12:49 PM, Patient grabbed this nurse by the hand, breaking the skin. He then knocked over desktop computer multiple times, tried knocking over printer, and repeatedly slammed bedroom door. Redirection was unsuccessful, PRN ABH gel applied. Patient is now sitting watching tablet in chair near nurse's desk. Record review did not reflect any new interventions added to R9's care plan following the resident-to-resident altercation between R1 and R9 on 01/09/2025. Care plan was not updated following any of the behavioral incidents from 12/30/2024 through 01/22/2025. Care goal was updated to 02/06/2025. Record review of progress notes did not reflect any documentation of the resident-to-resident altercations between R9 and R1 on 01/09/2025 in his medical records. Nor did it reflect any new interventions placed in his care plan to protect other residents.

This citation pertains to Intake #MI00149504 Based on interview and record review the facility failed to thoroughly investigate allegations of abuse for one of two residents (R1, R9) reviewed for abuse from a total sample of nine; resulting in known allegations of abuse to go uninvestigated and the potential for abuse to occur with no intervention or protection. Findings include: Resident #1 (R1) Review of the medical record reflected R1 was an initial admission to the facility on [DATE]. Diagnoses of unspecified fracture of upper end of left humerus, subsequent encounter for fracture with routine healing, difficulty with walking, Type 2 Diabetes Mellitus, and history of falling. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/2024, revealed R1 had a Brief Interview of Mental Status (BIMS) of 11 out of 0 to 15 being (moderate cognitive impairment). Under section G0100, Activities of Daily Living (ADL) Assistance reveals R1 needs set up assistance for meals and oral hygiene. R1 requires substantial to maximum assistance with showers, toileting, and getting dressed. During an interview and observation on 01/22/25 at 8:24 AM, R1 was eating breakfast in her room. R1 was sitting in her wheelchair with the over the bed table in front of her. R1 stated that R9 hit her and added that he hit her on the left arm that was broken. R1 stated she was sitting in her wheelchair, out in the hallway. R1 then stated R9 moves around the facility in his wheelchair. R1 then stated R9 rolled his wheelchair up to hers and purposefully hit her a couple of times in the left arm. R1 stated that it startled her, and it hurt where R9 hit her. During an interview on 01/22/25 at 11:30 AM with LNA A, writer asked for the incident report and investigation on the resident-to-resident incident on 01/09/25 between R1 and R 9. LNA A stated he had started one yesterday as writer entered the building and would go get it. Upon reading the incident report, it was as followed: Incident Description reads, another resident made contact with this resident left shoulder. Doctor notified and a shoulder Xray was ordered due to it being the shoulder that was post-op. Under section was this incident witnessed: Patient stated that she was experiencing no increased pain in shoulder. Stated that she does not feel the other resident hit her on purpose. Incident report completed by Licensed Practical Nurse (LPN) G. Writer asked LNA A if he reported this incident of resident to resident to the state, and he stated no. During an interview on 01/22/25 at 12:08PM, LPN G stated that R9 had come up to R1 and purposefully hit her a couple of times in the left shoulder. LPN G stated R1 complained of pain, and the Nurse Practitioner (NP) L was still in the building, and she came over to assess R1. LPN G stated the process is to make sure both residents are safe, contact LNA A then go through the incident report. LPN G stated, they look at new interventions to prevent it from happening again. LPN G stated R1 was sitting in her wheelchair up by the nurse's station because she was a fall risk. LPN G also stated they changed R1's room so she would not be close to R9, however R9's room was not changed. LPN G stated she re-assessed R1 and it should be documented in the nursing progress notes. LPN G also stated they usually assess residents for 3 days and they were assessing that area due to R1 still having staples in arm. LPN G also stated that R1 did have left arm/shoulder pain following the incident, but by the time she started to fill out the incident report, R1 was no longer having pain in the left arm/shoulder. Record review did not reveal a nursing progress note on this incident from LPN G. No nursing progress notes on this incident from any nursing staff caring for R1. NP L documented R1's . This is a [AGE] year-old female patient being seen today at the request of nursing staff for an altercation involving another resident. The other resident (R9) approached the patient (R1) and then struck the patient on her left injured arm. The patient was very upset and painful. Vital signs were completed, all within range. Her left arm is in a sling. She has staples on her left shoulder from her surgery. The staples are intact and no redness or oozing and no visible edema or ecchymosis. Reevaluated patient prior to leaving for the day and no changes. Pain is managed. Her vital signs are stable . Continue to monitor for increased pain. May need to perform an x-ray after altercation with other residents . During an interview on 01/23/25 at 12:06 PM, LNA A stated R9 goes all over the place in the facility. LNA A stated he was told R9 hit R1 in the shoulder, nurse asked LNA A to come down to the unit. LNA A stated R1 was startled, she told LNA A she was hit, it scared her. LNA A stated that it seemed like it was more of R9 seeking attention kind of thing verses being harmful on the other residents (R1) end. LNA A stated he let the doctor know, didn't see any bruising on her, so they moved her off that hall, to get her closer to the nursing station and away from him (R9). LNA A then stated, this specific incident, no injury, or intent. Writer asked LNA A if the incident was investigated, he stated yes, stated they put interventions in place. Writer asked to see the investigation. Record review revealed R1 had an X-Ray since this was a fresh surgical left arm that was hit.FINDINGS: There is postoperative change with a side plate and screws at the proximal humerus. Fracture alignment maintained. CONCLUSION: Postoperative changes . During an interview on 01/23/25 at 12:30 PM, Unit Manager/RN F stated her and other nurse in her office, Minimum Data Set (MDS) Nurse K stated the changes to interventions would not be on R1's care plan as she didn't do anything wrong, it would be on R9's care plan. During this same interview, MDS Nurse K also stated that R9 cannot go off his unit without supervision. MDS Nurse K added that they cannot stop him from going where he wants to go within the facility, but he would have a supervision with him. Record review of the incident report on the resident-to-resident incident was not completed, areas were left blank and unanswered. It did not mention the fact that R1 had an x-ray ordered for the left shoulder due to the incident and pain in that area. The report did not reflect the results of the X-rays. Writer request for the investigation that went along with the incident report was never provided before the exit of the survey. This resident to resident incident was not investigated or reported to the state. Resident #9 (R9) Review of the medical record reflected R9 was an initial admission to the facility on [DATE]. Diagnoses of Pericardial Effusion, Difficulty walking, Unspecified lack of expected normal Physiological Development in Childhood, Brief Psychotic Disorder, Anxiety, Unspecified Speech Disturbances. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/ 23 /2024, revealed R9 functions at a 9-year-old child. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R9 is dependent of all care. During an interview and observation on 01/22/25 at 8:24 AM, R1 was eating breakfast in her room. R1 was sitting in her wheelchair with the over the bed table in front of her. R1 stated that R9 hit her and added that he hit her on the left arm that was broken. R1 stated she was sitting in her wheelchair and sitting out in the hallway. R1 then stated R9 rolled his wheelchair up to hers and purposefully hit her a couple of times in the left arm. R1 stated that it startled her, and it hurt where R9 hit her. During an interview on 01/22/25 at 11:30 AM with LNA A, writer asked for the incident report and investigation on the resident-to-resident incident on 01/09/25 between R1 and R 9. LNA A stated he had started one yesterday as writer entered the building and would go get it. Upon reading the incident report, it was as followed: Incident Description reads, another resident made contact with this resident left shoulder. Doctor notified and a shoulder Xray was ordered due to it being the shoulder that was post-op. Under section was this incident witnessed: Patient stated that she was experiencing no increased pain in shoulder. Stated that she does not feel the other resident hit her on purpose. Incident report completed by Licensed Practical Nurse (LPN) G. Writer asked LNA A if he reported this incident of resident to resident to the state, and he stated no. During an interview on 01/22/25 at 12:08PM, LPN G stated that R9 had come up to R1 and hit her a couple of times in the left shoulder. LPN G stated R1 complained of pain, and the Nurse Practitioner (NP) L was still in the building, and she came over to assess R1. LPN G stated the process is to make sure both residents are safe, contact LNA A then go through the incident report. LPN G stated R1 did have pain from the hitting of her left shoulder. LPN G stated they look for new interventions, to prevent it from happening again. LPN G stated R1 was sitting up by the nurse's station because she was a fall risk. LPN G also stated they changed R1's room so she would not be close to R9, however R9's room was not changed. LPN G stated she re-assessed R1 and it should be documented in the nursing progress notes. LPN G also stated they usually assess residents for 3 days and they were assessing that area due to R1 still having staples in arm. Record review did not reveal a nursing progress note on this incident from LPN G. No nursing progress notes on this incident from any nursing staff caring for R1. NP L documented R1's . This is a [AGE] year-old female patient being seen today at the request of nursing staff for an altercation involving another resident. The other resident (R9) approached the patient (R1) and then struck the patient on her left injured arm. The patient was very upset and painful. Vital signs were completed, all within range. Her left arm is in a sling. She has staples on her left shoulder from her surgery. The staples are intact and no redness or oozing and no visible edema or ecchymosis. Reevaluated patient prior to leaving for the day and no changes. Pain is managed. Her vital signs are stable . Continue to monitor for increased pain. May need to perform an x-ray after altercation with other residents . During an interview on 01/23/25 at 12:06 PM, LNA A stated R9 goes down all the halls in the facility. LNA A stated he was told R9 hit R1 in the shoulder, nurse asked LNA A to come down to the unit. LNA A stated R1 was startled, she told LNA A she was hit, it scared her. LNA A stated that it seemed like it was more of R9 seeking attention kind of thing verses being harmful on the other residents (R1) end. LNA A stated he let the doctor know, didn't see any bruising on her, so they moved her off that hall, to get her closer to the nursing station and away from him. LNA A then stated, this specific incident, no injury, or intent. Writer asked LNA A if the incident was investigated, he stated yes, stated they put interventions in place. Writer asked to see the investigation. During an interview on 01/23/25 at 12:30 PM, Unit Manager/RN F stated. Her and other nurse in her office, Minimum Data Set (MDS) Nurse K stated the changes to interventions would not be on R1's care plan as she didn't do anything wrong, it would be on R9's care plan. During this same interview, (MDS) Nurse K also stated that R9 cannot go off his unit without supervision. MDS Nurse K added that they cannot stop him from going where he wants to go within the facility, but he would have a supervision with him. Record review of R9's care plan revealed under Need: R9 had an actual behavior problem R/T: Patient will pinch, hit and kick. Patient will throw items such as remote and silverware during mealtimes. Patient will put self onto floor. Per guardian, patient will sit on the floor per preference. Guest will lay down on the floor when he is tired Date Initiated: 12/26/2024, Revision on: 01/04/2025. Under Goal: Patient will have fewer episodes of behaviors by review date. 12/26/2024, Target Date: 02/06/2025. Under Interventions: Guest needs plastic silverware no knives, 2-person care for ADL's. If patient get combative, ensure patient is safe and reapproach. Patient likes to hug and expresses emotion through hands. Will sometimes touch without meaning harm. Redirect resident. Document behaviors, and resident response to interventions. Ensure resident doesn't get in reach of other residents during increased supervision during waking hours. Move guest to lower stimulus environment when guest becomes agitated. Offer to wheel resident around facility as this is calming to him. Set firm boundaries and let patient know this is not appropriate behavior. Record review of a nursing progress note reported dated 12/29/2024 at 5:29PM, Behavior Note Text . Throughout the day resident was sitting at nurses' station and staff was watching his iPad with him. He was happy and calm and cooperative at this time of watching it ith him. While in the middle of his show he became upset and started to grab this nurse's arm scratching her, hitting her, and attempting to bite her. Staff offered toys/games/movies in his room. He again was cooperative with nurse playing with his toys with him when he again lashed out and took the toy and struck the nurse in the head/shoulder. He then proceeded to run up the hallway knocking off papers, phones, med cups, gloves, iso carts, chairs down. He was not able to be redirected, and all interventions were exhausted. Staff administered compound medication of Ativan, Benadryl and Haldol (ABH) cream. This was only mildly effective. He has had outburst throughout the entire day of this caliber. Staff had notified on call manager and administrator of his behaviors. He does calm with time but will repeat this behavior . Record review of a nursing progress note reported dated 12/30/2024 at 3:23 PM, Resident left to go to [NAME] Battle Creek (BBC) emergency room (ER) for evaluation/treatment related to behavioral symptoms and aggression towards staff. Patient left facility on stretcher with Emergency Medical System (EMS). Record review of a social work progress note reported dated 12/30/2024 at 4:27 PM, Guardian informed patient petition for inpatient psych sent to BBC for behaviors and aggression towards others. Guardian would like for patient to go to inpatient psych. Rapport with BBC social worker given. Record review of a nursing progress note reported dated 12/30/2024 at 6:06 PM, Resident arrived back to facility. No new orders at this time. Record review of a nursing progress note reported dated 1/4/2025 at10:39 PM, Guest walking around the unit and upset because his tablet is not charged, however staff has been plugging it in and he will immediately unplug it and use it until the battery dies. Guest throwing stuff on the unit pulling things off the wall, grabbing and pinching staff attempts to redirect unsuccessful, ABHR cream applied, and guest settled down laying on the floor trying to sleep, staff attempted to get guest to bed and guest declined, guest made safe on the floor per his preference and continued to encourage guest to lay down in bed. Record review of a nursing progress note reported dated on 1/9/2025 at 4:01AM, Guest was aggressive with staff at the beginning of the shift this evening. He was choosing to throw items around the nurse's station, throw pens at the nurse, and hit the nurse with closed hands. After multiple attempts by staff, he eventually calmed himself with the help of his tablet and sat on his bed watching television. He has been up periodically throughout the night with no further issues. Record review of a nursing progress note reported dated 1/19/2025 00:00 Telehealth - Nurse states that guest is still not sleeping, he does have anxiety and is having a rough night. He is pacing and running up and down the hallways, hitting the wall, and just unable to be calmed. He is already on melatonin 10mg and 0.5mg of Ativan and neither are helping. Advised to give trazodone 50mg x1. Update: nurse reports that script was effective. Record review of a nursing progress note reported dated 1/19/2025 at 02:00 AM, Behavior Note: Guest has struggled this shift to regulate his emotions. He has been anxious and running about the facility with staff close behind. He is expressing desire to go home but is not seeking exit. This nurse gave his PRN dose of Ativan without relief and was able to obtain a one-time order for trazodone 50mg which was effective and allowed him to rest. Phone call was placed to guardian with no answer. Administrator and on call nurse notified. Record review of a nursing progress note dated 1/20/2025 at 4:11pm, Patient has been extremely agitated and physically & verbally aggressive this shift. He has been screaming, running through hallway, throwing things off the nurse's desk, knocking things over, slamming his room and other patient's room doors. He bit this nurse on the breast, abdomen, and arm. Several attempts were made to redirect patient and were ineffective. PRN ABH gel was administered and unsuccessful. Patient then began to hit himself in head and bang head against wall. No injuries were noted. Patient hit, bit, and pinched several other staff members. Management was notified of this. Patient was eventually calmed down and given different options to keep him entertained such as coloring pages, a blow-up set of dice, and playing catch with staff. Record review of a nursing progress note reported dated 1/22/2025 at12:49 PM, Patient grabbed this nurse by the hand, breaking the skin. He then knocked over desktop computer multiple times, tried knocking over printer, and repeatedly slammed bedroom door. Redirection was unsuccessful, PRN ABH gel applied. Patient is now sitting watching tablet in chair near nurse's desk. Record review did not reflect any new interventions added to R9's care plan following the resident-to-resident altercation between R1 and R9 on 01/09/2025. Care plan was not updated following any of the behavioral incidents from 12/30/2024 through 01/22/2025. Care goal was updated to 02/06/2025. Record review of progress notes did not reflect any documentation of the resident-to-resident altercations between R9 and R1 on 01/09/2025 in his medical records. Nor did it reflect any new interventions placed in his care plan to protect other residents.

Based on observations and interviews, the facility failed to provide sufficient staffing related to Dietary Services effecting 107 residents, resulting in the increased likelihood for delayed meal preparation and delivery service. Findings include: On 09/11/24 at 09:05 A.M., A comprehensive tour of the food service was conducted with Dietary Manager P. The following items were noted: Dietary Manager Q and Dietary [NAME] R from another regional corporate facility were observed assisting facility staff with the Breakfast Meal preparation and delivery service protocol. On 09/11/24 at 09:14 A.M., An interview was conducted with Dietary Manager P regarding current facility staffing levels. Dietary Manager P stated: We are currently down one Dietary [NAME] and two Dietary Aides (one AM and one PM). 32064 Review of the meal schedule provided by the facility revealed lunch service in the main dining room was scheduled for 11:45 AM. An observation on 09/10/24 at 11:55 AM in the main dining room revealed one Certified Nursing Assistant (CNA) was serving beverages. The first meal was served at 12:35 PM. Resident #169 (R169) Review of the medical record revealed R169 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/10/24 revealed R169 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 09/10/24 at 10:27 AM, R169 was observed sitting in their chair in their room. R169 reported yesterday, they did not receive breakfast in their room until after 10:00 AM. According to the meal schedule, breakfast for R169's hall was scheduled for 8:30 AM 38383 Resident #216 (R216): On 09/10/24 at 12:58 PM, R216 was observed seated in a wheelchair, in his room. He stated meals were always late, and he had not yet received his lunch that day. 45038 Resident #90 (R90) Review of the medical record revealed R90 was admitted to the facility 12/13/2023. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/19/2024, revealed R90 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 09/10/2024 at 02:17 p.m. R90 was observed lying in bed. R90 explained that on one day in the past that she had not received breakfast until 11:00 a.m. and had not received lunch on another day until 02:30 p.m. R90 also explained that one night she had not received dinner until 07:15 p.m. R90 explained that frequently (sometimes two to three times per week) the facility would buy pizza from an outside vendor and provide it to the residents at the facility.

Based on observations, interviews, and record reviews, the facility failed to: (1) clean and maintain food service equipment, (2) clean food production kitchen flooring surfaces, (3) properly store and label food products, and (4) effectively date mark potentially hazardous ready-to-eat food products effecting 107 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 09/11/24 at 09:05 A.M., A comprehensive tour of the food service was conducted with Dietary Manager P. The following items were noted: The flooring surface was observed soiled with accumulated and encrusted (dust, dirt, grease) residue. The wall/floor junctures, corners, and entrance door frame cavities were also observed soiled with accumulated and encrusted dust, dirt, and grime. The entrance door exterior surface between the Main Dining Room and Food Production Kitchen was observed soiled with accumulated and encrusted dust/dirt/grime. The emergency eye wash station receptacle was observed soiled with accumulated and encrusted dust/dirt deposits. The 2017 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. The mechanical dish machine wash temperature gauge was observed to read 136 degrees Fahrenheit during the wash cycle. The mechanical dish machine final rinse temperature gauge was also observed to read 176 degrees Fahrenheit during the final rinse cycle. The PSI (pounds per square inch) gauge was further observed to read 0 psi during the final rinse cycle. Note: The thermal verification tape turned black during the final rinse cycle indicating proper sanitization had occurred (160 degrees Fahrenheit or greater). Dietary Manager P indicated he would contact the contractual company for repairs as soon as possible. The 2017 FDA Model Food Code section 4-501.112 states: (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90oC (194oF), or less than: (1) For a stationary rack, single temperature machine, 74oC (165oF); or (2) For all other machines, 82oC (180oF). (B) The maximum temperature specified under (A) of this section, does not apply to the high pressure and temperature systems with wand-type, hand-held, spraying devices used for the in-place cleaning and SANITIZING of EQUIPMENT such as meat saws. The 2017 FDA Model Food Code section 4-501.113 states: The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 pounds per square inch) or more than 200 kilopascals (30 pounds per square inch). The water supply valve was observed leaking, directly above the ice machine in-line filter. The Crown steamer copper drain line connection was observed leaking water onto the flooring surface, adjacent to an electrical supply line wrapped with black electrical tape. The service sink faucet was observed loose-to-mount. Dietary Manager P indicated he would contact maintenance for necessary repairs as soon as possible. The 2017 FDA Model Food Code section 5-205.15 states: A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair. One gallon of Mooville Whole Milk was observed open (approximately one-sixteenth full) without an effective open or out date mark. Dietary Manager P indicated he would in-service train all staff on proper date marking procedures as soon as possible. The 2017 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The Juice Machine exterior was observed soiled with food residue. The South Bend convection oven interior and exterior was observed with accumulated and encrusted food residue. The South Bend (oven, stove, griddle) was observed with accumulated and encrusted food residue. Dietary Manager P stated: We recently ordered a new oven unit. The Vulcan hot box interior/exterior surfaces and interior door gasket were observed soiled with accumulated and encrusted food residue. The garbage disposal overhead spray arm valve assembly was observed soiled with accumulated and encrusted food residue. The Amana microwave oven interior ceiling and wall surfaces were observed soiled with accumulated and encrusted food residue. Dietary Manager P indicated he would have staff thoroughly clean and sanitize the soiled food service equipment as soon as possible. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The return-air-exhaust ventilation grill was observed heavily soiled with accumulated and encrusted dust/dirt deposits. The soiled ventilation grill measured approximately 24-inches-wide by 24-inches-long. Dietary Manager P indicated he would have maintenance thoroughly clean the soiled ventilation grill as soon as possible. The 2017 FDA Model Food Code section 6-501.14 states: (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. (B) If vented to the outside, ventilation systems may not create a public health HAZARD or nuisance or unLAWful discharge. On 09/13/24 at 09:00 A.M., Record review of the Policy/Procedure entitled: Dietary Cleaning and Sanitation dated 11/12/2021 revealed under Policy: It is the policy of this facility to maintain the sanitation of the kitchen through proper cleaning and sanitizing stationary food service equipment and food contact surfaces to minimize the growth of microorganisms that may result in food contamination. Food-contact surfaces are washed, rinsed, and sanitized: (1) After each use, (2) Before switching preparation to another food type, and (3) When the tool or items being used may have been contaminated. On 09/13/24 at 09:15 A.M., Record review of the Policy/Procedure entitled: Nourishment Room Refrigerators dated 11/08/2021 revealed under Policy: Nourishment Room Refrigerators will be maintained under Sanitary Conditions. Record review of the Policy/Procedure entitled: Nourishment Room Refrigerators dated 11/08/2021 further revealed under Procedure: (1) Temperatures will be checked and recorded twice a day, morning and evening, on the temperature logs by a facility Designee. (4) Guest/Resident food, snacks, and nourishments stored in the Nourishment Refrigerator will be covered, labeled, and dated with an In-Date, Open Date, and Use-by-Date. (5) All opened food and beverage items will be discarded after 3 days, counting the day the item was opened as Day 1. (6) The Manufacturer's Expiration Date on commercial supplements, soda, and sealed manufacturer products will be used until the item is opened. (7) Any item that is brought in by family or visitors that is not clearly dated will be discarded. 45038 During an observation on 09/10/2024 at 08:56 a.m. the kitchen floor was observed to be soiled with black substance, water was observed under the tray line table, and multiple cracked or chipped floor tile were observed. During an observation on 09/10/2024 at 09:07 a.m. the walk-in freezer a boxed pie crust was observed to have frozen clear substance on the outside of the box. During an observation on 09/10/2024 at 09:10 a.m. of the dry storage room it was observed to have multiple boxes on the floor which included: torte shells, open box of cups, open boxes of napkins, and empty boxes. Floor of the dry storage was visibly soiled. In an interview on 09/10/2024 at 09:12 a.m. Dietary Manager (DM) P explained that food and products had been delivered to the facility on [DATE]. DM P could not explain why products were on the floor and had not been placed on the appropriate shelves at the facility. DM P explained that kitchen staff were currently placing the delivered items on the appropriate shelving units.

Based on observations, interviews, and record reviews, the facility failed to provide palatable food products for seven of seven reviewed (R4, R29, R72, R84, R85, R99, and R169) effecting 107 residents, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline. Findings include: On 09/11/24 at 12:29 P.M., Lunch meal food trays were observed leaving the food production kitchen, within a stainless steel non-insulated transport cart. On 09/11/24 at 12:30 P.M., Lunch meal food trays were observed arriving to the 100 Hall, within a stainless steel non-insulated transport cart. On 09/11/24 at 12:35 P.M., Food products were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident #29's lunch meal food tray: Chicken Teriyaki - 120.8 degrees Fahrenheit* Fluffy Steamed Rice - 122.0 degrees Fahrenheit* Asian Blend Vegetables - 131.5 degrees Fahrenheit* Dinner Roll substituted for (Spring Roll) due to Mechanical Soft Dietary Status - 113.0 degrees Fahrenheit* Beverage (2% Milk) - 47.6 degrees Fahrenheit* (*) The 2017 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5 C (41 F) or less. On 09/12/24 at 08:23 A.M., An interview was conducted with Resident #44 regarding facility food products. Resident #44 stated: The food is always lukewarm to cold. Resident #44 also stated: The eggs were cold today for breakfast and the hash browns were not browned. Resident #44 additionally stated: The coffee is usually only lukewarm. On 09/12/24 at 12:47 P.M., Lunch meal food trays were observed leaving the food production kitchen, within a stainless steel non-insulated transport cart. On 09/12/24 at 12:48 P.M., Lunch meal food trays were observed arriving to the 200 Hall, within a stainless steel non-insulated transport cart. On 09/12/24 at 01:10 P.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident #85's lunch meal food tray: Lasagna Italian Style - 132.7* Italian [NAME] Beans - N/A Garlic Bread - N/A Bread Pudding - Room Temperature Beverage (Ice Water) - 34.2 degrees Fahrenheit On 09/12/24 at 01:15 P.M., Record review of Resident #85's meal ticket information revealed the following: (1) no bread, and (2) no green vegetables per dietary guidance. (*) The 2017 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5 C (41 F) or less. On 09/13/24 at 11:00 A.M., Record review of the Policy/Procedure entitled: Food Handling and Production dated 11/12/2021 revealed under Policy: It is the policy of this facility to comply with strict time and temperature requirements and use proper food handling techniques to prevent foodborne illness. Record review of the Policy/Procedure entitled: Food Handling and Production dated 11/12/2021 further revealed under Procedure: (1) The kitchen and equipment will be maintained in a clean, neat, and orderly manner to minimize bacteria formation and food contamination. (11) Prepared food will be transported to service and dining areas in covered containers and kept covered until served. On 09/13/24 at 11:15 A.M., Record review of the Policy/Procedure entitled: Tray Accuracy and Test Trays dated 11/03/2021 revealed under Policy: It is the policy of this facility to set up trays accurately to provide guests/residents with meal trays correctly reflecting Therapeutic Diets, Proper Texture Diets, and Food Preferences listed on the tray ticket. Record review of the Policy/Procedure entitled: Tray Accuracy and Test Trays dated 11/03/2021 further revealed under Procedure: (1) The Dietary Manager, Dietician or [NAME] will be responsible for ensuring all foods needed for tray assembly are present for service. (5) The Dietary Manager, Dietician, or Designee will complete a Test Tray Worksheet (See Attached) to monitor the food temperature as received by the guest/resident at least weekly. (6) The Dietary Manager or Dietician is responsible for identifying problem areas, training needs, documenting, follow-up, and reporting findings to the Quality Assurance Performance Improvement Committee. 32064 Resident #169 (R169) Review of the medical record revealed R169 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/10/24 revealed R169 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 09/10/24 at 10:27 AM, R169 was observed sitting in their chair in their room. R169 reported they ate in their room and the food was served stone cold. Resident #72 (R72) Review of the medical record revealed R72 was admitted to the facility on [DATE]. The MDS with an ARD of 8/2/24 revealed R72 scored 14 out of 15 (cognitively intact) on the BIMS. On 09/10/24 at 12:51 PM, R72 was observed sitting in a wheelchair in their room. R72 reported the food was yuck, all I can say is yuck. R72 reported they ate in their room and most of the meals were served cold. Resident #85 (R85) Review of the medical record revealed R85 was admitted to the facility on [DATE]. The MDS with an ARD of8/9/24 revealed R85 scored 13 out of 15 (cogitinvely intact) on the BIMS. On 09/10/24 at 10:54 AM, R85 was observed sitting in a wheelchair in their room. R85 reported they ate in their room and the food was cold every time. 38383 Resident # 84 (R84): On 09/10/24 at 11:40 AM, R84 was observed seated in a wheelchair, in her room. She reported the facility's food was either cold or hard as a rock. If she requested an alternate, half the time they did not have what she ordered, although it was on the menu. Resident #99 (R99): On 09/10/24 at 11:55 AM, R99 was observed seated on his bed. He reported the food was usually cold, including his breakfast that morning. R99 stated the food was sometimes served warm but not hot. 45038 Resident #4 (R4) Review of the medical record revealed R4 was admitted to the facility 11/15/2018. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/02/24, revealed R4 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During interview and observation on 09/10/2024 at 10:55 a.m. R4 was observed lying down in bed. R4 explained that the food at the facility is not very good. R4 explained that frequently she does not like the food and that she gets an alternative for meals. R4 explained that she is getting tired of requesting peanut butter and jelly as a replacement because the food is so bad. Resident #29 (R29) Review of the medical record revealed R29 was admitted to the facility 03/18/2024. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/24/2024, revealed R29 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. During interview and observation on 09/10/2024 at 11:44 a.m. R29 was observed sitting on the side of his bed. R29 explained that the facility meals are never hot.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 107 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 09/12/24 at 09:20 A.M., A common area environmental tour was conducted with Director of Maintenance T and Director of Housekeeping and Laundry Services S. The following items were noted: Beauty Shop: The desk fan was observed soiled with accumulated dust/dirt deposits. Director of Housekeeping and Laundry Services S indicated she would have staff thoroughly clean and sanitize the desk fan as soon as possible. 100 Hall Shower Room: Two return-air-ventilation grills were observed heavily soiled with accumulated dust and dirt deposits. Ambulance Entrance/Exit Door: The door sweep was observed worn and torn, exposing an open space between the door slab and threshold plate. The damaged door sweep measured approximately 12-inches-long, creating daylight between the door slab and metal threshold plate. Director of Maintenance T indicated he would have staff replace the worn door sweep as soon as possible. 200 Hall Restroom [ROOM NUMBER]: The commode base standpipe supply line was observed leaking water, adjacent to the collar nut. Main Dining Room: Four 24-inch-wide by 24-inch-long acoustical ceiling tiles were observed stained from a previous moisture leak. Center Nursing Station: The oscillating floor fan was observed soiled with accumulated and encrusted dust/dirt deposits. 300 Hall Janitor Closet: The mop sink basin was observed heavily soiled with accumulated and encrusted soil residue. The return-air-exhaust ventilation grill was also observed heavily soiled with accumulated dust and dirt deposits. Tub Room: The hot water supply handle was observed leaking water at the hand sink faucet assembly. Director of Maintenance T indicated he would have staff make necessary repairs as soon as possible. Shower Room: The return-air-exhaust ventilation grill was observed soiled with accumulated and encrusted dust/dirt deposits. On 09/12/24 at 10:20 A.M., An environmental tour of sampled resident rooms was conducted with Director of Maintenance T and Director of Housekeeping and Laundry Services S. The following items were noted: 105: The restroom paper towel dispenser was observed loose-to-mount. 111: The Bed B oscillating floor fan was observed soiled with accumulated dust and dirt deposits. 112: The Bed A drywall surface was observed (etched, scored, particulate), adjacent to the headboard. The damaged drywall surface measured approximately 8-inches-wide by 24-inches-long. 113: The Bed B overbed light assembly was observed non-functional. The Bed B bedding (flat and fitted sheets) was also observed soiled with accumulated bodily waste and debris. The Bed B oscillating floor fan was further observed soiled with accumulated dust and dirt deposits. The restroom wall/floor vinyl coving strip was additionally observed loose-to-mount. The damaged vinyl coving strip measured approximately 2-3 feet-long. 200: The restroom entrance door interior surface was observed (etched, scored, particulate). The damaged door surface measured approximately 3-feet-wide by 4-feet-high. 201: The restroom entrance door interior surface was observed (etched, scored, particulate). The damaged door surface measured approximately 3-feet-wide by 4-feet-high. 204: The restroom entrance door interior surfaces were observed (etched, scored, particulate). The damaged door surfaces measured approximately 3-feet-wide by 4-feet-high. 206: The restroom entrance door interior surfaces were observed (etched, scored, particulate). The damaged door surfaces measured approximately 3-feet-wide by 4-feet-high. 301: The restroom wall/floor vinyl coving base was observed loose-to-mount. The damaged vinyl coving base measured approximately 6-feet-long. 305: The Bed A and Bed B oscillating floor fans were observed soiled with accumulated dust and dirt deposits. The restroom hand sink basin was also observed draining very slow. The restroom entrance door interior surface was further observed (etched, scored, particulate). The damaged door surface measured approximately 3-feet-wide by 4-feet-high. 307: The Bed A and Bed B oscillating floor fans were observed soiled with accumulated dust and dirt deposits. The restroom hand sink basin was also observed draining very slow. The restroom entrance door interior surface was further observed (etched, scored, particulate). The damaged door surface measured approximately 3-feet-wide by 4-feet-high. 308: The Bed A desk fan was observed soiled with accumulated dust and dirt deposits. The restroom entrance door interior surfaces were observed (etched, scored, particulate). The damaged door surfaces measured approximately 3-feet-wide by 4-feet-high. The restroom drywall surface was additionally observed (etched, scored, particulate). The damaged drywall surface measured approximately 12-inches-wide by 6-feet-long. The corner drywall surface, adjacent to the restroom entrance door, was further observed (etched, scored, particulate). The damaged corner drywall surface measured approximately 12-inches-high by 8-inches-long. 311: The restroom drywall surface was observed (etched, scored, particulate). The damaged drywall surface measured approximately 12-inches-wide by 24-inches-long. The wall/floor vinyl coving base was also observed loose-to-mount. The damaged vinyl coving base measured approximately 3-feet-long. 312: The restroom entrance door interior surface was observed (etched, scored, particulate). The damaged door surface measured approximately 3-feet-wide by 4-feet-high. The restroom entrance metal door frame was also observed (etched, scored, particulate). The damaged door frame measured approximately 3-inches-wide by 15-inches-high. 317: The restroom entrance door interior surface was observed (etched, scored, particulate). The damaged door surface measured approximately 3-feet-wide by 4-feet-high. The restroom entrance metal door frame was also observed (etched, scored, particulate). The damaged door frame surface measured approximately 3-inches-wide by 15-inches-high. 321: The restroom entrance door interior surface was observed (etched, scored, particulate). The damaged door surface measured approximately 3-feet-wide by 4-feet-high. The restroom entrance metal door frame was also observed (etched, scored, particulate). The damaged door frame surface measured approximately 3-inches-wide by 15-inches-high. The restroom drywall surface was further observed (etched, scored, particulate). The damaged drywall surface measured approximately 4-inches-wide by 24-inches-long. 324: The Bed B overbed light assembly pull string extension was observed missing. The restroom wall/floor vinyl coving was also observed loose-to-mount. The damaged vinyl coving measured approximately 11 feet-long. The restroom entrance door interior surface was further observed (etched, scored, particulate). The damaged door surface measured approximately 3-feet-wide by 4-feet-high. The restroom entrance metal door frame was additionally observed (etched, scored, particulate). The damaged metal door frame measured approximately 3-inches-wide by 15-inches-high. 09/12/24 02:05 PM An interview was conducted with Director of Housekeeping and Laundry Services S regarding the facility maintenance work order system. Director of Housekeeping and Laundry Services S stated: We have the TELS program. On 09/13/24 at 10:00 A.M., Record review of the Policy/Procedure entitled: Housekeeping Services dated 02/22/2023 revealed under Policy: To promote a sanitary environment. (I.) Frictional Cleaning: (A) Thorough scrubbing will be used for all environmental surfaces that are being cleaned in guest/resident care areas. (II.) Routine Cleaning of Horizontal Surfaces: (A) In guest/resident care areas, cleaning of non-carpeted floors and other horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs. On 09/13/24 at 10:15 A.M., Record review of the Policy/Procedure entitled: Maintenance Department dated 08/17/2021 revealed under Policy: To assure proper maintenance of the physical plant. On 09/13/24 at 10:30 A.M., Record review of the Direct Supply TELS Work Orders for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on observation, interview, and record review the facility failed to ensure accurate advance directive (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for one resident (#1) of one resident reviewed for advance directives from a total sample of 22 residents. Findings Included: Resident #1 (R1) Review of the medical record revealed R1 was admitted to the facility 04/01/2017 with diagnoses that included Huntington's Disease (an inherited condition in which nerve cells in the brain break down over time), ulcerative colitis, left and right thigh muscle contractures, anxiety, adult failure to thrive, contracture of right hand, dysphagia (difficulty swallowing), cognitive communication deficient, aphonia (loss of ability to speak), Tourette's Disorder (a neurological disorder that causes people to have tics, which are sudden, repetitive, and involuntary movements or sounds), dementia, epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), moderate intellectual disabilities, anemia (low red blood cells), pressure ulcers of upper back, pressure ulcer of left hip, pressure ulcer of other sites. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/29/2024, revealed R1 had a Brief Interview of Mental Status (BIMS) was not completed because he is rarely/never understood. During observation and attempted interview on 09/10/2024 at 09:56 a.m. R1 was observed lying down in bed and appeared well groomed. R1 did not respond to verbal stimuli. Review of R1 medical record demonstrated that he had a court appointed Guardian. Reivew of R1 Resident Code Status, dated 01/15/2024 demonstrated a signature by R1's Guardian and was date 01/15/2024. The same documents demonstrated attestation of witness that was signed by one witness but had not demonstrated the date of the signature. The attestation of witness, second witness section, was not signed or dated. In an interview on 09/11/2024 at 10:57 a.m. Social Worker (SW) C explained that she coordinates a residents Advance Directive on admission and whenever a new Advance Directive is requested. SW C explained that she would verify if the resident was their own person, had Durable Power of Attorney, or a Guardian was in place for the resident. SW C explained that it was her responsibility that the Resident Code Status document was completed in its entirety. SW C explained that the Resident Code Status document was to have two witnesses present and date of those signatures. SW C verified that R1's Resident Code Status document dated 01/15/2024 had one witness signature but did not have the date present of that signature. SW C also confirmed that no signature was present on the same above document. SW C could not explain why the Resident Code Status document did not have dates of signature and lacked a second witness signature. Review of facility policy entitled Advance Directives-Michigan, origination date 07/11/2023 and last revision date 07/06/2023, demonstrated Procedures: Generally D which stated, . a Code Status Form will be completed by the resident and a DNR order will be signed by the resident, 2 witnesses and the physician .

This citation pertains to MI 775. Based on observation, interview and record review, the facility failed to provide services to prevent and treat pressure ulcers, in two of three residents reviewed for pressure ulcers (Resident #22 & #62), resulting development of avoidable and worsening pressure ulcers. Findings include: Resident #22 (R22) R22's Minimum Data Set (MDS) assessment dated [DATE], indicated she admitted to the facility on [DATE] and readmitted to the facility 6/29/21. R22's cognition was severely impaired, she required extensive assistance (staff provided weight bearing support) of two plus persons for bed mobility and was completely dependent (full staff performance) for transfers with two plus person assist. The same MDS assessment indicated R22 did not have any pressure ulcers. In review of R22's discharge summary, dated 6/29/21, in April 2021 she was hospitalized following a stroke and a feeding tube was placed. The same source indicated R22 was hospitalized in May 2021 and she was diagnosed with pneumonia and pulmonary abscess (lung infection). R22 presented with right lower [CONDITION(S)] (swelling) and was found to have a [CONDITION(S)] (DVT, blood clot) as well as aspiration pneumonia during her hospital stay from 6/23/21 to 6/29/21. In review of R22's Braden Scale for Predicating Pressure Sore Risk, dated 6/29/21, the assessment was not completed until 7/21/21, and the same assessment indicated she was at high risk for pressure ulcers. Nurses notes dated 7/11/21 at 6:17 AM, indicated R22 had three new wounds. On right hip, a bruise was noted as approximately 4.0 centimeters (cm) by 3.0 cm in size, with a darker area at core; and a darkened area on the back of her right heel and tip of her right great toe. The same note indicated the plan would be to continue to reposition every two hours per policy. There were no new interventions added to R22's care plan. According to the Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.17.1, October 2019 manual, the care planning process for skin conditions should include efforts to stabilize, reduce or remove underlying risk factors (excess moisture, tissue exposure to urine or feces, immobility, and co-morbid conditions), to monitor the impact of the interventions; and to modify the interventions as appropriate. In review of R22's progress notes dated 7/11/21 at 10:15 AM, plan was to limit time lying on her right side. This intervention was not added to R22's care plan. In review of R22's care plans, an air mattress to her bed, pressure relieving boots on feet all times except during care, and to bridge heels in bed as she allowed was initiated on 7/12/21, after the development of 3 pressure ulcers. Nursing Comprehensive Evaluation dated 6/29/21, lock date/signed (completed date) was 7/21/21 and revealed R22 had actual skin breakdown on her right heel, sacrum (below spine), right great toe and second to last toe and her right hip. The same document under Actual Skin Breakdown Care Plan did not include individualized information regarding R22, when prompted to fill in data: under interventions Turn and Reposition (specify) was not specified; and Apply (specify: pressure relieving/reducing mattress, pillows, etc.) to protect the skin while in bed was not specified. In review of R22's July 2021 Treatment Administration Record (TAR), an air mattress to her bed and pressure reducing boots on all times except during care, bridge heels in bed as she allows was ordered on 7/13/21. The same TAR indicated R22's right hip wound treatment was to apply skin prep, cover with a foam dressing and change every 5 days; on 7/26/21 there was no documentation the treatment was completed. The same TAR revealed treatment to R22's sacrum was to be completed every Monday, Wednesday and Friday; there was no documentation on 7/16/21 and 7/21/21. R22's July 2021 TAR reflected treatments for the right great toe ulcer and right heel were not completed twice daily as ordered on 7/18/21, 7/20/21, 7/26/21. Wound Care Initial Consultation dated 7/26/21, revealed R22 had a blister to the right foot, fourth digit, and skin prep to the area twice daily was recommended. There was no treatment located on R22's July 2021 TAR. The same wound consultation indicated R22 had a blister on the left outer foot, and skin prep twice daily was also recommended. There was not a treatment located in R22's July TAR for the left lateral foot. The same wound consultation indicated R22 had a blister on the left heel, and skin prep twice daily was recommended, however; there was no treatment found on the TAR. The same wound consultation revealed R22 had a wound on the left outer ankle area, skin prep was recommended twice daily, there was no documentation on the TAR treatment was completed. The same Wound Consultation indicated R22's sacral pressure ulcer measured 5.02 cm by 1.44 cm. The same consultation indicated R22 hip was not open, and a foam dressing was ordered for protection. R22's right heel measured 1.36 cm by 0.79 cm and her left heel was 3.05 cm 1.86 cm; on the 7/26/21 consultation. In review of R22's August 2021 TAR, treatment to the left heel began on 8/20/21, and there was no documentation treatment was completed on 8/31/21. R22's Wound Care Progress Note dated 8/20/21 indicated her right hip wound had worsened and was a stage III pressure ulceration (full thickness tissue loss) that measured 0.7 cm by 0.7 cm, and 100 percent (%) slough (non-viable yellow, tan, gray, green or brown tissue) at wound bed was noted. R22's sacrum had slough in the wound bed and measured 4.0 cm by 2.5 cm. R22's left heel blister (stage II pressure ulcer may present as an intact or open/ruptured blister) increased in size, 3.2 cm by 1.9 cm. R22's same wound progress note revealed her right heel measured 2.6 cm by 1.6 cm. Director of Nursing (DON) B was interviewed on 10/13/21 at 10:57 AM and stated the previous wound nurse did not work out, she didn't remember when he had last worked. DON B did not have explanation as to why R22's Nursing Assessment was not completed timely upon readmission on 6/29/21. Resident #62 (R62) R62 was observed in his sitting in his wheelchair outside his room in the hallway on 10/13/21 at 7:25 AM and stated what he planned to eat for breakfast. In review of R62's MDS assessment dated [DATE], he was admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents score of 05 (00-07 Severely Impaired). The same MDS assessment indicated he did not have any unhealed pressure ulcers and required extensive assistance in bed mobility. On 10/13/21 at 8:01 AM, MDS Nurse C stated she was not actually managing the residents' wounds, she had just delegated where she could and when they could. MDS Nurse C clarified in the same interview that no one was managing resident wounds. MDS Nurse C stated in the same interview there was enough staff to manage day to day resident needs, but in terms of follow-up there was not enough staff to meet resident care needs. During an interview with DON B on 10/13/21 at 11:09 AM, she stated that on 9/14/21 the facility had found that communication between the nurse and the primary physician was lacking when residents had a wound. DON B stated in the same interview the facility implemented a wound log, and a past non-compliance with a compliance date of 10/01/21. During an interview with Licensed Practical Nurse (LPN) L on 10/13/21 at 12:48 PM, she confirmed she wrote a nurses note on 10/04/21 regarding R62's open areas to his buttocks and redness to the scrotum was noted. LPN L stated in the same interview, she did not receive a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/13/21 at 2:00 PM, R62 was observed lying in bed on his back, wearing a brief, Registered Nurse (RN) Q assisted R62 to turn to his right side after unfastening his brief, skin breakdown with redness surrounding was noted on both buttocks. R62 was positioned back onto his back, directly onto his buttocks; the ventral aspect of the penis was bright red as well as his scrotum. R62 stated it hurt when he was in his chair. In review of R62's Activities of Daily Living (ADL) care plan dated 2/21/21, briefs were not to be worn while in bed. R62's Actual skin impairment care plan, revised on 9/15/21, indicated R62 had 2 pressure ulcers on the buttocks; there was no mention of redness to the scrotum or penis.

This Citation Pertains To Intake MI 276 Based on observation, interview and record review the facility failed to ensure the sling was correctly connected to the mechanical lift prior to initiating a transfer from bed to wheelchair for 1 residents (#3) of 3 residents reviewed for mechanical lift transfers. Resulting in a displaced fifth mid metacarpal fracture and a right femur fracture, pain and the inability to eat independently with utensils. Findings Include: Resident#3 According to the clinical record including the Minimum Data Set ((MDS) dated [DATE], Resident #3 (R3) was a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. bilateral hips and knees. Review of the MDS reflected R3 scored a 15 out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Further review of the MDS revealed R3 required extensive assistance from two staff for transfers and bed mobility, and was independent with set up from staff for eating. Review of the facility incident report dated 02/02/2021 reflected R3 fell out of a mechanical lift while being transferred from her bed to a wheelchair. The report read in part The sling came off the right front of the sling, causing R3 to fall out of lift and onto the floor. The Incident and Accident Investigation form also dated 02/02/21 reflected Licensed Practical Nurse (LPN) N was called to R3's room and she observed R3 on the ground . LPN N documented she observed a hematoma was noted on the left forehead, right knee was bruised and swollen, outer portion of left hand was bruised and swollen. The facility investigation reflected LPN N reported the sling came loose from the lift which caused the fall and that upon her inspection of the lift LPN N found no rips, tears or abnormalities with the lift and sling. Radiology report dated 02/02/2021 reflected R3 Concern for nondisplaced extra-articular distal femur fracture and Displaced fifth mid metacarpal fracture. R3 complained of increased pain leg pain with movement and was transferred to the emergency department (ED) on 02/03/2021. Hospital record reviewed revealed fracture deformity of the right femoral metaphysis. [MEDICATION NAME] (narcotic medication used for pain) was administered intramuscularly in the emergency department in efforts to control R3's pain. The hospital notes reflected ED physician consulted with an orthopedic and a right long leg splint and a left hand short arm splint was applied due to R3's history of contracture's. On 3/16/2021 at 11:30 am during an interview with Certified Nursing Assistant (CNA) C she reported she had been a CNA at the facility for several years and was very familiar with R3, and was one of the CNA's that was involved with in the transfer when R3 fell on [DATE]. CNA C reported that CNA D was assigned to R3 on 02/02/2021 and CNA D requested her to assist with R3's mechanical left transfer. CNA C reported by the time she got to R3's room CNA D had already hooked the sling onto the lift as soon as they pulled R3 out of the bed, R3 Went head first out of the sling and onto the floor. It was very horrible. CNA C reported she received an educational write up CNA C stated CNA D should not have hooked up the sling without both CNA's present, and that 2 staff persons were to be in the room for the entire transfer process, including hooking the loops of the sling to the lift. CNA C stated R3 was able to feed herself and brush her hair prior to the fall on 02/02/2021, but was currently not able to perform those tasks because of her fractured finger. On 3/16/2021 at 11:50am during an interview with CNA D she stated she had worked at the facility for [AGE] years and had cared for R3 on and off for several years. CNA D stated on 02/02/2021 was like a normal day, CNA D stated she hooked up the sling to the mechanical lift around 11:30 am and then and went to get CNA C to assist. CNA D stated somehow the hook to the sling and the lift came undone and R3 fell . CNA D reported hoop on the sling was not hooked to the lift correctly. CNA D reported she too received an educational write up from management, but in contrast to CNA C, CNA D reported it is still ok to hook up the sling to the lift without back up or assistance from staff. On 03/16/2021 at 12:10 during a bedside interview with R3, she was asked to explain what happened on 02/02/21, R3 reported the sling wasn't hooked up correctly and she fell . R3 reported going to the ED, and that she does not like the brace on her right leg that she has had since the fall, R3 further stated she has pain in the right leg daily and she was not able to feed herself due to the broken finger. On 03/16/2021 at 1:00PM, during an interview with Registered Nurse (RN) / Unit Manager (UM) E, she reported any resident that required a transfer via a mechanical lift, 2 staff must be present for the entire transfer including but not limited to hooking the sling to the actual lift. RN UM E stated that was in the best interest for everyone's safety. On 03/17/2021 at 1:35 PM, during an interview with Maintenance Director O he reported he inspected the lift and the sling on 02/02/2021 and found no mechanical defects. During an interview with Physical Therapist (PT) I and Occupational Therapist (OT) O on 03/16/2021 at 2:30 PM, OT O reported being R3's treating therapists after the fall and fracture that occurred on 02/02/2021. PT I reported R3 had a lot of pain during sessions particularly when getting out of bed and that she was frightened to be moved by the mechanical lift. OT O reported R3's prior level of functioning was being able to play bingo, brush her hair and feed herself with utensils but currently has pinch grasp capabilities. OT O reported function should return in time. Review of occupational therapy notes dated 02/10/2021 reflected R3 was dependent for eating related to 5th metacarpal fracture, high complaint of pain with movement. Review of occupational therapy notes dated 03/01/2021 reflected R3 was able to feed self with left hand with 2 point pinch. Discharge from occupational therapy note dated 03/09/2021 reflected R3 was able to demonstrate feeding herself with finger foods using left hand and digits one and two. According to Lippincott Procedures -Transfers with hydraulic lift with a revision dated of 5/15/2020 , Pg. 1.Make sure that clips, latches and hangar bars are fastened securely during use. On 03/17/2021 at 8:45 am, Director of Nursing (DON) B reported the fall for R3 was an unfortunate accident.

This citation pertains to intake number MI 2980. Based on interview and record review the facility failed to ensure the necessary treatment was provided for one out of seven residents (Resident #7 (R7)) resulting in worsening of pressure ulcers, and formation of new pressure ulcers. Findings Included: Per the facility face sheet R7 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. R7 no longer resided at the facility at the time of the survey. Review of a wound progress note from the wound clinic, dated 2/19/2020, revealed R7 had a pressure ulcer to her sacrum that measured 1 x 2.4 x 2.4 centimeters (cm) in size. Record review of Physician G's Initial History and Physical (H&P), dated 2/28/2020, revealed no documented pressure ulcers. Record review of a Braden Scale For Predicting Pressure Sore Risk assessment, dated 2/28/2020, which is an assessment of R7's ability to respond meaningfully to pressure related discomfort, the degree her skin was exposed to moisture, her degree of physical activity, ability to change and control her body position, her nutritional food intake, and risk of friction and shear to her skin, revealed she was at a low risk for developing pressure ulcers. Another Braden Scale For Predicting Pressure Sore Risk assessment, dated 3/12/2020, revealed R7 had a moderate risk of developing pressure ulcers, and on 3/19/2020 R7 was assessed to be at a high risk for developing pressure ulcers. Review of a Skin and Wound Total Body Skin Assessment, dated 3/18/2020 revealed R7 had no new wounds, and an assessment, dated 3/22/2020, revealed R7 had one new wound, and another assessment, dated 3/29/2020, revealed R7 had no new wounds. Review of R7's pressure ulcer wound care/treatment notes, and timeline revealed that when she was admitted on [DATE] she had a pressure ulcer wound to her rectum, on 3/4/2020 she had a purple blister on her right foot, on 3/22/2020 she had an open area on her left buttocks, and on 3/26/2020 she had a wound on her right buttocks. The timeline also revealed R7 had a pressure injury to her left buttocks, and excoriation (skin breakdown) to her groin area on admission to the facility. The timeline further noted that R7 was unable to turn and/or reposition herself in bed, and required staff assistance for turning while in bed every two hours. Review of R7's wound care/treatment notes revealed a wound care note, dated 4/10/2020, that addressed R7's right heel deep tissue injury (DTI (a purple area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue)) pressure ulcer, but no wound care/treatment notes were found or received for the date of 4/10/2020 that addressed R7's pressure ulcer wound to her rectum, and left and right buttocks. Review of physician's Wound Care Progress Note, dated 3/20/2020, revealed no documentation of any pressure ulcers. A physician's progress note, dated 4/10/2020, revealed R7 had a stage two pressure ulcer to her left buttocks, and a DTI to her right heel. A physician's progress note, dated 4/24/2020, only revealed R7 had a history of [REDACTED]. Further review of Physician's progress notes, dated 5/1/2020, revealed R7 was assessed to have a stage two pressure ulcer to her left buttocks, a DTI to her right heel which measured 0.5 x 0.8 x 0.0 centimeters (cm), a stage two pressure ulcer to her right buttocks, a DTI to her left, and lateral (the side) left heel. Review of a wound care/treatment note, dated 5/1/2020, revealed R7's right heel DTI measured 0.28 x 0.46 x 0.77 cm. Review of another Physician's progress note, dated 5/8/2020, revealed R7 had an ulcer to her left buttocks, but did not reveal documentation of the stage of the ulcer, a DTI to her left heel, a sacral pressure ulcer, which was noted to not have been documented by Physician G in his previous progress notes, a DTI to her left lateral heel, and a pressure ulcer to her right buttocks, but the stage of her right buttocks pressure ulcer was not documented. The note also revealed that R7 had debridement (surgical removal of unhealthy tissue from a wound) of her left buttocks, sacral, and right buttocks pressure ulcer wounds. The note did not reveal any documentation of R7's right heel DTI. Review of the Physician's progress notes revealed that on 5/8/2020 R7's sacral pressure ulcer wound was documented to have measured 2.1 x 0.7 x 0.1 cm, on 5/15/2020 her sacral pressure ulcer wound was documented to measure 1.2 x 2.2 x 0.1 cm, and on 5/29/2020 her sacral pressure ulcer wound was documented to measure at 3 x 3.0 x 0.1 cm. Review of a Physician's progress note, dated 5/15/2020, revealed R7 continued to have a DTI to her left heel, left buttock, a sacral pressure ulcer, a DTI to her left lateral heel, right buttocks, which also did not have documentation of the stage of this ulcer. The note did not reveal any documentation regarding R7's right heel DTI. Review of a Physician's progress note, dated 5/22/2020, revealed the only documentation regarding R7's pressure ulcers was that she had a history of [REDACTED]. R7's pressure ulcer wounds to her left heel were not documented on this Physician's progress note, and her right heel pressure ulcer was documented as a history of a DTI injury. Review of a Physician's progress note, dated 5/29/2020, revealed R7's continued to have pressure ulcers to her left heel documented as a DTI, right buttocks ulcer that was not staged, sacral ulcer that was also not staged, and her right heel pressure ulcer that now measured 5.1 x 5.5 cm. Review of R7's wound care/treatment notes revealed a wound care note, dated 4/10/2020, that addressed R7's right heel DTI pressure ulcer that was documented to measure 4.09 x 2.68 x 2.2 cm. No wound care/treatment notes were found or received for the date of 4/10/2020 that addressed any other pressure ulcer wounds R7 had on 4/10/2020. Further review of R7's wound care/treatment notes, revealed the date of 4/10/2020 was the first wound care/treatment note that was documented for R7's pressure ulcer wounds. In an interview on 7/1/2020, at 11:00 AM, Registered Nurse (RN) H stated it was on 3/22/202 when R7's left buttocks was observed to have a pressure area, and said it appeared that her left buttocks was an open wound on 3/22/2020, but stated that it was actually present on R7's admission to the facility, and said the pressure ulcer wound should have been documented as such on R7's admission. RN H said R7's left buttocks pressure ulcer wound was not documented right away that it was a pressure ulcer, and stated that she was aware of the omission of this documentation. RN H stated that R7 had one new skin condition to her right heel documented on 3/4/2020. RN H was requested to provide wound care/treatment notes for the months of February and March 2020. Per an email, dated 7/1/2020, at 2:14 PM, Administrator A, was asked to provide R7's wound care/treatment notes for February and March 2020, and an email response was receive on 7/1/2020, at 2:43 PM, from Administrator A that stated the facility did not have any wound care/treatment notes for February and March 2020 in regards to R7's pressure ulcer wounds. In an interview on 7/1/2020, at 3:40 PM, Director of Nursing (DON) B stated that she was not able to located the complete documentation of R7's pressure ulcer wounds. Review of the facility's policy and procedure titled, Skin Management, dated 10/2019, revealed under, Practice Guidelines, #4 Guest/residents admitted with any skin impairment will have .wound location, measurements and characteristics documented., and under #13, Guests/residents with pressure injury and lower extremity ulcers with be evaluated, measured, and staged weekly . In an interview on 7/1/2020, at 3:20 PM, Physician G stated that he saw R7 on 4/10/2020 for the first time related to her pressure ulcer wounds, when he examined her wounds. Physician G said in, regards to documentation of a pressure ulcer wound R7 had documented on 3/4 2020 of a purple blanchable area on her right heel, he was not able to locate any progress notes he had dictated for R7's pressure ulcer wounds on her right nor left heels. Physician G again stated that he saw R7 on 4/10/2020, and could not say if he was notified or made aware of R7's pressure ulcer wounds prior to 4/10/2020. Physician G also stated that R7 was not able to ambulate or move herself around. Review of a hospital note revealed R7 was admitted to the hospital on [DATE] for shortness of breath and fever. Further review of R7's hospital notes revealed that on 6/17/2020 R7's discharge from the hospital was canceled due to the state of her pressure ulcers on her coccyx and heel. The hospital notes further revealed that on 6/19/2020 R7 had a debridement of her pressure ulcer, but did not reveal which one, although dated 6/21/2020 revealed her sacral pressure ulcer was a stage four ulcer. Review of a Certified Nurse Aid (CNA) Nursing Care Card, dated 2/26/2020, revealed R7 was dependent on staff for bed mobility and skin care. The card revealed R7 was to be turned while bed every two hours. Record review of the CNA Activities of Daily Living (ADL) March 2020 documentation revealed the CNAs were to initial every shift, or three times a day, that they provided, routine standard care which includes evaluating skin daily and reporting changes, and turning and repositioning. The March ADL record revealed that for the dated of 3/1, 3/8, 3/9, 3/10, 3/11, 3/12, 3/13, 3/14, 3/16, 3/ 20, 3/21, 3/22, 3/24, 3/26, and 3/29/2020, 17 shifts were not initialed that the ADL activities were provided for R7. Review of the CNA ADL record for the month of April 2020 revealed that on 4/4, 4/7, 4/12, 4/15, 4/16, 4/17, 4/18, 4/19, 4/20, 4/21, 4/23, 4/25, and 4/29/2020, 15 shifts were not initial that the ADL activities of routine standard care which includes evaluation skin daily and reporting changes, and turning and repositioning. were provided for R7. Review of the CNA ADL record for the month of May 2020 revealed that on 5/9, 5/10, and 5/13/2020, 3 shifts were not initialed that the ADL activities of routine standard care which includes evaluation skin daily and reporting changes, and turning and repositioning. were provided for R7. Review of the CNA ADL record for the month of June 2020 revealed that on 6/7 and 6/8/2020, 2 shifts were not initialed that the ADL activities of routine standard care which includes evaluation skin daily and reporting changes, and turning and repositioning. were provided for R7. Review of a Treatment Administration Record (TAR) for the month of March 2020 revealed R7 had a treatment to float her heels (keep off the mattress or pressure areas) every shift, and wear Prevalon boots (protective boots for the skin) at all times, which had a start date of 3/4/2020, revealed that on 3/16 and 3/29/2020 for the night shift no nursing initials that indicated the treatments were in place. Further review of R7's March TAR revealed she had an air mattress on her bed that was to be initialed two times per day that her air mattress was in place. On 3/16/2020 for the night shift there were no nursing initials to indicate R7's air mattress was in place. Review of a TAR for the month of April 2020 revealed R7 had a treatment to float her heels every shift, and wear Prevalon boots at all times, with a start date of 3/4/2020, revealed that on 4/5/2020 the evening and night shift had no nursing initials that indicated the treatment was in place, on 4/8/2020 the night shift had no nursing initials, on 4/17/2020 the evening shift had no initials, and on 4/23/2020 the night shift had no nursing initials. Further review of R7's March TAR revealed she had an air mattress on her bed that was to be initialed two times per day that her air mattress was in place. On 4/5, 4/8, and 4/23/2020 for the night shift there were no nursing initials to indicate R7's air mattress was in place. The TAR also revealed R7 had a treatment that was ordered on [DATE] to apply a skin prep (protective barrier) to both of her heels twice a day, but on 4/5/2020 no nursing initials were documented that the prep was applied. Review of a TAR for the month of May 2020 revealed R7 had the continued treatment to float her heels every shift, and wear Prevalon boots at all times. The TAR revealed that on 5/18 for the day shift, 5/21 for the evening shift, 5/22 for the evening shift, 5/26 for the night shift, and 5/31/2020 for the evening shift there were no nursing initials that indicated the treatments were in place. The TAR also revealed that on 5/18 for the day shift, and 5/26/2020 for the night shift there were no nursing initials that indicated R7's skin prep was applied to both of her heels. Record review of a June 2020 TAR revealed R7 had an ordered treatment in place to apply [MEDICATION NAME] Wound/Burn Dressing Gel (Wound Dressings), and cleanse her wounds with normal saline then cover with a foam dressing. The treatment was ordered to be applied to both sides of her buttock and sacrum every day shift for wound healing, and was ordered to begin on 5/09/2020. The TAR revealed that on 6/4 and 6/9/2020 no nursing initials were documented on the TAR that indicated the treatment was completed for R7. The June 2020 TAR also revealed R7 was to continue with her skin prep and Prevalon boot treatment, and revealed that on 6/2, 6/3, and 6/4/2020 for the night shift no nursing initials that indicated the treatments were provided.

Based on observation, interviews, and record review, the facility failed to provide the assistance of 2 staff persons during bed mobility and remove a tourniquet after Intravenous placement for 2 of 3 (Resident #10 and Resident #31) sampled residents, resulting in complaints of pain to the left arm, left hip, head and bodily injury from falling 3 feet off the ground, and the potential for fall with fractures. Also, resulting in numbness, decreased circulation, bruised and swollen skin. Findings Include: Resident #10: On 05/16/18 at 09:29 AM Resident (R) #10 was interviewed during the initial tour of the facility. R10 was observed sitting up in her bed with her TV dressed in sleepwear, with her call light clipped to her bedding near her abdomen. She was observed to not move the left side of her body much. R10 revealed that during a dressing change, A Certified Nursing Assistant (CNA) tried to changed me by herself and I am a 2 person change. She did it by herself. She was on the left side of the bed and I fell out of the right side of the bed and broke my arm. On 05/16/18 at 04:00 PM, Resident (R) #10 was observed sitting up in her wheelchair, padded arm rest, and a pillow behind her head in the TV room. She was cleanly dressed, with bilateral padded green prafo like cushioned boot on her feet. She was observed to not move the left side of her body, but upon command was able to move her left arm, but her hand remained in a fist like position with her thumb on top of her fingers. On 05/18/18 at 09:04 AM, R10 incident/accident was requested and later provided. The Incident Report dated 4/7/18 at 9:00 PM, and completed by Licensed Practical Nurse (LPN GG), reflected R10 had a witnessed fall from her bed, with injuries that included: Complaints/Of (c/o) pain to left hip and left arm waiting X-ray. The Post-Fall Report completed by Registered Nurse (RN M) dated 4/16/18 reflected the guest stated: She was washing me up and had me too close to the edge and I rolled over. The described situation and assistance being provided reflected: Performing bed mobility with one person. Bed at approx 3 ft high. providing personal care. The (Name of company) Educational Opportunity sheet dated 4/7/18 with CNA FF's name listed (CNA present during incident) reflected: Episode and date that it occurred: Resident fall out of bed with resident care. Guest being turned with only 1 staff member. Care card indicated Extensive assist of 2 for bed mobility. Education/Policy Discussed: Read care card for all guests. Ask for help when needed and ensure the help stays until task completed. The above document was prepared and signed by RN M on 4/7/18. The Nursing Care Card used by CNA's reflected: Weakness of the right/left arms and legs, and contractures of the right/left hands, arms, legs and feet. Bed Mobility/Skin Care: Extensive assist of 2. Dressing/Grooming: Dependent. In the comments section handwritten reflected, *Do Not brief when in bed. The Nurses Notes, dated 4/8/18 at 06:25 AM, reflected: Note Text: Resident was being provided personal care with one assist with bed at waist height approx 3ft and rolled to the floor. Hitting her head on the floor and falling on left side. Res was assess no injuries notes, Res c/o of head shoulder and hip hurting. VS WNL. Res was max assisted back in bed. Neuro assessment started. Notified (daughter's name) and (doctor's name), Stat order for 2 view X-rays received. PRN [MEDICATION NAME] given for pain. Will continue to monitor. Review of R10's Electronic Medical Record (EMR), on 05/18/18 at 10:00 AM, reflected R10 had a significant change Minimum Data Set (MDS: resident assessment tool) that was in progress dated 5/18/18. R10's annual MDS dated [DATE] reflected R10 was cognitively intact, required extensive assistance of 2 persons for bed mobility/toilet use/dressing, total assistance of 2 persons for transfers/bathing, and verbalized vocal complaints of pain. CNA FF was contacted by phone on 05/18/18 at 10:12 AM, and asked to recall the fall incident that occurred on 4/7/18. CNA FF stated, I was turning her and she slid on off the hoyer pad. I tried to catch her but I could not. I was turning her towards me to take the pad out. I was checking her to see if she wet. She was on her back before I turned her toward me. CNA FF was queried if another aide was present during patient care while turning. CNA FF replied, No, there was another aide (CNA HH) but he took off. There wasn't anybody and I was by myself. If was only 2 aides working that night. During the day there is 3 on north. When I turned her towards me she slid off the bed and we had to use the hoyer to get her up. The hoyer pads are slippery. LPN GG helped me and CNA HH get R10 in the bed. RN M was working that night because they were short, she asked what happened and I told her. I was working over. I had worked 18 hours. When asked if any education had been done after the incident CNA FF stated, They had me sign and paper and said I was supposed to use 2 person. I had to do what I had to do because no one was available to help. The facility working schedule for 4/7/18 during the second shift reflected a facility census of 92, with 1 RN and 2 CNA's working on R10's hall that night. LPN GG was called on 05/18/18 at 10:36 AM, and CNA HH was called on 05/18/18 at 10:44 AM. Neither staff person was available by phone. The callers name, number, reason for call and call back request was left on their voice mail. Upon exit of the facility on 5/18/18 at 5:40 PM, neither staff had called writer back. On 05/18/18 at 11:21 AM, RN M was interviewed related to R10's fall on 4/7/18. RN M revealed she was not working at the time of the incident, and that R10 was a 2 person assist with bed mobility. The CNA was providing care and rolled R10 over to do other side and slid off the bed. RN M stated, I asked her why she was doing it by herself. There was another CNA there but he left. I asked him if she asked him for help, and he said No, she did not need any help. I talked to him, but don't have any documentation related to the conversation. Also, that the CNA (when turning R10) brought her towards her, and before turning her she was on her back. X-rays were performed on 4/8/18 for R10's skull, left hip, left forearm, left femur, left shoulder and were all negative for fractures. The (MONTH) (YEAR) Medication Administration Record [REDACTED] 4/6/18 medicated only one time at 12:54 PM, pain (0-10 point scale) 3 effective. 4/7/18 at 21:30 PM (after fall), pain 10 Uneffective (U). 4/8/18 at 04:51 AM, pain 10 Effective (E). 4/8/18 at 16:10 PM, pain 4 E. 4/9/18 at 12:51 PM, pain 10 E. 4/9/18 at 22:31 PM, pain 10 U. Review of the Electronic Medical Record (EMR) on 05/16/18 at 04:33 PM, reflected Resident (R) #31 was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #31 On 05/15/18 at 11:36 AM, R31 was observed to have bilateral padded siderails up from the hallway near his entry door, from his waist down as the privacy curtain was pulled half closed. Upon entering R31's room his was observed to be awake, did not respond with greeted or attempted conversation. R31 was observed to randomly grab the side rails, look aimlessly while laying awake in his bed. 05/16/18 at 04:33 PM, the Electronic Medical Record (EMR) reflected R31 was admitted to the facility on [DATE] and re-entered on 4/20/18 with [DIAGNOSES REDACTED]. Review of R31's significant change Minimum Data Set (MDS: resident assessment tool) dated 3/19/18 reflected a Brief Interview of Mental Status (BIMS) score of 10 out of 15 (moderately impaired). Also, that R31 required extensive assistance of 1 person for bed mobility, dressing, hygiene and extensive to total assistance of 2 persons for transfers and bathing. The facility Incident Report for R31 dated 4/26/18 at 12:45 PM reflected Type of Occurrence listed as: 11. Other: IV (Intravenous) insertion-IV tourniquet. Type of Injury: dried skin ring around swollen around arm. Type of Care' A&D ointment to raised dry ring around arm. Immediate Intervention: Monitored Site. The form was completed by RN M. The Investigative Summary of Incident dated 4/26/19 completed by RN M reflected: Guest was ordered to have IV started at 50 ml/hr for [MEDICAL CONDITION]. IV tourniquet was found on right upper arm by oncoming shift at approximately 7:30 PM. Tourniquet was removed and guest arm was noted cool to touch with numbness to fingers. Noted to right upper arm at tourniquet location small bruise and small area of swelling. Noted raised ring around the upper arm that has very dry skin. Guest was observed frequently through night and circulation evaluation were done . Nurses noted dated 4/26/18 at 14:03 PM by RN M reflected, after 1st attempt #22 Introcan Safety 3 needle inserted to right forearm with saline adapter applied and flushed without difficulty. IV D5W hung to infuse at 50 ml/hr as ordered. Guest tolerated procedure well. Nurses notes dated 4/26/17 at 14:20 by RN CC reflected: 95.7, 68, 20, 134/82 Guest finished antibiotic therapy. No adverse reaction noted. Yet, it was not until 7:30 PM that nursing staff discovered the tourniquet was still placed on R31's right arm, since first applied at around 12:45 PM. RN M was interviewed on 05/18/18 at 11:17 AM, to discuss the incident dated 4/26/18. RN M revealed, she had started R31's IV access on 4/26/18, and used the tourniquet. RN M continued, I looked everywhere, moved it up higher to look and put IV in and the gown apparently slid over it and I did not see it, and that's kind of what happened. RN M revealed, RN CC placed a geri- sleeve on R31's arm so he did not pull his IV out and apparently did not see the tourniquet.

This Citation pertains to intake number MI 421 Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status for 1 (Resident #500) of 3 residents, out of a total sample 5, resulting in Resident #500 being hospitalized for [REDACTED]. Findings include: Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #500 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #500 had clear speech was understood and understands others, and had no cognitive impairment. Review of the hospital "Patient Transfer Sheet" dated 3/23/2013 revealed Resident #500 upon transfer to the facility had a secondary [DIAGNOSES REDACTED]. Review of the "history and physical examination ...having a lot of diarrhea about five or six times a day and feeling tired. The report revealed that Resident #500's labs were as follows: Creatinine 0.7mg/dl (normal is 0.6-1.1mg/dl), BUN (Blood Urea Nitrogen) is 13 mg/dl (normal is 6-23 mg/dl), sodium is 129 mmol/L (normal is 135-145 mmol/L, Potassium is 3.7 mmol/L (normal is 3.5-5.3 mmol/L). Review of the "Admission Nutritional Status / Diet Care Plan" dated 3/24/2013 revealed there were no interventions to address Resident #500's diarrhea or ileus. Review of a physician's orders [REDACTED]. Review of a Laboratory Report dated 4/5/2013, revealed that Resident #500's stool was negative for [MEDICAL CONDITION]. Review of a physician's orders [REDACTED]. Review of Regional Medical Laboratories Microbiology Report dated 4/17/2013 revealed that Resident #500's stool was positive (infected) for [MEDICAL CONDITION]. Review of the Facilities "Timeframe Guidelines for Nutritional Documentation" dated 7/2002 revealed, Interdisciplinary Nutrition Care Plan to be completed 7 days following the completion of the comprehensive assessment (MDS). The Dietary Professional responsible for the Care Plan has to ensure the Care Plan is current. Review of the "Facilities Dietary Care Plans" policy dated 07/2002, revealed, "Care plans will include measurable objectives and timetables for identified nutritional or hydration problems or potential problems...Dietary care plans will be updated...with a significant change of condition...Dietary Care Plans will address nutrition and hydration-related issues and problems. Examples include, but are not limited to the following...Significant weight loss or gains". Review of Resident #500's medical record revealed a comprehensive assessment (MDS) was completed on 3/30/2013, an Interdisciplinary care plan for nutrition was completed 4/11/2013 and revealed, to observe for signs and symptoms of dehydration, Obtain weight at a minimum of monthly and report significant weight changes of 5% x30 days to the physician and Dietician and to follow NAR (Nutrition at Risk) per protocol. Review of the Registered Dietician (RD) note dated 3/25/2013 revealed Resident #500 was at moderate risk related to decreased intake. Review of "Nutrition at Risk Monitoring" record dated 3/27/2013 (4 days after admission) revealed Resident #500's weight was 167 lbs., current diet was regular, and recommendations were to continue to monitor and yogurt 3 times a day for snack. Review of the Nutrition at Risk Monitoring Record dated 4/11/2013, revealed on 4/1/2013, Resident #500's weight was 155 lbs. which was a 12 pound or 7.2% weight loss over 5 days. The record revealed Resident #500's current diet was regular, and was provided yogurt 3 times a day at snack time, recommended Resident #500 be reweighed and continue to monitor. The facility was unable to produce record of Resident #500 being reweighed. Review of the Nutrition at Risk Monitoring Record dated 4/18/2012 revealed Resident #500's weight on 4/8/2013 was 151.2 lbs., indicating a 15.8 pound (9.5%) weight loss over 12 days. The record indicated that Resident #500 was discharged to the hospital on [DATE]. Review of the "Nutrition at Risk Program" policy dated 7/2002 revealed, "The Director of Nursing or designee is responsible for notifying the Dietary Manager/Dietitian and attending physician of all guest place on the Nutritional Risk Tracking Sheet...If the Dietary Manager is not a Dietitian, it will be his/her responsibility to review the updated Nutritional Risk Tracking Sheet with the Consultant Dietician on the consultant's next visit...If...questions concerning a guest's nutritional status arise, contact their Consultant Dietician as soon as possible by phone. Appropriate intervention for guests at nutritional risk must occur as soon as possible after the condition is discovered. In an interview on 5/15/2013 at 3:00 PM, Registered Dietician (RD) #9 stated, she had no recollection of the facility informing her of Resident #500's weight loss and if she was notified of this would have offered supplements and Med Pass to address her nutritional needs. In a telephone interview on 5/16/2013 at 1:44 PM, Attending Physician #10 stated, he did not remember the facility contacting him about Resident #500's weight loss, had he been informed of the weight loss, and with the resident having a lot of diarrhea, he would have suggested possible IV fluids and nutritional supplements. In an interview on 5/15/2013 at 3:00 PM, Registered Dietician (RD) #9 stated, she had no recollection of the facility informing her of Resident #500's weight loss and if she was notified of this would have offered supplements and Med Pass to address her nutritional needs. In a telephone interview on 5/16/2013 at 1:44 PM, Attending Physician #10 stated he did not remember the facility contacting him about Resident #500's weight loss, had he been informed of the weight loss, and with Resident #500 having a lot of diarrhea, he would have suggested possible IV fluids and nutritional supplements. In an interview on 5/16/2013 at 9:34 AM, Dietary Manager (DM) #11 stated, Resident #500 was a picky eater, and that she (DM #11) implemented yogurt 3 times a day on 3/27/2013 to address the fact that Resident #500 would not eat what was offered to her at meal time. DM #11 stated that she could not find on the care plan that Resident #500 was a picky eater, and yogurt should be offered 3 times a day. DM #11 stated, the unit manager would be responsible for notifying the physician about Resident #500's weight loss, but she could not remember if she had told the Unit Manager (UM) about the weight loss. DM #11 stated, she did not work April 1-5, and was not certain who would have followed up with Resident #500's nutritional needs at that time. When asked what interventions were put into place regarding resident #500's weight loss, DM #11 stated, that yogurt was to be offered to the resident 3 times a day as a snack. In an interview on 5/16/2013 at 1:40 PM, the UM, Registered Nurse (RN) #12 stated, she could not recall DM #11 informing her about Resident #500's weight loss. RN #12 stated, Resident #500 was on NAR (Nutrition at Risk) program, and remembers discussing Resident #500's case during interdisciplinary team meetings, but does not remember ever being told of the weight loss. Review of facility's "Guidelines for Completing the Resident Assessment Protocols" (RAP) revised 5/2005 revealed, "Automatic triggers requiring further assessment by the Dietary Professional for the Nutrition RAP based on completion of the MDS (include) Weight Loss...For each triggered RAP, the Dietary Professional shall review...the nature of the condition...complications and risk factors that affect the clinician's decision to proceed to care planning...Topics of discussion within the Nutrition RAP may include: level of nutrition risk...weight status...diagnosis' impacting nutritional status (including) malabsorption, diarrhea..." Review of the MDS dated [DATE] revealed, Resident #500 "triggered" for a weight loss of 5% or more in the last month. Review of Resident #500's "Nutrition at Risk Monitoring Record" dated 3/27/2013, 4/11/2013 and 4/18/2013, revealed there was no documentation by the Dietary Professional of risk factors or diagnosis' impacting nutritional status, after the MDS on 4/4/2012 was completed. In an interview on 5/16/2013 at 9:34 AM DM #11 stated, the Certified Nursing Assistants (CNAs) were responsible for completing food intake records on the computer, and that is how she monitors resident's daily food intake. In an interview on 5/16/2013 at 10:00 AM, DON #1 stated, it would be normal to have a lot of fluid loss with diarrhea, and it would be normal to not have much of an appetite with diarrhea. DON #1 stated that Resident #500 was a picky eater. In an interview on 5/16/2013 at 1:30 PM, Nursing Home Administrator #2 stated, "Only intervention we could have done was a feeding tube or TPN (Total Parental Nutrition, meaning providing necessary nutrients by an IV)". In an interview on 5/16/2013 at 1:50 PM, CNA #13 stated, resident #500 was a very picky eater, wasn't a whole lot that she liked. CNA #13 stated resident #500 would eat a lot of yogurt and soup. CNA #13 stated if a resident felt there was too much to eat on a food tray and the resident would only eat a small portion, she would document 75%. CNA #13 stated, for instance if a resident would not touch the main meal, but would eat all of the oatmeal she would record 75-100% on the food intake record, because they were satisfied with the meal. During observations made on 5/16/2013 from 9:05 AM until 9:15 AM, CNAs were observed removing trays from resident's rooms and placing them on a rack in the hall, but they were not observed documenting food intake. In an interview on 5/16/2013 at 3:16 PM, CNA #14 stated that she normally chart resident's food intake at the end of the shift. When asked how she remembered what the residents ate, CNA #14 stated, I just remember, CNA #14 further stated she would normally chart on 13-14 residents each day. In an interview on 5/16/2013 at 3:35 PM, CNA #15 stated she would document resident's food intake sometime before she left at the end of her shift. CNA #15 stated she did not write down resident intake at the time of meals, rather she "just remembered" what they ate when she would complete her resident food intake charting. On 5/16/2013 from 9:10 AM until 9:30 AM, end of meal resident breakfast trays were observed on a tray rack in the hallway. Off sample resident #505's tray had an empty bowl of oatmeal, and a full plate of sausage gravy and biscuits. Off sample resident #506's tray had a plate with 2 half pieces of toast and 2 tablespoons of scrambled eggs. Off sample resident #507's tray had an empty banana peel, a full bowl of oatmeal and a full plate of sausage gravy and biscuits on it. Off sample resident #508's tray had nothing missing from it. Off sample resident #509's tray had a full bowl of oatmeal and most of the sausage gravy and biscuits still remained on the plate. Review of resident breakfast food intake records for 5/16/2013, with RN #16 present, revealed the following: Off sample resident #505 ate 75% of breakfast. Off sample resident #506's food intake was not charted yet, RN #16 had to find the CNA responsible for this resident and then reported that 100% of breakfast had been consumed. Off sample resident #507 ate 100%. Off sample resident #508's food intake was not charted yet, RN #16 had to find the CNA responsible for this resident and then reported that 75% consumed. Off sample resident #509 ate 0% of breakfast. Review of hospital "Emergency Department" Report dated 4/18/2013 revealed that Resident #500 was admitted to the hospital on [DATE] for abnormal labs. Report revealed Resident #500's Sodium was 117 low (normal 135-145mmol/L), Potassium was 2.6 low (normal 3.5-5.3mmol/L), Chloride 81 low (normal 101-111 mmol/L), BUN 18 (normal 8-20 mg/dL), Creatinine 1.1 (normal 0.4-1.2 mg/dL), Lactic Acid 5.7 critically high (normal 0.4-1.3 mmol/L). The report revealed, "(Resident #500) complained of diarrhea and abdominal discomfort...appeared dehydrated with dry mucous membranes...was hypotensive (low blood pressure). Review of hospital "History and Physical" Report dated 4/18/2013 revealed, Resident #500 was assessed to have "[MEDICAL CONDITION] (low sodium levels). Current sodium level is 117 with urine sodium of 22. This is inappropriate urine sodium excretion in light of the severe dehydration...This is multifactorial...likely also an aspect of acute dehydration in light of the diarrhea and anorexia (loss of appetite and inability to eat)...We will correct this slowly with fluid resuscitation". According to an article dated 1/29/2013 from Lab Test Online, "A doctor may also order an [MEDICATION NAME] test...to check or monitor a person's nutritional status...decreases can reflect protein deficiencies and [MEDICAL CONDITION] levels are a warning and an indication that further investigation may be warranted...Low [MEDICATION NAME] levels can also be seen in inflammation, shock, and [MEDICAL CONDITION]. They may be seen with conditions in which the body does not properly absorb and digest protein...or in which large volumes of protein are lost from the intestines" (http://labtestsonline.org/understanding/analytes/[MEDICATION NAME]/tab/test) Review of Resident #500's medical record revealed her [MEDICATION NAME] level (normal 3.5-4.8 gm/dL) decreased from 3.0 on 3/19/2013 to 2.8 on 3/26/2013, to 2.6 on 4/17/2017, a 13% decrease in less than a month. ( )

This Citation pertains to intake number MI 421 Based on interview and record review, the facility failed to provide sufficient amounts of fluids for 1 of 3 (Resident #500) residents, out of a total sample of 5, resulting in Resident #500 being hospitalized and found to be severely dehydrated. Findings include: Review of the Minimum Data Set ((MDS) dated [DATE], revealed Resident #500 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #500 had clear speech was understood and understands, and had no cognitive impairment. Review of the hospital "Patient Transfer Sheet" dated 3/23/2013 revealed Resident #500 upon transfer to the facility had a secondary [DIAGNOSES REDACTED]. Review of the "history and physical examination ...having a lot of diarrhea about five or six times a day and feeling tired. The report revealed that Resident #500's labs were as follows: Creatinine 0.7mg/dl (normal is 0.6-1.1mg/dl), BUN (Blood Urea Nitrogen) is 13 mg/dl (normal is 6-23 mg/dl), sodium is 129 mmol/L (normal is 135-145 mmol/L), Potassium is 3.7 mmol/L (normal is 3.5-5.3 mmol/L). Review of the "Admission Nutritional Status / Diet Care Plan" dated 3/24/2013 revealed there were no interventions to address Resident #500's diarrhea or ileus. Review of resident #500's ADL sheet dated 3/23/2013 thru 4/17/2013 revealed, Resident #500 continued to have loose stool through 4/4/2012, and then again 4/9/2012 until discharge on [DATE]. Review of a physician order [REDACTED]. Review of Resident #500's interdisciplinary care plan for nutrition dated 4/11/2013 revealed, "observe for signs and symptoms of dehydration (dry mouth, poor skin turgor, lethargy, low blood pressure)". Review of the Registered Dietician (RD) note dated 3/25/2013 revealed; Resident #500 was at moderate risk related to decreased intake. In a telephone interview on 5/16/2013 at 1:44 PM, Attending Physician #10 stated, he did not remember the facility contacting him about Resident #500's weight loss, had he been informed of the weight loss, and with the resident having a lot of diarrhea, he would have suggested possible IV fluids and nutritional supplements. Review of the "Nutrition at Risk Monitoring Record" dated 3/27/2013, 4/11/2013 and 4/18/2013, completed by DM#11, revealed there was no documentation of DM#11 addressing Resident #500's risk factors or diagnosis' impacting fluid status/needs. In an interview on 5/16/2013 at 10:00 AM, DON #1 stated, it would be normal to have a lot of fluid loss with diarrhea. Review of the "Nutritional Assessment" dated 3/25/2013 revealed Resident #500's fluid requirements were calculated to be 1898 ml of fluid per day. Review of Resident #500's "ADL Data Report" dated 3/23/2013 thru 4/17/2013 revealed, resident received on average 1754 ml of fluid per day during her stay. According to an article on MedicineNet.com, dated 9/5/2012, "Dehydration occurs when the amount of water leaving the body is greater than the amount being taken in ... More fluid would be needed to replace ...fluid loss from ...diarrhea ...Diarrhea is the most common reason for a person to lose excess amounts of water. A significant amount of water can be lost with each bowel movement." (http://www.medicinenet.com/dehydration/article.htm). According to an article on Medscape.com, dated 3/12/2012, "Dehydration describes a state of negative fluid balance that may be caused by numerous disease entities. Diarrheal illnesses are the most common etiologies (causes)...Hyponatremic (low sodium)...dehydration occurs when the lost fluid contains more sodium than the blood...Relatively more sodium than water is lost. Because the serum (blood) sodium is low, intravascular (within the blood vessel) water shifts to the extravascular space (outside of the blood vessel), exaggerating intravascular volume depletion for a given amount of total body water loss." (http://emedicine.medscape.com/article/ 9-overview). Review of hospital Emergency Department Report dated 4/18/2013 revealed that Resident #500 was admitted to the hospital on [DATE] for abnormal labs. Report revealed Resident #500's Blood Urea Nitrogen (BUN - detects dehydration) 18 mg/dL (normal 8-20), Creatinine (measurement of renal function - slight elevation indicates dehydration) of 1.1 mg/dL (normal 0.4-1.2 ), Lactic Acid 5.7 mmol/L - critically high (indicating severe dehydration). The report revealed, "(Resident #500) complained of diarrhea and abdominal discomfort...appeared dehydrated with dry mucous membranes...was hypotensive (low blood pressure)". Review of hospital History and Physical Report dated 4/18/2013 revealed Resident #500 was assessed to have "[MEDICAL CONDITION] (low sodium levels). Current sodium level is 117 with urine sodium of 22. This is inappropriate urine sodium excretion in light of the severe dehydration...This is multifactorial...likely also an aspect of acute dehydration in light of the diarrhea and anorexia (loss of appetite and inability to eat)...We will correct this slowly with fluid resuscitation". ( )

This citation pertains to intake number MI 318 Based on observation, interviews, and record review, the facility failed to provide the necessary care and services to attain the highest practicable physical well-being for 1 resident (Resident #502) of 4 sampled residents, from a total sample of 4 residents, by not initiating the facility's Cardiopulmonary Resuscitation (Heartsaver CPR) policy and procedure, resulting in an Immediate Jeopardy when Resident #502 was found unresponsive, without a pulse and no respirations on [DATE] at approximately 2:00 AM. Facility staff did not call emergency medical services (EMS) until 2:46 AM. Resident #502 subsequently died at 3:42 AM. This deficient practice places 38 residents identified as requesting CPR at high risk for harmand/or death. Findings include: Review of the Face Sheet (not dated) revealed that Resident #502 was a [AGE] year-old female admitted to the facility on [DATE] at 7:45 PM. [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #502 had no Advanced Directive (Health Care Directive) in the medical record. Review of the facility's 24 hour report, submitted to the state on [DATE], revealed that Resident #502 was admitted to the facility at approximately 7:45 PM on [DATE]. At approximately 2:05 AM on [DATE], Resident #502 was coded by the facility staff, EMS was called and continued the code. Resident #502 passed away at approximately 3:47 AM. Record review of a "Nursing Admission Assessment", dated [DATE], revealed that Resident #502, on her admission to the facility, was assessed to be alert, oriented to time, place, and person, calm, and had clear speech. The assessment did not include complete documentation of Resident #502's cardiovascular assessment, respiratory assessment, or neurological assessment. In an interview on [DATE] at 1:43 PM, Registered Nurse (RN) #1 stated that at approximately 2:05 AM on [DATE], Certified Nurse Aid (CNA) #2 reported to her that Resident #502 "did not look right". RN #1 said that she immediately went into Resident #502's room and found Resident #502 without a pulse and without respirations (not breathing). RN #1 said she kept a pocket mask in her pocket and gave Resident #502 breaths because she found Resident #502 to have shallow breathing. RN #1 said she began chest compressions. RN #1 then said that she first yelled out Resident #502's room door that she needed help, and stated that she hoped Licensed Practical Nurse (LPN) #4 knew that she meant to call 911, and then went back and began CPR. RN #1 said LPN #4 called the sheriff's department and stated that she did not know why LPN #4 called the sheriff's office instead of calling 911. RN #1 said that she did CPR for approximately ,[DATE] minutes, until the Emergency Medical Technician (EMT) arrived. RN #1 stated that no other staff ever came into Resident #502's room while she performed CPR. RN #1 said that she was aware that an announcement was to be made over the facility intercom in the event of an emergency, and stated that she did not know if that was ever done because no other staff ever came into Resident #502's room. RN #1 also stated that at one point she left Resident #502's room and grabbed a back board off of the crash cart, but stated that she did not take the entire crash cart into Resident #502's room. RN #1 stated that when the EMT's arrived there were 4 EMT's and the 4 EMT's put Resident #502 on the floor. RN #1 said that she documented in her nurses' notes that at 2:10 AM CPR was "called" and stated that "called" meant started by her until the EMT's arrived at 2:45 AM. RN #1 said that she performed CPR alone and stated that she did not perform CPR vigorously because she had to rest. RN #1 was asked why she did not document the details of her CPR in the nurses' notes. RN #1 said that she did not document in the nurses's notes because Resident #502 was under LPN #4's care, although RN #1 stated that she began documentation in the nurses' notes when the paramedics arrived. In another interview on [DATE] at 10:23 AM, RN #1 said that she entered Resident #502's room at approximately 2:05 to 2:10 AM on [DATE], began CPR which RN #1 described that she performed 2 rescue breaths and then 30 chest compressions, rechecked for a pulse, gave 2 more rescue breaths and then 30 more chest compressions. RN #1 stated that she performed CPR for approximately 30 minutes. RN #1 said that at approximately 2:,[DATE]:25 AM she went to Resident #502's room door yelled for help; saw LPN #4 pick up the nurses' station desk phone, and she then proceeded to go back to performing CPR on Resident #502 and stopped at approximately 2:30 AM. RN #1 was asked if she was aware of what the facility policy and procedure was for stopping CPR once started and RN #1 then stated that it indicates once you start CPR you are not to stop until EMS takes over and she then stated that she began CPR again for about ,[DATE] minutes. RN #1 stated that she did not announce that Resident #502 was "coding" (full cardiopulmonary arrest, no pulse and not breathing), but revealed that she only stated "get help". RN #1 also again stated that she obtained the back board off of the crash cart before she yelled out for help (RN #1 was not able to clarify at what point she obtained the back board). RN #1 said no other staff responded and stated that she observed LPN #4 sitting at the nurses' station on the phone. RN #1 was not able to clearly explain why she did not tell LPN #4, who was sitting at the nurses' station when she obtained the back board off the crash cart, that Resident #502 was coding and needed CPR performed. RN #1 said that LPN #4 never got up from the nurses' station during the entire incident and also stated that one other nurse was in the building (RN #5) but stated that RN #5 did not come to the skilled hall until the EMT's arrived. RN #1 said she never saw any of the CNA's that were on duty during the incident. RN #1 stated that she continued CPR on Resident #502 and did not leave Resident #502's room until the EMT personnel arrived. RN #1 said she was in Resident #502's room when 4 EMT personnel entered the room. RN #1 said that she documented all that the EMT's did for Resident #502. RN #1 said the EMT personnel questioned her about Resident #502's medical history and stated that she told the EMT's to go to the nurses' station and ask LPN #4 for the information. Review of facility policy and procedure for "Cardiopulmonary Resuscitation (Heartsaver CPR)", dated [DATE], revealed under "Policy', "For guests who have designated a Health Care Directive to indicate that they wish CPR to be performed or in the absence of a Health Care Directive, the facility will initiate Cardiopulmonary Resuscitation ..."Under" Procedures" #2,3,& 4,the policy revealed, "...commence Heartsaver CPR ...while alternate staff obtains the emergency cart, have another staff member notify 911 for immediate transport ..."Under a "Note" the policy revealed, "If the guest does not respond, once CPR had been initiated it may only be stopped by emergency transport personnel at the direction of a physician." Record review of nurses' notes, dated ,[DATE] through [DATE], revealed that at 7:45 PM on [DATE], Resident #502 was admitted to the facility. On [DATE] at 12:20 AM Resident #502 was assessed to have an oxygen saturation of 88% (amount of oxygen in a person's blood, normal is greater than 90%). The notes revealed that 1 liter of oxygen was placed on Resident #502, and Resident #502 was repositioned in bed and her breathing calmed down. The notes revealed that on [DATE] at 2:00 AM the following: "Resident (#502) had difficulty breathing when checked, she had quit breathing, CNA (#2) notified nurse. (Registered Nurse RN #1) went in to check on resident and observed her (resident #502) not breathing and (without) heart rate. Family, doctor, and facility staff notified. Sheriffs's office notified to send corner's (coroner) to facility, resident (#502) had post-mortem care given, CPR attempted (without) results." The notes further revealed that at 6:00 AM the funeral home picked Resident #502 up from the facility. Another nurses' note dated [DATE], beginning at 2:10 AM, revealed the following: "2:10 AM, RN note, found (without) pulse irregular respirations CPR called. (Ambulance) was called and here, 2:20 AM, breathing shallow, pO2 (oxygen) 88%, 02 2L n/c (2 liters via nasal cannula, tubing in the nose that administers oxygen), 2:30 AM breathing still shallow, 2:45 AM no pulse CPR started (with) board under back, compressions (on the chest to stimulate the heart) started and going, 2:50 AM, compressions, 3:00 AM, IV (intravenous line) attempted by (ambulance), 3:00 AM, monitor showing asystole (flat line), 3:01 AM, IO (intraosseous IV, inserted into the bone) given lift knee, 3:05 AM, IO given right knee, chest compression continued, (no) pulse, auto chest compression, 3:12 AM, ET (endotracheal tube, breathing tube) inserted by (ambulance), 3:15 AM, (no) pulse, 3:20 AM, IV inserted L (left) antecubital (crease of the elbow) CPR continued, 3:20 AM, Epin 1:10 (medication administered), 3:22 AM, [MEDICATION NAME] (medication) 40 units given IV, 3:24 AM, calcium 1 gr (gram) IV, 3:25 AM, sodium barcarb ([MEDICATION NAME], medication) CPR cont ' d (continued), 3:27 AM, Epin 1:10 IV, 3:28 AM Accu check (blood sugar level) =53, 3:30 AM D50 25 gram (IV fluids) IV, 3:31 AM, [MEDICATION NAME] (medication) IV, 3:33 AM, Epin 1:10 IV eyes (pupils) fixed and dilated (no pupil reaction to light), 3:36 AM, code called, asystole (flat line). Record review of a "Prehospital Care Report Summary" (ambulance run sheet), dated [DATE], revealed that the ambulance was called at 2:46 AM and 10 seconds, dispatched at 2:46 AM and 19 seconds, on scene (at the facility) at 2:55 AM, and made contact with Resident #502 at 2:57 AM. The report revealed that CPR was started at 2:57 AM and stopped at 3:42 AM and Resident #502 was pronounced dead at 3:42 AM. The narrative section of the report revealed, " The patient (Resident #502) was last seen at 2:00 AM complaining of difficulty in breathing. The CNA witnessed the patient (Resident #502) arrest at 2:05 AM. The CNA informed the RN staff at 2:05 AM. The RN staff did not call 911 ...until approximately 2:45 AM. Once arrived at the (facility) the RN staff was at there (their) desk charting. When asked where the patient (Resident #502) was located they (RN staff, #1 & #4) responded with she (Resident #502) was down the hall. I (EMT) then had the CNA (#2) show me were the patient (Resident #502) was. Once we found the patient (Resident #502) I (EMT) assessed the patient's (Resident #502) pulse and respirations. The patient (Resident #502) was pulseless and apneic (not breathing). We (EMT's) then moved the patient (Resident #502) to the floor and initiated CPR." Review of an incident report submitted from the ambulance company, dated [DATE], revealed the following, "...Upon arrival we (EMT's) are called to the nurses desk as we (EMT's) are attempting to figure out where the patient (Resident #502) is located. The RN (not identified) states that she did not want us to come and requested the coroner. The RN (not identified) eventually tells us where the patient (Resident #502) is located. Upon arrival to the patients side we find the patient ...pulseless and apneic. The patient is lying in her bed. No medical personal (personnel) in the room. No one performing CPR. The patient is warm to the touch and has no obvious signs of death. The RN (not identified) is asked several times if the patient (Resident #502) is a DNR (do not resuscitate), we (EMT's) are eventually able to get her to tell us no. The RN (not identified) is not able to tell us why she was not performing CPR. We (EMT's) began to work the patient. We (EMT's) ask questions about the patient the RN (not identified) will not give us any information. The staff (facility staff) remain very uncooperative with us for the entirety of this call. At one point (EMT) and myself (EMT) go to the nurses station to look at the patients medical record, the RN (not identified) states to us (EMT's) that she cannot allow us to view the medical record. After arguing she (not identified) eventually takes the sheet with her (Resident #502's) medical history out of the binder and tells me (EMT) I can look at it there at the desk ...The RN (not identified) states that she went to the room (Resident #502's room) when the CNA's (not identified) had told them she (Resident #502) had quit breathing, she (nurse) then states, "I checked for a pulse and she (Resident #502) didn't have one, she (Resident #502) was already gone." The RN states that she then called her DON (director of Nursing) who then instructed her to call the coroner. The RN does not state why she did not begin CPR. When asked she she didn't call for the paramedics until 2:45 AM she (nurse) states, "I don't know the number, it's not in the phone. " In an interview on [DATE] at 6:52 PM, Paramedic #6 stated that upon his initial entrance into the facility he approached the skilled hall nursing desk, where two female nurses' (did not know their names) were sitting charting, and asked where the patient (Resident #502) was. Paramedic #6 said that the unidentified nurses asked why they (paramedics) were there and stated that they wanted the coroner to respond. Paramedic #6 said the unidentified nurses stated that they could not find the coroner's number so they dialed 911 and asked for the coroner, and also stated that they (nurses) did not need them (paramedics). Paramedic #6 said that he told the unidentified nurses that other steps needed to be taken first and asked again where Resident #502 was. Paramedic #6 said that a male CNA (CNA #2) took the paramedics to Resident #502's room. Paramedic #6 stated that upon initial assessment of Resident #502, Resident #502 was still warm, but had no heart rate or respirations. Paramedic #6 said Resident #502 and had no signs and symptoms of death. Paramedic #6 said that CPR was performed right away on Resident #502 and also stated that while CNA #2 was in Resident #502's room CNA #2 stated that Resident #502 had difficulty in breathing at 2:00 AM and that he reported it to RN #1. Paramedic #6 said that CNA #2 informed him that RN #1 went into Resident #502's room, checked for a pulse, did not find Resident #502 with a pulse and then stated that Resident #502 was "already gone." Paramedic #6 said that when he requested Resident #502's medical record, Licensed Practical Nurse (LPN #4) would not give to him, and said that LPN #4 told him that she could not give Resident #502's medical record to him. Paramedic #6 said that he ended up just taking Resident #502's medical record. In another interview on [DATE] at 11:11 AM, Paramedic #6 said that his documentation of Resident #502 not having any signs and symptoms of death referred to, Resident #502 was warm, did not have rigor mortis (stiffening) not liver mortis (discoloration of the dependent parts of the body after death). Paramedic #6 was asked about documentation that Resident #502 did not have any respirations but the documentation also revealed that Resident #502's lungs sounds were wet (both right and left). Paramedic #6 stated that Resident #502 was not breathing upon his assessment of her and stated that Resident #502's lung sounds documented as "wet" after a breathing tube was inserted and paramedics administering breathes to Resident #502. In an interview on [DATE] at 3:43 PM, Paramedic #18 said that Paramedic #6 and his self were the only two who initially entered the facility for the call to 911. Paramedic #18 said that upon entrance into the facility RN #1 and LPN #4 were observed to be sitting at the nurses' station. Paramedic #18 said that upon approaching RN #1 and LPN #4 at the nurses' station, he and Paramedic #6 asked where Resident #502 was. Paramedic #18 said that RN #1 then asked them (Paramedic #6 & 18) why they were there and that RN #1 told them that they wanted the coroner. Paramedic #18 said CNA #2 then showed them were Resident #502's room was located. Paramedic #18 said that no staff were in Resident #502's room upon entrance. Paramedic #18 said, upon initial assessment, Resident #502 was warm and had no heart rate. Paramedic #18 said Resident #502 had no signs and symptoms of death, and stated that meant Resident #502 was still warm, flaccid (loose) and did not have rigor mortis. In an interview on [DATE] at 11:38 AM, RN #5 (who worked in the center hall) said that at approximately 2:00 AM he went outside for a break and stated that he returned inside at approximately 2:10 AM and was told by CNA #11 that RN #1 had phoned to the central nurses' station and said that she "needed help with something." RN #5 said he walked to the skilled nurses' station and saw RN #1 and LPN #4 sitting at the nurses' station. RN #5 said RN #1 asked him if he knew where the coroner's phone number was located. RN #5 said it was approximately 2:20 AM and RN #1 and LPN #4 were looking through the phone book to locate the coroner's phone number. RN #5 said he did not question as to why RN #1 and LPN #4 wanted the coroner's phone number. RN #5 said he showed RN #1 and LPN #4 a number to call. RN #5 said that for any emergency the nursing staff at the facility is to always call 911, but stated that he was not aware of any emergency/[MEDICAL CONDITION] in progress. RN #5 said he never met Resident #502 and that he never heard any announcement over the facility intercom system that a resident was in [MEDICAL CONDITION]. RN #5 said he never heard any other staff member say that help was needed and stated that if a "code" (cardiopulmonary arrest) had been called any CNA would have gone outside and got him. RN #5 said there were 3 nurses on staff the night of [DATE], his self, RN #1, and LPN #4. RN #5 said that in the event of a resident in cardia arrest, per facility policy and procedure, an overhead announcement was to be made, 911 called, one staff member was to obtain the crash cart (emergency cart), while another staff member checked the resident's code status (do not resuscitate, DNR vs. full code, do emergency care), another staff member was to do documentation and all staff were to respond to an emergency call. In an interview on [DATE] at 12:44 PM, Medical Examiner #9 said that he was not sure why the police were called and why 911 was not called until approximately 40 minutes after Resident #502 died . In an interview on [DATE] at 12:47 PM, Detective #10 stated that the only reason the police department looked into the incident was because the time that 911 was called and the police had questioned why staff at the facility had waited to call 911. In an interview on [DATE] at 2:39 PM, and another interview on [DATE] at 2:38 PM, Certified Nurse Aid (CNA) #2 stated that he was assigned to Resident #502 in [DATE] and stated that Resident #502 was admitted to the facility between the hour of 7:30 PM and 8:00 PM. CNA #2 said Resident #502 was alert and oriented and did not have any confusion. CNA #2 said Resident #502 put her call light on at approximately 2:00 AM and asked to be cleaned up due to incontinence. CNA #2 said Resident #502 was not short of breath and spoke clearly at the time she had put her call light on. CNA #2 stated that he and CNA #3 assisted Resident #502 to clean her up, including turning Resident #502 side to side and then pulling her up in bed. CNA #2 said that as he and CNA #3 pulled Resident #502 up in bed Resident #502 became short of breath. CNA #2 said that he and CNA #3 put Resident #502's head of her bed up and then Resident #502 stated that she was getting hot. CNA #2 said CNA #3 left the room to go get a wash cloth to put in Resident #502's head and stated that when CNA #3 returned to resident #502's room CNA #3 put the wash cloth on Resident #502's face and stated that Resident #502 did not look good. CNA #2 said that he checked Resident #502's pulse, on her wrist, and could not find one. CNA #2 said Resident #502 did not move; was not talking, and her breathing was labored (struggling to breath). CNA #2 said CNA #3 checked Resident #502's pulse (in her wrist) and did not find a pulse. CNA #2 said Resident #502 had long pauses in-between each breath. CNA #2 said CNA #3 told him to go get RN #1. CNA #2 said he told RN #1 that she was needed in Resident #502's rooms right away and stated that RN #1 did immediately go into Resident #502's room. CNA #2 said he reported to RN #1 that he was not able to get a pulse from Resident #502 and stated that he then left Resident #502's room. CNA #2 said that he did not know if RN #1 ever called for help and stated that he did not hear an overhead announcement of a code being called (help needed). CNA #2 said that he knew the ambulance arrived at the facility first but stated that he did not know the time of their arrival. CNA #2 said he knew because the ambulance personnel asked him to assist with getting Resident #502 onto the floor. CNA #2 stated that he was in the hallway when one of the Emergency Medical Technicians (EMT grabbed him to come assist with Resident #502. CNA #2 said that only two (2) EMT's were in Resident #502's room when he entered and stated that he did not see RN #1 or Licensed Practical Nurse (LPN) #4 in Resident #502's room when he entered. CNA #2 said he did not see a back board under Resident #502 when he assisted the EMT's to place her on the floor. CNA #2 also stated that he assisted to clean up Resident #502's room at approximately 6:00 AM and said that he did not find a back board in Resident #502's room. CNA #2 said that from the time he informed RN #1 at approximately 2:10 AM to the time the EMT's asked him to assist with Resident #502 he had walked past Resident #502's room, because that was the hall he was assigned to, and did not see anyone performing CPR on Resident #502. CNA #2 said that if he would have seen a staff member performing CPR he would have stopped to see if help was needed. CNA #2 said that he was not aware of an emergency and that nothing triggered him to have any concern until the EMT pulled him into Resident #502's room for assistance. CNA #2 said he saw LPN #4 sitting at the nurses' station and stated that he did not know where RN #1 was. In an interview on [DATE] at 3:13 PM, CNA #3 stated that CNA #2 asked him to assist with Resident #502, did not know the time, and that his self and CNA #2 went into Resident #502's room to clean her up. CNA #3 said Resident #502 had a C-collar (neck brace) on and had been complaining of the C-collar. CNA #3 said Resident #502 complained of being to hot. CNA #3 said that upon finishing care for Resident #502 he left the room to get a cool wash clothe. CNA #3 said when he returned to place the wash cloth on Resident #502 he noticed that Resident #502 "did not look right." CNA #3 said Resident 3502's eyes look "glazed", she was not moving, and had deep long respirations. CNA #3 said that he and CNA #2 both checked for a pulse on both side of Resident #502's wrist and stated that they were not able to feel a pulse. CNA #3 said he stayed with Resident #502 while CNA #2 went out and got RN #1. CNA #3 said RN #1 then entered Resident #502's room and told him that she had "this" and he needed to go answer call lights. In another interview on [DATE] at 4:18 PM, CNA #3 said that when RN #1 told him to go answer his call lights he left Resident #502's room and did his own work. CNA #3 said that between the hours of 2:00 and 2:45 AM he saw both RN #1 and LPN #4 sitting at the nurses' station. CNA #3 said RN #1 and LPN #4 were looking through the phone book, but stated that he did not know what they were looking for. CNA #3 said that he cleaned up Resident #502's room after the paramedics had worked on her and stated that he did not find a backboard in the room. In an interview on [DATE] at 8:20 PM, LPN #4 said she was in orientation and being oriented to the third shift by RN #1 on [DATE]. LPN #4 said that at approximately 12:30 AM on [DATE] she went into Resident #502's room to administer medications. LPN #4 said Resident #502 had complained of shortness of breath and was very anxious. LPN #4 said she got Resident #502 comfortable and checked on her approximately 30 minutes later. LPN #4 said RN #1 entered Resident #502's room with her and the two of them checked Resident #502's oxygen level, which LPN #4 stated was 79%. LPN #4 said RN #1 instructed CNA #2 to go get an oxygen tank, which then 1 liter of oxygen was placed on Resident #502. LPN #4 said Resident #502's physician was not notified that oxygen was placed on Resident #502. LPN #4 said RN #1 did not make any phone call until after Resident #502, "was dead." LPN #4 said she and RN #1 re-checked Resident #502's oxygen level approximately 20 minutes later and it was 88%. LPN #4 said Resident #502 was made comfortable and then her self and RN #1 left Resident #502's room. LPN #4 said she never entered Resident #502's room again until the EMT's (paramedics) arrived. LPN #4 said CNA #2 came out of Resident #502's room at approximately between 2:00 and 2:10 AM and told RN #1 that it looked like Resident #502 was "gone." LPN #4 said RN #1 immediately got up and went into Resident #502's room and then came out approximately 10 minutes later. LPN #4 said RN #1 told her that Resident #502 was not breathing and had no pulse. LPN #4 stated that RN #1 told her that she (RN#1) stayed a few extra minutes to double check Resident #502's pulse and even checked for a pulse in more than one place. LPN #4 said that after RN #1 came out of Resident #502's after the 10 minutes, RN #1 asked her to call the coroner. LPN #4 said that she did could not remember if RN #1 asked her to look to see if Resident #502 was a "code" (perform CPR) or not, but stated that when RN #1 went into Resident #502's initially, after told by CNA #2, she began to attempt to find Resident #502's code status. LPN #4 said RN #1 did not question her about Resident #502's code status until she sat down at the nurses' station, and stated that she told RN #1 that she was not able to locate a code status on Resident #502. LPN #4 said RN #1 did not comment. LPN #4 said when RN #1 sat down at the nurses' station, where she also was sitting, RN #1 told her that Resident #502 was "gone" and that she (RN #1) needed to show her what was to be done "now", and stated that a lot of phone calls needed to be made. LPN #4 said RN #1 began to make phone calls and told CNA #2 and 3 to begin post-mortem care. LPN #4 stated that RN #1 told her that she (RN #1) had performed CPR but did not give any details of the CPR. LPN #4 said RN #1 did not take a back board into Resident #502's room and stated that the "crash" cart never left the closet that it was stored in. LPN #4 said RN #1 did not call a "code" to indicate that there was an emergency. LPN #4 said she was not able to locate and number for the coroner and as a result she called the number for information. LPN #4 said information put her through to dispatch. LPN #4 said she told dispatch that the facility had a death of a resident who had been admitted to the facility less than 8 hours prior and they (RN #1 and LPN #4) needed the coroner to pronounce the time of Resident #502's death. LPN #4 said that was how the paramedics, police, and fire department all became aware and arrived at the facility. LPN #4 said RN #1 was with her at the nurses' station when the EMT's (paramedics) arrived at the facility. LPN #4 said RN #1 got up and met the EMT's at Resident #502's room door. LPN #4 said that one of the EMT's asked her for Resident #502's medical chart and LPN #4 stated that she because she did not know of an emergency that was taking place she refused to give Resident #502's chart to the EMT's, due to protection of medical information laws. LPN #4 said she commented to the EMT's as to why they were they at the facility because they (RN #1 & LPN #4) had called for the coroner. LPN #4 that she had been an LPN since the year 2000. LPN #4 said she was oriented to the facility policy and procedure and understood that if a code status of a resident was not found on the resident's chart then the resident was considered a "full code" and life saving measures were to be taken. LPN #4 said she did not get up and check on Resident #502 nor did she call a "code". LPN #4 said she was :kicking herself" for not doing that and stated that she was not sure why she did not check on Resident #502. LPN #4 said she was not thinking an emergency because RN #1 did not indicate there was an emergency. In an interview on [DATE] at 3:03 PM, RN #17 stated that she oriented LPN #4 on the second shift. RN #17 said she educated LPN #4 on the facility policy and procedure in the event that a resident coded. RN #17 stated that she informed LPN #4 that in the event a resident coded it was called a "code blue". RN #17 said she told LPN #4 that if a resident did not have a heart beat and no respirations then she was to check the resident's code status in the resident's chart and stated that she showed LPN #4 where the sticker was located in a resident chart. RN #17 said she instructed LPN #4 that if a resident did not have an advanced directive then the resident was considered a "full code" and stated that she told LPN #4 to call an announcement over the intercom that a "code blue" was in progress, have someone obtain the crash cart, call 911, and initiate CPR. RN #17 said she showed LPN #4 where the non-emergent numbers were located, and where all the crash carts in the facility were located. RN #17 said LPN #4 told her that she already knew all that and that she (LPN #4) was an experienced nurse. RN #17 said she told LPN #4 she had to tell her anyway. In an interview on [DATE] at 5:50 PM, Administrator #7 stated that on [DATE] at 2:20 AM (timed stamped to his phone) he received a phone call from RN #1, who had left a message for him to phone the facility. Administrator #7 stating that he returned the call to the facility at 2:21 AM and spoke with RN #1. Administrator #7 said RN #1 reported to him that a newly admitted resident (#502) had passed away and stated that he directed RN #1 to call the medical examiner due to Resident #502 being newly admitted to the facility. In an interview on [DATE] at 5:09 PM, Director of Nursing (DON) #8 stated that she received a call at 2:50 AM (time stamped) from RN #1 stating that Resident #502 was going to pass or had passed away. DON #8 said RN #1 told her that she had been instructed by Administrator #7 to call the coroner. DON #8 said she went back to sleep and woke up at approximately 4:45 AM and called RN #1 back. DON #8 said she asked RN #1 if Resident #502 was "coded" and stated that RN #1 told her yes. DON #8 said she did not ask RN #1 who performed the code. Observation of the location of the crash carts in relation to Resident #502's room was conducted on [DATE] at 9:00 AM. It was observed that a crash cart was located in a closet across the hall from Resident #502's room and also another one in a closet that was right next to the nurses' station in the hall (skilled) Resident #502 resided in. Administrator #7 was notified on [DATE] at 3:30 PM, of the Immediate Jeopardy that began on [DATE], and was identified on [DATE], as a result of the facility's failure to meet 1 of 4 sampled resident's (Resident #502), from a total sample of 4 residents, highest practicable physical well-being by not initiating the facility's policy and procedure for Cardiopulmonary Resuscitation (Heartsaver CPR) when Resident #502 was found to be unresponsive, without a pulse, and no respirations on [DATE] at approximately 2:00 AM, and facility staff did not call emergency services until 2:46 AM. Resident #502 subsequently died at 3:42 AM. On [DATE] the surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: 1). All residents (91 of 91) emergency directives were initiated on [DATE] and completed on [DATE] to ensure their emergency directives were complete. All emergency directives were current as of [DATE]. 2). A complete audit of current residents' (91 of 91) records was initiated on [DATE] and was completed on [DATE] to ensure code status is clearly identified with code status stickers in place on the inside of the medical record. All stickers were current and present as of [DATE].

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IDENTIFY, AND IMPLEMENT TIMELY INTERVENTIONS AND TREATMENTS TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS FOR 2 OF 3 RESIDENTS (#38, #42) REVIEWED FOR PRESSURE ULCERS, FROM A TOTAL SAMPLE OF 10 PLUS 1 INCLUDED IN THE EXTENDED SAMPLE, RESULTING IN THE DEVELOPMENT OF AN INFECTION, [MEDICAL CONDITION], A SURGICAL PROCEDURE, AND UNNECESSARY DISCOMFORT FOR RESIDENT #38, AND THE LACK OF IDENTIFICATION AND treatment for [REDACTED].#42. THE BUREAU OF HEALTH CARE SERVICES, LONG TERM CARE DIVISION, MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS HAS IDENTIFIED "A SITUATION IN WHICH THE PROVIDER'S NONCOMPLIANCE WITH ONE OR MORE REQUIREMENTS OF PARTICIPATION HAS CAUSED OR IS LIKELY TO CAUSE SERIOUS INJURY, HARM, IMPAIRMENT OR DEATH TO A RESIDENT." (SEE 42 CFR PART 489.3). THE IMMEDIATE JEOPARDY BEGAN ON 2/13/13 AT 3:20 AM WHEN FACILITY NURSING DOCUMENTATION REFLECTED SYMPTOMS OF INFECTION, LATER IDENTIFIED AS RELATED TO RESIDENT #38'S INFECTED LEFT HIP PRESSURE SORE. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 2/13/13, AT 1:31 PM, WHEN RESIDENT #38'S LEFT HIP PRESSURE ULCER WAS OBSERVED AS A LARGE REDDENED AREA THAT EXTENDED FROM THE LEFT HIP TO THE LEFT BUTTOCK AND CONTAINED 4 PEA-SIZED WHITE/YELLOW PUSTULES, AND STAFF IDENTIFIED THAT RESIDENT #38 HAD AN ELEVATED BODY TEMPERATURE OF 101 DEGREES FAHRENHEIT (F). RESIDENT #38 WAS THEN TRANSFERRED BY AMBULANCE AND admitted to the hospital with [REDACTED]. THE ADMINISTRATOR OF THE FACILITY WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 2/15/13 AT 12:08 PM IN THE ADMINISTRATOR'S OFFICE. THE IMMEDIATE JEOPARDY WAS REMOVED BY FACILITIY ACTIONS ON 2/19/13 AT 2:15 PM, WHEN INTERVENTIONS AND physician's orders [REDACTED].#42'S PLAN OF CARE AND EDUCATION WAS PROVIDED TO FACILITY STAFF REGARDING PRESSURE ULCER PREVENTION. IT WAS DETERMINED THAT NONCOMPLIANCE REMAINED AT THE LOWER SCOPE AND SEVERITY OF ISOLATED ACTUAL HARM THAT IS NOT IMMEDIATE JEOPARDY. FINDINGS INCLUDE: ACCORDING TO THE FACILITY FACE SHEET (UNDATED) RESIDENT #38 WAS A [AGE] year OLD MALE REadmitted to the facility on [DATE]. RESIDENT #38'S "CUMULATIVE [DIAGNOSES REDACTED]. RESIDENT #38'S MINIMUM DATA SET (MDS) WITH THE ASSESSMENT REFERENCE DATE OF 1/22/13 REFLECTED THAT RESIDENT #38 HAD A BRIEF INTERVIEW FOR MENTAL STATUS (BIMS) SCORE OF 5 OUT OF 15, WHICH REFLECTED COGNITIVE IMPAIRMENT. THE SAME MDS ALSO REFLECTED RESIDENT #38 REQUIRED "EXTENSIVE ASSISTANCE" BY "ONE PERSON PHYSICAL ASSIST" FOR BOTH "BED MOBILITY" AND "TRANSFER", AND REFLECTED THAT RESIDENT #38 WAS AT RISK FOR DEVELOPING PRESSURE SORES. RESIDENT #38'S LABORATORY VALUES COLLECTED ON 1/26/13 REFLECTED A LOW TOTAL PROTEIN LEVEL OF 6.1 GRAMS PER DECILITER (G/DL - NORMAL RANGE = 6.4 - 8.2) AND A LOW [MEDICATION NAME] LEVEL OF 3.2 G/DL ( NORMAL RANGE = 3.4 - 5.0.) THE DOCUMENT REFLECTED HAND WRITTEN NOTATIONS FROM THE PHYSICIAN, BUT NO INDICATION OF ANY TYPE OF SUPPLEMENT ORDERED TO HELP INCREASE RESIDENT #38'S PROTEIN STORES. REVIEW OF THE DIETARY PROGRESS NOTES FOUND IN RESIDENT #38'S MEDICAL RECORD, REFLECTED NO DOCUMENTATION REGARDING RESIDENT #38'S LOW PROTEIN LEVELS. THE LAST NOTE WRITTEN BY THE FACILITY'S DIETICIAN, DIETICIAN "M" WAS DOCUMENTED ON 11/5/12. THE FACILITY DOCUMENT "BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK" REFLECTED A SCORE OF 18 ON 11/1/12 AND A SCORE OF 17 ON 1/30/12 FOR RESIDENT #38. THE KEY FOUND ON THE DOCUMENT REFLECTED "TOTAL SCORE OF 17 OR LESS INDICATED THAT THE INDIVIDUAL IS AT RISK." THE FACILITY DOCUMENT "SHOWER/SKIN OBSERVATION" (DATED 1/24/13) REFLECTED A CIRCLE AROUND THE SCROTUM AREA ON THE BODY MAP WITH THE BOX CHECKED NEXT TO "REDDENED AREA" AND THE HAND WRITTEN DOCUMENTATION "TX (TREATMENT) APPLIED". THE FACILITY DOCUMENT "WEEKLY SKIN ASSESSMENT" (DATED 1/31/13) REFLECTED ON THE BODY MAP A CIRCLE AROUND RESIDENT #38'S ENTIRE PUBIC AREA AND UPPER RIGHT LEG. THE BOX NEXT TO "HAS EXISTING (CIRCLE): WOUND CONDITION / PRESSURE ULCER" WAS CHECKED BUT NEITHER "WOUND CONDITION" OR "PRESSURE ULCER" WAS SPECIFIED. THE FACILITY DOCUMENT "PRESSURE ULCER RECORD" (DATED 2/2/13) REFLECTED THAT RESIDENT #38 HAD DEVELOPED A "R (RIGHT) HEEL" "MUSHY/DARK IN COLOR UNSTAGEABLE AT THIS TIME DEEP TISSUE INJURY" THAT MEASURED "4.0 CENTIMETERS (CM) X 4.0 CM" AND DESCRIBED THE COLOR AS "BLACK/PURPLE". THE NURSING "PROGRESS NOTE" (DATED 2/2/13 AT 7:00 PM) REFLECTED "AREA ON R (RIGHT) HEEL 4 CM X 4 CM THAT IS MUSHY AND DARK IN COLOR (PHYSICIAN "F") NOTIFIED AND ORDERS RECEIVED. DAUGHTER NOTIFIED." THE FACILITY DOCUMENT "physician's orders [REDACTED]. AREA IS 4 X 4 CM SURROUNDING IS REDDENED. TOTAL 6 X 6 CM. STEPS HAVE BEEN TAKEN FOR PRESSURE RELIEF - DAUGHTER IS AWARE." AND THE HANDWRITTEN RESPONSE FROM THE PHYSICIAN (DATED 2/4/13) "NOTED - AVOID PRESSURE - HEELS OFF FROM BED - WOUND TEAM FU (FOLLOW UP)". THE FACILITY DOCUMENT "SHOWER/SKIN OBSERVATION" (DATED 2/4/13) REFLECTED ON THE BODY MAP THAT RESIDENT #38 HAD DEVELOPED A "BRUISE" ON HIS LEFT HIP, AND THE HAND WRITTEN "BLUE GOO (A SKIN PROTECTION CREAM) APPLIED TO SCROTUM". RESIDENT #38'S PHYSICIAN NOTE, BY PHYSICIAN "F" (DATED 2/4/13), REFLECTED UNDER THE SECTION "SKIN", "INTACT, WARM, PINK. NO RASHES, LUMPS, ULCERS". THE FACILITY HAD DISCOVERED AN UNSTAGEABLE PRESSURE ULCER ON RESIDENT #38'S RIGHT HEEL ON 2/2/13. THE FACILITY DOCUMENT "SHOWER/SKIN OBSERVATION" (DATED 2/7/13) REFLECTED ON THE BODY MAP A CIRCLE AROUND RESIDENT #38'S PUBIC AREA WITH THE HAND WRITTEN DOCUMENTATION "TESTICLES RED/BLEEDING", A CIRCLE ON RESIDENT #38'S UPPER LEFT BUTTOCK WITH THE HAND WRITTEN DOCUMENTATION "REDDENED AREA", AND A CIRCLE AROUND RESIDENT #38'S RIGHT HEEL WITH THE HAND WRITTEN DOCUMENTATION "DISCOLORED AREA". THE FACILITY DOCUMENT "PRESSURE ULCER RECORD" (DATED 2/9/13) REFLECTED "SITE LEFT HIP" AND DESCRIBED THE SITE AS A "STAGE 1" PRESSURE ULCER MEASURING 4 CM X 3.2 CM AND A "REDDENED AREA TENDER TO TOUCH". THE FACILITY DOCUMENT "PRESSURE ULCER RECORD" (DATED 2/9/13) REFLECTED RESIDENT #38'S RIGHT HEEL PRESSURE ULCER HAD INCREASED IN SIZE TO "4 CM X 5.5 CM" WITH A "1 CM X 1.5 CM MUSHY BLACK CENTER REGION". THE DOCUMENT REFLECTED THE REST OF RESIDENT #38'S HEEL CONTINUED TO APPEAR "BLACK/PURPLE". THE FACILITY DOCUMENT "INVESTIGATION OF CLINICAL EVENT (I.C.E.)" (DATED 2/9/13) REFLECTED "IN HOUSE ACQUIRED PRESSURE AREA SITE: L BUTTOCK" AND "3.2 X 4 CM PRESSURE AREA PREFERS L SIDE TO LAY ON GUEST NON-COMPLIANT C (WITH) TURNING AND REPOSITIONING. KICKS PILLOW OUT AND REPOSITIONS SELF." 5 DAYS AFTER A "BRUISE" WAS IDENTIFIED BY THE FACILITY ON RESIDENT #38'S LEFT HIP. THE NURSING "PROGRESS NOTE" (DATED 2/10/13) AT 4:45 PM REFLECTED "WRITER ASSESSED SKIN AFTER CENA'S (CERTIFIED NURSES AID) ALERTED ME TO NEW SKIN ISSUE ON L (LEFT) BUTTOCK. PRESSURE AREA NOTED 3.2 X 4 CM....OBTAINED PRESSURE MATTRESS..." RESIDENT #38'S "ADL (ACTIVITIES OF DAILY LIVING)" CARE PLAN (DATED 11/1/12) REFLECTED THE HANDWRITTEN DOCUMENTATION "GUEST HAS LIMITED ROM (RANGE OF MOTION) IN BLE (BILATERAL LOWER EXTREMITIES) AND BUE (BILATERAL UPPER EXTREMITIES)" DATED 1/8/13. RESIDENT #38'S "SKIN" CAREPLAN (DATED 11/1/12) REFLECTED THE HAND WRITTEN DOCUMENTATION "GUEST REFUSES TO TURN AND REPOSITION AND NON-COMPLIANT C (WITH) TURNING AND PILLOW PLACEMENT FOR OFF-LOADING VULNERABLE AREAS" DATED 2/9/13, 5 DAYS AFTER THE FACILITY DISCOVERED A "BRUISE" ON RESIDENT #38'S LEFT HIP, AND 2 DAYS AFTER THE FACILITY DISCOVERED A STAGE 1 PRESSURE SORE ON RESIDENT #38'S UPPER LEFT BUTTOCK. THE FIRST DOCUMENTATION OF RESIDENT #38 BEING "NONCOMPLIANT C (WITH) REPOSITIONING IN BED" WAS FOUND IN THE NURSING "PROGRESS NOTE" FOR 2/12/13 AT 3:00 PM, 8 DAYS AFTER THE FACILITY DISCOVERED A "BRUISE" ON RESIDENT #38'S LEFT HIP, AND 5 DAYS AFTER THE FACILITY DISCOVERED A STAGE 1 PRESSURE SORE ON RESIDENT #38'S UPPER LEFT BUTTOCK. RESIDENT #38'S NURSING "PROGRESS NOTES" REFLECTED DOCUMENTATION OF "NO BEHAVIORS NOTED" ON 2/1/13 AT 12:30 PM, 2/2/13 AT 10:00 PM, 2/3/13 AT 6:45 PM, AND 2/4/13 AT 10:45 AM. A DIFFERENT "SKIN" CAREPLAN FOR RESIDENT #38 (DATED 12/21/12) REFLECTED THE HAND WRITTEN DOCUMENTATION "FLOAT HEELS WHILE IN BED" DATED 2/1/13, THE DAY BEFORE THE FACILITY DISCOVERED AN UNSTAGEABLE PRESSURE ULCER ON RESIDENT #38'S RIGHT HEEL. RESIDENT #38'S "NURSING CARE CARD" (UNDATED) REFLECTED BOTH INTERVENTION "FLOAT HEELS" AND "TURNING AND POSITIONING SCHEDULE: Q (EVERY) 2 HOURS" BUT NO DATES AS TO WHEN THESE INTERVENTIONS WERE IMPLEMENTED. THIS DOCUMENT DID NOT REFLECT ANY DOCUMENTATION REGARDING RESIDENT #38 BEING NON COMPLIANT WITH TURNING AND REPOSITIONING IN BED. RESIDENT #38'S "NUTRITION" CAREPLAN (DATED 11/19/12) REFLECTED THE INTERVENTION "PROVIDE SUPPLEMENTS PER ORDERS". NO DOCUMENTATION NOR INTERVENTIONS REGARDING RESIDENT #38'S LOW PROTEIN AND LOW [MEDICATION NAME] LEVEL FROM 1/26/13 WAS FOUND ON THIS CAREPLAN. REVIEW OF RESIDENT #38'S "physician's orders [REDACTED].#38'S LOW PROTEIN AND LOW [MEDICATION NAME] LEVEL. RESIDENT #38'S "FLU" CARE PLAN (DATED 1/29/13) REFLECTED THE INTERVENTION "OBSERVE FOR NEED FOR INCREASED ASSISTANCE ADL'S: TRANSFERS, AMBULATION DURING ILLNESS" WITH A START DATE OF 1/29/13. THE FACILITY DOCUMENT "PRESCRIBER'S TELEPHONE ORDER" (DATED 2/10/13) REFLECTED "L (LEFT) BUTTOCK: CLEANSE C (WITH) NS (NORMAL SALINE) APPLY ALLEVYN GENTLE BORDER Q (EVERY) 3 DAYS AND PRN UNTIL HEALED - PRESSURE AREA". THIS TELEPHONE ORDER WAS NOT SIGNED BY THE PHYSICIAN. CENA "A" WAS INTERVIEWED IN THE 200 HALLWAY ON 2/12/13 AT 2:45 PM. CENA "A" STATED SHE WORKED WITH RESIDENT #38 "ABOUT ONCE A WEEK" AND STATED THAT HE "IS COMPLIANT WITH BRIDGING HEELS AND TURNING AND REPOSITIONING IN BED WITH PILLOWS." DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) AT THE "CENTER" NURSES STATION ON 2/12/13 AT APPROXIMATELY 2:30 PM, THE DON CONFIRMED RESIDENT #38'S DRESSING CHANGE ON HIS LEFT HIP WAS TO BE DONE ON SECOND SHIFT THE FOLLOWING DAY, AND THAT THE STAFF WOULD BE INSTRUCTED TO WAIT FOR THIS SURVEYOR TO OBSERVE IT. DURING AN INTERVIEW AT THE "CENTER" NURSES STATION ON 2/12/13 AT 3:15 PM, REGISTERED NURSE (RN) "C", THE UNIT MANAGER, WAS ASKED TO PROVIDE THE MEASUREMENTS FOR RESIDENT #38'S PRESSURE AREAS ON HIS RIGHT HEEL, LEFT HIP, AND LEFT BUTTOCK. RN "C" RESPONDED THAT RESIDENT #38 "ONLY HAS ONE OPEN AREA. HIS LEFT HIP. HIS HEELS ARE INTACT. I JUST LOOKED AT IT YESTERDAY." IN RESIDENT #38'S ROOM ON 2/12/13 AT 3:25 PM CENA'S "D" AND "E" WERE OBSERVED HELPING RESIDENT #38 BACK TO BED. DURING THE OBSERVATION CENA "D" WAS OVERHEARD ASKING CENA "E" ABOUT THE PILLOWS IN RESIDENT #38'S BED. CENA "D" STATED "I'M NOT FAMILIAR WITH THOSE PILLOWS" IN REFERENCE TO THE PILLOWS ON RESIDENT #38'S BED USED FOR POSITIONING. OBSERVATION OF RESIDENT #38'S RIGHT HEEL PRESSURE ULCER OCCURRED ON 2/12/13 AT 3:40 PM IN HIS ROOM WITH CENA"I", LICENSED PRACTICAL NURSE (LPN) "K", AND RN "C". THE BACK OF RESIDENT #38'S ENTIRE RIGHT HEEL WAS OBSERVED TO BE BROWN, LOOSE SKIN WITH A SMALL INNER SECTION OF BLACK ESCHAR (NECROTIC TISSUE). LPN "K" STATED "IT'S DRAINING A LITTLE NOW" AND DABBED RESIDENT #38'S RIGHT HEEL WITH A WASH CLOTH. BROWN DRAINAGE WAS OBSERVED ON THE WASHCLOTH. LPN "K" ALSO STATED "WHEN HE SLEEPS ON HIS LEFT SIDE HIS RIGHT INNER HEEL LAYS ON HIS LEFT FOOT SO WE TRIED TO PUT A PILLOW BETWEEN HIS LEGS WHEN HE'S LAYING ON HIS LEFT SIDE." AFTER THE OBSERVATION CENA "I" WAS ASKED WHEN THE FACILITY BEGAN ELEVATING RESIDENT #38'S HEELS OFF THE BED. CENA "I" RESPONDED THAT RESIDENT #38 HAD RECENTLY DEVELOPED THE FLU AND HAD "LOST A LOT OF ENERGY." "BEFORE HE HAD THE FLU HE WAS INDEPENDENT AND WE WEREN'T FLOATING HIS HEELS. AFTER HE GOT SICK WE STARTED ELEVATING HIS HEELS." THE FACILITY DOCUMENT "physician progress notes [REDACTED]. GLUTEAL [MEDICAL CONDITION] SUPPORT - 1 GRAM [MEDICATION NAME] ([MEDICATION NAME] - AN ANTIBIOTIC) IV Q 24 HOURS (INTRAVENOUS EVERY 24 HOURS) ...." ON 2/13/13 AT 9:30 AM RESIDENT #38 WAS OBSERVED IN HIS BED SLEEPING. A POLE WAS OBSERVED NEXT TO HIS BED WITH THE MEDICATION "[MEDICATION NAME] 1 GRAM" HANGING AND BEING ADMINISTERED INTRAVENOUSLY. ON 2/13/13 AT 10:23 AM CENA "G" WAS OBSERVED IN RESIDENT #38'S ROOM BEING INSTRUCTED BY RN "C". RN "C" WAS HEARD SAYING TO CENA "G" "HIS FOOT CANNOT ACTUALLY TOUCH THE PILLOW. IT NEEDS TO BE COMFORTABLY UNDER HIS LEG. WE NEED TO KEEP PILLOWS UNDER HIS LEGS." CENA "G" WAS OBSERVED TO CLOSE THE DOOR WHEN SHE SAW THIS SURVEYOR WAS STANDING NEAR THE DOORWAY TO RESIDENT #38'S ROOM. DIETARY MANAGER (DM) "H" WAS INTERVIEWED IN HER OFFICE ON 2/13/13 AT 10:30 AM. DM "H" REVEALED THAT SHE WAS AWARE THAT RESIDENT #38 HAD PRESSURE ULCERS ON HIS RIGHT HEEL AND LEFT HIP. DM "H" WAS THEN ASKED IF SHE WAS AWARE OF RESIDENT #38'S LOW PROTEIN AND LOW [MEDICATION NAME] LEVELS, AND RESPONDED "THE DIETICIAN WOULD TRACK THAT." SHE REVEALED THAT DIETICIAN "M" CAME TO THE FACILITY EVERY MONDAY AND THAT DIETICIAN "M" REVIEWED RESIDENTS WITH A SIGNIFICANT WEIGHT LOSS OR WEIGHT GAIN, AND REVIEWED RESIDENTS WITH WOUNDS. DM "H" THEN STATED DIETICIAN "M" WOULD MAKE RECOMMENDATIONS AND GIVES A COPY TO NURSING AND PUTS A COPY IN THE LOG BOOK. DM "H" WAS THEN ASKED TO REVIEW THE LOG BOOK FOR 2/11/13, THE PREVIOUS MONDAY, TO SEE IF ANY RECOMMENDATIONS WERE MADE REGARDING RESIDENT #38'S PRESSURE SORES, OR LOW PROTEIN AND [MEDICATION NAME] LEVELS. DM "H" THEN REVIEWED THE LOG BOOK AND STATED "I DON'T SEE ANY NEW RECOMMENDATIONS" AND STATED THAT RESIDENT #38 WAS ON THE LIST TO BE SEEN "NEXT MONDAY." CENA "G" WAS INTERVIEWED IN THE 200 HALLWAY ON 2/13/13 AT 10:45 AM. CENA "G" WAS ASKED TO DESCRIBE INTERVENTIONS BEING DONE TO PREVENT PRESSURE ULCERS FOR RESIDENT #38. CENA "G" RESPONDED "WE ARE CHECKING THAT HIS HEELS ARE ELEVATED, TURING SIDE TO SIDE EVERY 2 HOURS." WHEN ASKED WHEN THESE INTERVENTIONS WERE IMPLEMENTED CENA "G" RESPONDED "WE STARTED ELEVATING HIS HEELS WELL BEFORE HIS HEEL OPENED" ALTHOUGH RESIDENT #38'S MULTIPLE "SKIN" CAREPLANS REFLECTED IT WAS IMPLEMENTED EITHER ON 2/1/13 OR 2/3/13. CENA "G" WAS THEN ASKED IF RESIDENT #38 WAS COMPLIANT WITH BRIDGING HIS HEELS OR WITH REPOSITIONING IN BED AND CENA "G" RESPONDED "HE'S MORE COMPLIANT RECENTLY BUT WAS NOT COMPLIANT WITH IT BEFORE" WHICH CONTRADICTED DOCUMENTATION IN THE FACILITY'S NURSING NOTES. ON 2/13/13 AT 10:45 AM THE DON WAS INTERVIEWED IN THE CONFERENCE ROOM. IT WAS AGAIN VERIFIED THIS SURVEYOR WOULD BE WATCHING RESIDENT #38'S LEFT HIP WOUND DRESSING CHANGE ON THE AFTERNOON SHIFT THAT DAY. THE DON ALSO REVEALED THAT THE FACILITY WAS NO LONGER REFERRING TO THE AREA ON RESIDENT #38'S LEFT HIP AS A PRESSURE SORE, "THE DOC (DOCTOR) SAYS IT'S AN ABSCESS." THE DON THEN VERIFIED THE [MEDICATION NAME] HAD BEEN ADMINISTERED DUE TO SUSPICION THAT RESIDENT #38'S LEFT HIP WOUND HAD BECOME INFECTED. DIETICIAN "M" WAS INTERVIEWED ON THE PHONE ON 2/13/13 AT 10:45 AM IN THE CONFERENCE ROOM. DIETICIAN "M" REVEALED SHE HAD BEEN IN THE FACILITY THE PREVIOUS MONDAY (2/11/13), BUT STATED "I HAVE NOT BEEN MADE AWARE YET OF HIS PRESSURE SORES" AND STATED SHE HAD NOT REVIEWED HIS LABORATORY RESULTS FROM 1/26/13 WITH LOW PROTEIN AND [MEDICATION NAME] LEVELS. DIETICIAN "M" THEN REVEALED "TYPICALLY I COORDINATE WITH THE UNIT MANAGERS ONCE A MONTH REGARDING PRESSURE SORES" AND "TYPICALLY, EVERY PRESSURE SORE I WOULD DO SOME PROSTAT (A PROTEIN SUPPLEMENT) BECAUSE EVERYONE SAYS THEY HEAL SO MUCH QUICKER." DIETICIAN "M" ALSO STATED THAT USUALLY DIETARY ORDERS AND RECOMMENDATIONS WOULD COME FROM HER BUT "THE DIETARY MANAGER COULD SUGGEST IT TO THE UNIT MANAGER IF NURSING REQUESTED IT." DIETICIAN "M" THEN STATED "I WOULD DEFINITELY DO SOME PROSTAT FOR THAT MAN (REFERRING TO RESIDENT #38)." AT 1:20 PM ON 2/13/13, SENIOR VICE PRESIDENT OF QUALITY ASSURANCE "L" STATED AT THE 300 HALL NURSES STATION THAT RESIDENT #38 WAS SOON BEING TRANSFERRED TO THE HOSPITAL AS PHYSICIAN "F" WANTED HIS LEFT HIP "ABSCESS" TO BE LOOKED AT. OBSERVATION OF RESIDENT #38'S LEFT HIP PRESSURE ULCER OCCURRED ON 2/13/13, AT 1:31 PM WITH CENA'S "P" AND "Q" AND RN "C". BOTH CENA'S "P" AND "Q" STATED THAT RESIDENT #38 HAD BEEN HAVING "CONTINUOUS DIARRHEA" THAT MORNING. WHILE ASSISTING RESIDENT #38 TO HIS RIGHT SIDE, RESIDENT #38 WAS OBSERVED GRIMACING AND MOANING. RN "C" ASKED RESIDENT #38 "HOW YA DOING (RESIDENT #38'S NAME)?" RESIDENT #38 RESPONDED "NOT GREAT!" WHILE ROLLING RESIDENT #38 TO HIS RIGHT SIDE, HIS SCROTUM WAS OBSERVED TO HAVE WHAT APPEARED TO BE SCABS ON BOTH THE LEFT AND RIGHT SIDES. OBSERVATION OF HIS LEFT HIP REVEALED A LARGE REDDENED AREA WHICH EXTENDED FROM HIS LEFT HIP TO HIS LEFT BUTTOCK, WITH 4 PEA-SIZED WHITE/YELLOW PUSTULES. THE FACILITY DOCUMENT "VITAL SIGNS AND WEIGHT RECORD" REFLECTED 3 DOCUMENTATIONS OF RESIDENT #38'S TEMPERATURE ON 2/13/13. THEY WERE 101.3 DEGREES F, 101 DEGREES F, AND 100.1 DEGREES F. NO TIMES WERE DOCUMENTED NEXT TO ANY OF THE TEMPERATURE MEASUREMENTS. THE DOCUMENT REFLECTED RESIDENT #38'S TEMPERATURE AS 98.8 DEGREES F, 97.8 DEGREES F, AND 98.1 DEGREES F, ALL DATED 2/12/13. THE FACILITY DOCUMENT NURSING "PROGRESS NOTES" (DATED 2/13/13 AT 3:20 AM) REFLECTED "TEMP. (TEMPERATURE) (UPWARD ARROW)", WHICH INDICATED AN INCREASE IN RESIDENT #38'S BODY TEMPERATURE. THE FACILITY DOCUMENT NURSING "PROGRESS NOTES" (DATED 2/13/13 AT 1400) REFLECTED "GUEST RUNNING TEMP OF 101 - TYLENOL GIVEN MINIMALLY EFFECTIVE 100.1. NEW ORDERS RECEIVED TURNING AND REPOSITIONING Q 2 HOURS AT PM. HEALS FLOATED ... (PHYSICIAN "F") IN TO SEE GUEST WHILE DAUGHTER IS AT BEDSIDE. (PHYSICIAN "F") ASSESSED GUEST AND STATED GUEST NEEDS TO BE DIRECT ADMIT TO (HOSPITAL NAME) D/T (DUE TO) ABCESS ON L HIP AS WELL AS (UPWARD ARROW) TEMP. GUEST TRANSFERRED VIA (AMBULANCE SERVICE) AT APPROX. (APPROXIMATELY) 1:55 PM TO (HOSPITAL NAME)". RESIDENT #38 WAS OBSERVED BEING TRANSFERRED OUT OF THE FACILITY, TO THE HOSPITAL BY AMBULANCE ON 2/13/13 AT 1:55 PM. THE DON AND RN "C", THE UNIT MANAGER, WERE INTERVIEWED IN THE CONFERENCE ROOM ON 2/13/13 AT 3:40 AM. THE DON VERIFIED THAT RESIDENT #38 HAD BECOME ILL WITH THE FLU ON 1/26/13, WHICH CAUSED RESIDENT #38 TO BECOME WEAK AND WAS THEN UNABLE TO TURN HIMSELF IN BED. RN "C" WAS THEN ASKED WHAT PROMPTED THE FACILITY TO INITIATE ELEVATING RESIDENT #38'S HEELS OFF THE BED ON 2/1/13, ONE DAY BEFORE A PRESSURE ULCER DEVELOPED. RN "C" RESPONDED "I MAY HAVE MADE A MISTAKE AND PUT IT ON THE CAREPLAN ON 2/1/13." THE DON WAS ASKED WHY THE FACILITY WAS NOT REFERRING TO THE PRESSURE SORE ON RESIDENT #38'S LEFT HIP AS A PRESSURE SORE ANYMORE, AND THE DON RESPONDED "IT IS NO LONGER PRESENTING AS A PRESSURE SORE. IT IS NOT A PRESSURE SORE ANYMORE. IT IS REDNESS AND IT DOESN'T HAVE AN OPENING. WHEN IT FIRST STARTED IT LOOKED MORE LIKE A PRESSURE SORE, BUT AS IT PROGRESSED IT LOOKED LESS LIKE A PRESSURE SORE." THE DON ALSO STATED HIS LEFT HIP AREA BEGAN WITH A SINGLE OPEN SPOT ON THE LEFT HIP. BOTH THE DON AND RN "C" WERE ASKED IF THEY WOULD EXPECT CENAS AND NURSES TO DOCUMENT WHETHER A RESIDENT WAS COOPERATE WITH ELEVATING HEELS AND REPOSITIONING IN BED. BOTH AGREED THEY HOPE IT WOULD BE CHARTED, BUT HAD NO INSIGHT AS TO WHY, THIS BEHAVIOR WAS NOT CHARTED IN RESIDENT #38'S NURSING NOTES BEFORE THE DEVELOPMENT OF HIS PRESSURE ULCERS. NEITHER RN "C" OR THE DON HAD ANY RESPONSE WHEN ASKED WHY THE DIETICIAN HAD NOT SEEN, OR IMPLEMENTED ANY INTERVENTIONS AS OF YET FOR RESIDENT #38. THE FACILITY DOCUMENT "PATIENT TRANSFER FORM" (DATED 2/13/13) REFLECTED IN REGARDS TO RESIDENT #38 "[DIAGNOSES REDACTED]. RN "C" WAS INTERVIEWED AT THE "MIDDLE" NURSES STATION ON 2/14/13 AT 9:40 AM. RN "C" REVEALED THAT NURSING WOULD REVIEW LABS LIKE THOSE DONE FOR RESIDENT #38 ON 1/26/13, AND COULD PUT INTERVENTIONS IN PLACE FOR A LOW PROTEIN OR LOW [MEDICATION NAME] LEVEL, BUT COULD NOT EXPLAIN WHY NO INTERVENTIONS HAD BEEN PUT IN PLACE. IN RN "C"S OFFICE ON 2/14/13 AT 10:00 AM, ANOTHER "SKIN CAREPLAN FOR RESIDENT #38 (DATED 12/21/12) WAS PROVIDED, BY RN "C" AND SENIOR VICE PRESIDENT OF QUALITY ASSURANCE "L" AND REFLECTED THE HAND WRITTEN DOCUMENTATION "GUEST PREFERS TO SLEEP ON L SIDE. ENCOURAGE TO CHANGE POSITIONS. WILL OFF LOAD HEEL WITH USE OF PILLOW" DATED ON 2/3/13, 1 DAY AFTER THE FACILITY DISCOVERED AN UNSTAGEABLE PRESSURE ULCER ON RESIDENT #38'S RIGHT HEEL. THE HOSPITAL DOCUMENT "FACE SHEET" (UNDATED) REFLECTED THAT RESIDENT #38 WAS admitted TO THE hospital on [DATE] AT 2:17 PM WITH THE "CHIEF COMPLAINT" OF "[MEDICAL CONDITION], ABSCESS W (WITH) [MEDICAL CONDITION] BUTTOX (SIC), REN (RENAL) FAILURE". THE admitting [DIAGNOSES REDACTED]. THE HOSPITAL DOCUMENT "CONSULTATION" (DATED 2/14/13), DICTATED BY RESIDENT #38'S SURGEON, REFLECTED "THE PATIENT IS A [AGE] year OLD GENTLEMAN WHO WAS SEEN BY MY PA (PHYSICIAN ASSISTANT) YESTERDAY IN REGARDS TO AN ABSCESS ON HIS LEFT BUTTOCK. AT THAT TIME (PHYSICIAN ASSISTANT) EVALUATED THE PATIENT, HE ALSO IDENTIFIED AN ESCHAR ON THE PATIENT'S RIGHT HEEL, ALSO EVIDENCE OF ESCHAR ON THE PATIENT'S SCROTUM ... THEREFORE, AT THIS TIME, THE PATIENT WILL BE DIAGNOSIS (SIC) PRIMARILY WITH A LEFT BUTTOCK ABSCESS ESCHAR PRESSURE ULCER ON HIS RIGHT HEEL AND ESCHAR PRESSURE ULCERS ON THE SCROTUM ... CURRENT PHYSICAL EXAMINATION: EVALUATION OF HIS LEFT BUTTOCK BY MYSELF SHOWS A MARKEDLY INDURATED AREA ON THE LATERAL ASPECT OF THE LEFT BUTTOCK. THERE DOES APPEAR TO BE SOME NECROSIS AT THE CENTER WITH MARKED [DIAGNOSES REDACTED] SUGGESTING UNDERLYING ABSCESS.... PLAN: AT THIS TIME, BY MYSELF (SIC) WILL BE TO DO AN INCISION AND DRAINAGE OF THE LEFT BUTTOCK ABSCESS.... WE NEED TO ADVISE THE NURSING CARE FACILITY WHERE HE IS LIVING ABOUT BETTER CARE TO TRY TO PREVENT PRESSURE ULCERS. WE WILL ESTABLISH THIS CARE WHILE HE IS HERE IN THE HOSPITAL AND I WILL GET A CASE MANAGER WORKING ON THIS WITH (FACILITY NAME)." THE HOSPITAL DOCUMENT "PREPROCEDURE ASSESSMENT" (DATED 2/14/13 AT 10:48 AM REFLECTED "COMMENT: MULTIPLE NECROTIC PRERSSURE (SIC) SORES - LEFT HIP, SCROTUM, HEELS". THE HOSPITAL DOCUMENT "PHYSICIAN ORDERS" (DATED 2/13/13 AT 2:48 PM) REFLECTED "THIS ORDER WAS PLACED BECAUSE A NEWLY IDENTIFIED PRESSURE ULCER HAS BEEN DOCUMENTED. DETAILS OF THE NEWLY IDENTIFIED PRESSURE ULCER(S) INCLUDE: PRESSURE ULCER #1 LOCATION: RIGHT HEEL". THE HOSPITAL DOCUMENT "PHYSICIAN ORDERS" (DATED 2/13/13 AT 3:33 PM) REFLECTED ".... PRESSURE ULCER #2 LOCATION: LEFT BUTTOCK(S), STAGE: STAGE 2". THE HOSPITAL DOCUMENT "PHYSICIAN ORDERS" (DATED 2/13/13 AT 5:39 PM) REFLECTED ".... PRESSURE ULCER #3 LOCATION: LEFT, BUTTOCK(S) ... STAGE 2, PRESSURE ULCER #4 LOCATION: RIGHT, SCROTUM ... UNSTAGEABLE, PRESSURE ULCER #5 LOCATION: LEFT, SCROTUM". THE HOSPITAL DOCUMENT "PHYSICIAN ORDERS" (DATED 2/13/13 AT 6:11 PM) REFLECTED "NUTRITION REFERRAL PLACED DUE TO RESPONSES ON NUTRITION SCREENING: PRESENCE OF OPEN OR UNHEALING WOUNDS." THE HOSPITAL DOCUMENT "BRADEN ASSESSMENT" (DATED 214/13 AT 10:39 AM) REFLECTED A SCORE OF 11 (SCORE OF 17 OR LESS INDICATES A HIGH RISK OF DEVELOPING PRESSURE SORES). THE HOSPITAL DOCUMENT "DIRECT CHARTING FLOWSHEET" (DATED 2/13/13) REFLECTED "PRESSURE ULCER #1 PRESENT ON ADMISSION ... RIGHT HEEL", "PRESSURE ULCER #2 PRESENT ON ADMISSION ... LEFT, BUTTOCKS", "PRESSURE ULCER #3 PRESENT ON ADMISSION ... LEFT, BUTTOCK", "PRESSURE ULCER #4 PRESENT ON ADMISSION ... RIGHT SCROTUM", AND "PRESSURE ULCER #5 PRESENT ON ADMISSION ... LEFT, SCROTUM". THE HOSPITAL DOCUMENT "CHEMISTRY-GENERAL" (DATED 2/14/13 AT 6:11 AM) REFLECTED RESIDENT #38'S [MEDICATION NAME] LEVEL WAS 2.3 G/DL (NORMAL RANGE 3.4 - 5.0) AND HIS PROTEIN LEVEL WAS 5.7 G/DL (NORMAL RANGE (6.4 - 8.2). BOTH LEVELS WERE LOWER THAN WHEN THE FACILITY OBTAINED LABORATORY FINDINGS FROM 1/26/13. RESIDENT #38'S DAUGHTER WAS INTERVIEWED BY TELEPHONE ON 2/14/13 AT 4:50 PM. RESIDENT #38'S DAUGHTER REVEALED THAT HER FATHER HAD BEEN SICK WITH THE FLU AND "THEY (THE FACILITY) WOULDN'T LET HIM OUT OF BED BECAUSE THEY WERE QUARANTINING HIM. BEFORE HE WAS SICK HE WAS ABLE TO GET HIMSELF AROUND." RESIDENT #38'S DAUGHTER ALSO STATED THAT SHE DID NOT COME TO SEE HER FATHER WHILE HE WAS SICK AS SHE WAS AFRAID OF BECOMING ILL HERSELF. RESIDENT #38'S DAUGHTER ALSO STATED THAT SHE WAS INFORMED BY A NURSE AT THE HOSPITAL THAT "(PHYSICIAN "F") STATED HE WAS NOT AWARE OF THESE ISSUES" WITH RESIDENT #38. PHYSICIAN "F" WAS INTERVIEWED BY PHONE ON 2/15/13 AT 10:35 AM. PHYSICIAN "F" DESCRIBED THE AREA ON RESIDENT #38'S LEFT HIP AND BUTTOCK ON THE MORNING OF 2/13/13 AS "THE AREA ABOVE THE HIP JOINT, I SAW AN ABSCESS. THE SURROUNDING AREA WAS ABOUT 15 TO 20 CM, AND THE ABSCESS WAS HARD" AND DESCRIBED THE REST OF THE AREA AS OOZING". PHYSICIAN "F" WAS THEN ASKED IF HE BELIEVED THE AREA ON RESIDENT #38'S LEFT HIP AND LEFT BUTTOCKS WAS RELATED TO A PRESSURE SORE. PHYSICIAN "F" RESPONDED "IT MIGHT BE RELATED TO PRESSURE. IT'S HARD TO SAY 100% IF IT WAS DONE BY PRESSURE BUT I'M NOT SURE. IT MIGHT BE A DECUBITIS (ANOTHER WORD FOR PRESSURE SORE). 100% I CANNOT RULE OUT DECUBITIS." THE FACILITY POLICY "WOUND AND SKIN MANAGEMENT PROGRAM" (REVISED 06/11) REFLECTED "... THERE IS NO BETTER treatment for [REDACTED]. OUR BASIC WOUND PREVENTION PROGRAM CONSISTS OF: 1. ASSESSMENT - IDENTIFYING THOSE AT RISK AND EARLY DETECTION OF SIGNS AND SYMPTOMS OF SKIN BREAKDOWN. 2. MOBILITY - MOVE THEM 3. HYDRATION AND NUTRITION - FOOD AND WATER ...." AND "THERE ARE KNOWN CASES OF INDIVIDUALS WHO HAVE A BRADEN SCORE OF 18 OR GREATER (INDICATING THEY ARE NOT AT RISK) WHO HAVE DEVELOPED PRESSURE ULCERS. FOR THESE GUESTS, THE ASSESSMENT SHOULD BE INTERDISCIPLINARY WITH EMPHASIS ON NUTRITION AND HYDRATION, PRESSURE RELIEF, SKIN CARE, MOBILITY, AND INCONTINENCE MANAGEMENT." THE FACILITY FAILED TO RESPOND TO AN IDENTIFIED CHANGE OF CONDITION AFTER RESIDENT #38 BECAME ILL. THE FACILITY FAILED TO RESPOND BY NOT CONSISTENTLY AIDING RESIDENT #38 IN TURNING IN BED TO RELIEVE PRESSURE AREAS, NOT RELIEVING PRESSURE FROM RESIDENT #38'S RIGHT HEEL, AND FAILED TO IMPLEMENT DIETARY INTERVENTIONS TO INCREASE RESIDENT #38'S PROTEIN STORES TO AID IN PREVENTION OF AND HEALING OF PRESSURE SORES. ( ) RESIDENT #42 WAS A [AGE] year OLD MALE admitted to the facility on [DATE] ACCORDING TO THE FACILITY'S DOCUMENT TITLED"IDENTIFICATION SUMMARY" DATED 2/6/13 WITH THE [DIAGNOSES REDACTED]. ACCORDING TO THE FACILITY'S DOCUMENT TITLED "NURSING ADMISSION ASSESSMENT" DATED 2/5/13 RESIDENT #42'S COGNITIVE STATUS WAS DOCUMENTED AS ALERT AND ORIENTED ONLY TO PERSON. REVIEW OF RESIDENT #42'S MEDICAL RECORD REFLECTED A FACILITY DOCUMENT TITLED "NURSING ADMISSION ASSESSMENT" DATED 2/5/13 WHICH REFLECTED RESIDENT #42 "LIKES TO SLEEP, DOES NOT WANT TO GET UP"; AT HIGH RISK FOR PRESSURE ULCERS WITH A SCORE OF 11 ON THE BRADEN SCALE (A SCALE THAT IS UTILIZED TO DETERMINE RISK FOR SKIN BREAKDOWN AND A SCORE OF LESS THAN 17 DEEMS A RESIDENT AT RISK); AND ASKIN ASSESSMENT THAT REFLECTED AN OPEN RED 1 X 1 CM (CENTIMETER) AREA ON THE RIGHT COCCYX AND AN ESCHAR WOUND THAT MEASURED 1.5 X 1.5 CM ON THE RIGHT LATERAL HEEL. ON 2/19/13 AT APPROXIMATELY 10:00 A.M. IN RESIDENT #42'S ROOM AN OBSERVATION OF RESIDENT #42'S WOUNDS WAS MADE WITH THE DIRECTOR OF NURSING (DON) AND UNIT MANAGER/REGISTERED NURSE, STAFF "O". THE OBSERVATION REVEALED THE RIGHT HEEL ULCER HAD AN UNDATED DRESSING THAT WAS NOT SECURED OVER HIS RIGHT HEEL WOUND, AND AN OBSERVATION OF RESIDENT #42'S COCCYX AREA AND BUTTOCKS REVEALED AN OPEN AREA ON THE RIGHT BUTTOCKS THAT APPEARED TO BE LARGER THAN A PEA AND SMALLER THAN A DIME. THE UNIT MANAGER/RN, STAFF "O" INITIALLY STATED "THAT IS JUST A RED AREA IT ISN'T OPEN" THEN WHEN ASKED TO TAKE A CLOSER LOOK, STAFF "O" STATED "OH I GUESS IT IS OPEN." WHEN STAFF "O" WAS ASKED ABOUT THE TREATMENT THAT WAS ORDERED FOR THIS WOUND, STAFF "O" STATED "THIS IS NEW." REVIEW OF THE FACILITY DOCUMENT TITLED "TREATMENT RECORD" FOR RESIDENT #42 DATED 2/2013 REFLECTED THE RIGHT LATERAL HEEL ORDER WAS "CLEANSE WITH NS (NORMAL SALINE). SOLOSITE (A MEDICATED CREAM) AND ALLEVYN (AN ADHESIVE DRESSING) CHANGED EVERY 72 HOURS AND PRN (AS NEEDED)." THE RECORD INDICATED THE TREATMENT WAS ADMINISTERED ON 2/8/13 AND 2/10/13 AND NO OTHER TREATMENTS WERE ADMINISTERED UNTIL 2/19/213 AFTER THE SURVEYOR MADE THE OBSERVATION. THERE WERE NO ORDERS THAT ADDRESSED THE RIGHT BUTTOCK PRESSURE WOUND. REVIEW OF THE FACILITY'S DOCUMENT TITLED "WOUND AND SKIN CONDITION LOG" DATED 2/18/13 REFLECTED RESIDENT #42 HAD A IN-HOUSE ACQUIRED WOUND ON RIGHT BUTTOCK THAT WAS NOT MEASURED, CARE PLANNED, OR TREATED. IN ADDITION, THE PHYSICIAN AND RESIDENT REPRESENTATIVE WAS NOT NOTIFIED. THE RIGHT BUTTOCK SKIN BREAKDOWN WAS INITIALLY OBSERVED AS "SHEARING" WHICH WAS DOCUMENTED ON A FACILITY DOCUMENT TITLED "SHOWER/SKIN OBSERVATION" AND DATED 2/15/13. REVIEW OF RESIDENT #42'S MEDICAL RECORD DID NOT REFLECT DOCUMENTATION THAT ADDRESSED THE RIGHT BUTTOCK PRESSURE WOUND IN THE NURSING PROGRESS NOTES, CARE PLANS, OR PHYSICIAN ORDERS. ( )

BASED ON OBSERVATION, INTERVIEW, AND RECORD REVIEW THE FACILITY FAILED TO PREVENT THE DEVELOPMENT OF AN AVOIDABLE PRESSURE ULCER FOR 1 OF 3 RESIDENTS (#12) REVIEWED FOR PRESSURE ULCERS OUT OF A TOTAL SAMPLE OF 20 RESIDENTS RESULTING IN RESIDENT #12 DEVELOPING AN AVOIDABLE UNSTAGEABLE (FULL THICKNESS TISSUE LOSS IN WHICH THE BASE OF THE ULCER IS COVERED BY SLOUGH AND/OR ESCHAR IN THE WOUND BED) PRESSURE ULCER ON THE RIGHT HEEL. FINDINGS INCLUDE: RESIDENT #12 WAS A [AGE] year OLD MALE admitted to the facility on [DATE] WITH THE [DIAGNOSES REDACTED]. REVIEW OF RESIDENT #12'S MEDICAL RECORD REFLECTED A CARE PLAN FOR THE POTENTIAL FOR SKIN BREAKDOWN DATED 10/3/12 WITH A DOCUMENTED ENTRY DATED 10/10/12 UNSTAGEABLE ON LEFT HEEL. A NURSING PROGRESS NOTE DATED 10/15/12 REFLECTED "QUARTER SIZED HARD DARK AREA ON INNER RIGHT AREA LOWER ANKLE." THIS WAS THE ONLY DOCUMENTATION NOTED IN THE NURSING PROGRESS NOTES REGARDING WOUNDS FROM 9/18/12 THROUGH 11/6/12 WHEN RESIDENT #12 WAS SENT TO THE HOSPITAL. THE ORIGINAL NURSING ADMISSION assessment dated [DATE] DID NOT INDICATE ANY WOUNDS OR MARKINGS ON HEELS OR ANKLES AT THE TIME OF ADMISSION AND RESIDENT #12 WAS ASSESSED TO BE HIGH RISK FOR THE DEVELOPMENT OF PRESSURE ULCERS USING THE BRADEN SCALE. A SCORE OF 17 OR LESS DEEMS A RESIDENT AT RISK AND RESIDENT #12 SCORED 17. A PHYSICIAN'S PROGRESS NOTE DATED 10/15/12 REFLECTED UNDER ASSESSMENT "RIGHT HEEL ULCER-SKIN INTACT AND UNDER SECTION TITLED "PLAN" HEEL PROTECTORS AT ALL TIMES, REMOVE EVERY SHIFT FOR CARE. A WOUND PHYSICIAN'S DICTATED NOTE DATED 10/19/12 REFLECTED "RIGHT HEEL STABLE ESCHAR (TAN, BROWN, OR BLACK LOOKING SCAB) MEASURING 2 CM (CENTIMETERS) X 2 CM BY 0.0 CM. AT THIS TIME, THE PLAN WOULD BE DRY DRESSING AND OFFLOADING AND AN ALLEVYN GENTLE HEEL WITH PREVALON BOOTS (HEEL PROTECTORS) FOR OFFLOADING. A NURSING CARE PLAN DATED 11/1/12 FOR "ACTUAL SKIN BREAKDOWN RIGHT HEEL" REFLECTED WOUND DOCTOR TO FOLLOW AND TREATMENT PER physician's orders [REDACTED]." ON 12/11/12 AT 2:50 P.M. RESIDENT #12 WAS OBSERVED IN HIS ROOM LYING IN BED WITH HEELS TOUCHING THE MATTRESS AND ONLY SOCKS APPLIED TO BOTH FEET. ON 12/12/12 AT 3:50 P.M. RESIDENT #12 WAS OBSERVED IN HIS ROOM LYING IN BED, NO PREVALON BOOTS WERE APPLIED. ON 12/13/12 AT 10:20 A.M. RESIDENT #12 WAS OBSERVED IN HIS ROOM LYING IN BED POSITIONED ON LEFT SIDE, NO PREVALON BOOTS WERE APPLIED. ON 12/14/12 AT 9:20 A.M. LICENSED PRACTICAL NURSE, STAFF "B" WAS ASKED TO REVEAL RESIDENT #12'S FEET WHILE RESIDENT #12 WAS IN HIS ROOM AND LYING ON THE MATTRESS. NO PREVALON BOOTS WERE APPLIED. STAFF "B" STATED "HIS HEELS SHOULD BE OFF THE BED. WHERE ARE HIS BOOTS?" STAFF "B" THEN PROCEEDED TO FIND THE PREVALON BOOTS AND ADJUST RESIDENT #12'S HEELS OFF THE BED SURFACE. ON 12/14/12 AT 12:05 P.M. AN INTERVIEW WITH RESIDENT #12'S WIFE WAS CONDUCTED VIA TELEPHONE. SHE STATED SHE TRIES TO COME EVERYDAY AND WHEN ASKED ABOUT RESIDENT #12'S HEELS AND THE USE OF THE PREVALON BOOTS SHE STATED "SOMETIMES I SEE HIS FEET ON THE BED AND HIS HEELS DIGGING INTO THE MATTRESS. THE PILLOWS THEY USE TO RAISE HIS FEET OFF THE BED ONLY WORK HALF THE TIME." ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO MANAGE PAIN FOR 1 OF 21 SAMPLED RESIDENTS (#5) THAT INCLUDED 7 RESIDENTS REVIEWED FOR PAIN MANAGEMENT, RESULTING IN RESIDENT #5, A HOSPICE PATIENT, EXPERIENCING SEVERE PAIN BEFORE INTERVENTIONS WERE INITIATED. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S HOSPICE CARE PLAN, DATED 1/19/11, RESIDENT #5 WAS TO BE PROVIDED WITH THE FOLLOWING: "...COMFORT CARE (AND) HOSPICE SERVICES R/T (RELATED TO) DEMENTIA, HX (HISTORY) OF PENILE CA (CANCER)...AND...END OF LIFE CARE." ONE INTERVENTION ON THE CARE PLAN SPECIFICALLY DIRECTED STAFF TO "MONITOR FOR VERBAL AND NON-VERBAL INDICATORS OF PAIN." DURING AN OBSERVATION OF WOUND CARE, AT 12:40 P.M. ON 1/19/11, NURSE "H" IRRIGATED A WOUND ON THE RESIDENT'S RIGHT BUTTOCK WITH NORMAL SALINE BEFORE FILLING THE WOUND WITH A SPECIALLY PREPARED FOAM AND COVERING THE AREA WITH A DRESSING. THE RESIDENT'S WOUND WAS CONSISTENT IN APPEARANCE WITH A STAGE III PRESSURE ULCER AND WAS BEING TREATED WITH A [DEVICE]. A STAGE III PRESSURE ULCER IS A DEEP TISSUE WOUND THAT MAY INVOLVE DAMAGE DOWN TO THE MUSCLE. AT THE START OF THE OBSERVATION, RESIDENT #5 LAY ON HIS BACK IN BED AND WAS NOT OBSERVED TO PAY ANY ATTENTION AT ALL TO NURSE "H" OR THE ACTIVITY GOING ON AROUND HIM. PART WAY DURING THE TREATMENT, RESIDENT #5 BEGAN TO MOAN "...EH, EH, EH..." AND, A FEW MINUTES LATER, HE SAID OUT LOUD, "CAN'T YOU GET ME UP NOW?" HE BEGAN TO MOVE ABOUT RESTLESSLY AS NURSE "H" COMPLETED THE TREATMENT. NURSE "H" WAS NOT OBSERVED TO ASK THE RESIDENT ABOUT PAIN OR HEARD TO OFFER PAIN MEDICATION. ACCORDING TO THE RESIDENT'S JANUARY 2011 MEDICATION RECORD, HE RECEIVED SCHEDULED DOSES OF TYLENOL WITH [MEDICATION NAME] (PAIN MEDICATION) AT 12:00 A. M., 8:00 A.M. AND 5:00 P.M. HE ALSO HAD [MEDICATION NAME] (A NARCOTIC PAIN RELIEVER) AVAILABLE TO HIM ON A "PRN" (AS NEEDED) BASIS FOR BREAKTHROUGH PAIN. THE [MEDICATION NAME] COULD BE ADMINISTERED AS OFTEN AS EVERY FOUR HOURS. DURING AN INTERVIEW AT 12:35 P.M. ON 1/20/11, NURSE "I" SAID THAT SHE ONLY ADMINISTERED THE [MEDICATION NAME] IF THE TYLENOL WITH [MEDICATION NAME] DID NOT TAKE CARE OF THE PAIN. NURSE "I" SAID THAT RESIDENT #5 WOULD YELL OUT, EVEN IF HE WAS NOT IN PAIN, SO SHE WOULD SPECIFICALLY ASK HIM IF HE WAS HAVING PAIN BEFORE GIVING HIM THE [MEDICATION NAME]. NURSE "I" SAID THAT RESIDENT #5 WAS ABLE TO SAY WHETHER OR NOT HE WAS HAVING PAIN. SEVEN MINUTES LATER, AT 12:42 P.M., NURSE "I" WAS OBSERVED TO ADMINISTER 5 MG (MILLIGRAMS) OF [MEDICATION NAME] TO RESIDENT #5. ACCORDING TO THE MEDICATION RECORD, RESIDENT #5 HAD NOT RECEIVED ANY [MEDICATION NAME] EARLIER THAT DAY OR DURING THE PREVIOUS DAY. DURING AN INTERVIEW CONDUCTED THE FOLLOWING MORNING, AT 10:45 A.M. ON 1/21/11, NURSE "H" WAS ASKED BY THIS SURVEYOR IF SHE HAD DONE A PAIN ASSESSMENT ON RESIDENT #5 THAT MORNING. NURSE "H" RESPONDED THAT, WHEN SHE WAS IN THE RESIDENT'S ROOM WITH HIS MEDICATION, HE HAD NOT SEEMED TO BE HAVING ANY PAIN. (NURSE "H" SAID THAT SHE HAD STARTED HER SHIFT AT 6:30 A.M.) WHEN ASKED WHETHER SHE HAD SPECIFICALLY ASKED THE RESIDENT IF HE WAS HAVING PAIN, NURSE "H" ANSWERED, "NO." AT THIS SURVEYOR'S REQUEST, NURSE "H" RETURNED TO RESIDENT #5'S ROOM WHERE SHE WAS HEARD TO ASK THE RESIDENT IF HE WAS HAVING ANY PAIN. THE RESIDENT WAS HEARD TO SAY, "YES." NURSE "H" ASKED THE RESIDENT WHERE THE PAIN WAS AT, AND THE RESIDENT SAID, "MY FEET." NURSE "H" THEN ASKED RESIDENT #5 TO RATE HIS PAIN ON A "1 TO 10" SCALE (WHERE 10 INDICATES THE WORST POSSIBLE PAIN) AND RESIDENT #5 WAS HEARD TO SAY, "8." BASED ON REVIEW OF THE FACILITY'S PAIN CARE PLAN, DATED 10/6/10, NURSING STAFF WERE SUPPOSED TO ASSESS THE SEVERITY OF THE RESIDENT'S PAIN AND DOCUMENT THE OCCURRENCES. BASED ON REVIEW OF THE RESIDENT'S JANUARY 2011 MEDICATION RECORD, NURSING STAFF HAD ADMINISTERED 7 DOSES OF THE "PRN" [MEDICATION NAME] BETWEEN 1/14/11 (THE DATE THAT IT WAS PRESCRIBED) AND 1/21/11. THERE WAS NO DOCUMENTED ASSESSMENT OF THE INTENSITY OF THE PAIN EXPERIENCED BY RESIDENT #5 FOR ANY OF THE ENTRIES ON ANY OF THE DATES WHEN THE [MEDICATION NAME] WAS ADMINISTERED. FOR EXAMPLE, AT 10:45 A.M. ON 1/21/11, NURSE "H" DOCUMENTED THAT SHE HAD ADMINISTERED 5 MG OF [MEDICATION NAME] TO RESIDENT #5 THAT WAS "EFF" (EFFECTIVE), BUT SHE DID NOT DOCUMENT THAT RESIDENT #5 HAD RATED HIS PAIN AS AN "8" PRIOR TO RECEIVING HIS MEDICATION. BASED ON REVIEW OF A HOSPICE "INTERDISCIPLINARY CLINICAL NOTE" DATED 1/10/11, RESIDENT #5 HAD BEEN OBSERVED MOANING "DURING MOVEMENT." THE NOTE STATED THAT A "NEW" PAIN MEDICATION WOULD BE ORDERED TO ADDRESS THE NEED FOR ADDITIONAL PAIN CONTROL. A "HOSPICE SOCIAL WORK CLINICAL NOTE", DATED 1/19/11, REPORTED THAT RESIDENT #5 HAD COMPLAINED OF HIS BOTTOM HURTING AND HAD A PAIN LEVEL OF "2" ON THE "PAINAD" SCALE (A DIFFERENT SCALE FROM THE "1 TO 10" SCALE). ACCORDING TO THE CODING KEY ON THE BACK OF THE CLINICAL NOTE, A "2" ON THE "PAINAD" SCALE WAS COMPARABLE TO A "7 TO 10" RATING (SEVERE PAIN) ON THE "1 TO 10" SCALE. THE SOCIAL WORKER NOTES DOCUMENTED THAT, "...(HIS) PAIN WAS CONTROLLED WHEN MEDS WERE GIVEN." ALTHOUGH THE RESIDENT'S [MEDICATION NAME] COULD BE ADMINISTERED AS OFTEN AS EVERY 4 HOURS, THERE WAS NO DOCUMENTATION ON THE MEDICATION RECORD THAT NURSING STAFF ADMINISTERED ANY PAIN MEDICATIONS TO RESIDENT #5 THAT DAY UNTIL HIS ROUTINELY SCHEDULED TYLENOL WITH [MEDICATION NAME] WAS DUE. BASED ON REVIEW OF THE FACILITY NURSE'S PROGRESS NOTES, THE FOLLOWING INFORMATION WAS NOTED: - ON 1/8/11, THE RESIDENT REFUSED HIS SUPPER. THERE WAS NO PAIN ASSESSMENT DOCUMENTED ON THAT DATE IN THE PROGRESS NOTES AND NO REASON FOR THE RESIDENT'S REFUSAL WAS PROVIDED. - ON 1/9/11, THE RESIDENT REFUSED HIS SUPPER AGAIN. THERE WAS NO PAIN ASSESSMENT DOCUMENTED IN THE PROGRESS NOTES. - ON 1/10/11, NURSING DOCUMENTED: "...CONT(INUES) TO YELL OUT WHILE SLEEPING AND/OR AWAKE WHEN (ASKED) WHAT RES(IDENT) NEEDS, RES STATES 'I'M GOOD'..." THERE WAS NO PAIN ASSESSMENT DOCUMENTED IN THE NOTES. - ON 1/12/11, NURSING ADMINISTERED "PRN" [MEDICATION NAME] (AN ANTIANXIETY MEDICATION) TO THE RESIDENT, DUE TO INCREASED YELLING. NO PAIN ASSESSMENT WAS DOCUMENTED. - ON 1/15/11, NURSING DOCUMENTED THAT "PRN" [MEDICATION NAME] WAS ADMINISTERED TO THE RESIDENT FOR INCREASED PAIN, BUT THE [MEDICATION NAME] WAS EFFECTIVE FOR ONLY A SHORT TIME. BASED ON A COMPARATIVE REVIEW OF THE PROGRESS NOTES WITH THE MEDICATION RECORD FOR THAT DATE, NURSING ADMINISTERED 4 DOSES OF [MEDICATION NAME] BETWEEN THE HOURS OF 12:00 P.M. AND 2300 (11:00 P. M.) HOWEVER, THE INTENSITY OF THE PAIN REPORTED BY THE RESIDENT WAS NOT DOCUMENTED. ON THE FOLLOWING DATE (1/16/11) THERE WAS NO PAIN ASSESSMENT DOCUMENTED IN THE PROGRESS NOTES AND NO DOSES OF [MEDICATION NAME] WERE ADMINISTERED ON THAT DATE OR ON THE FOLLOWING DATE (1/17/11). BASED ON REVIEW OF AN UNDATED "PAIN ASSESSMENT", FILED IN THE RESIDENT'S PAPER CHART, THE RESIDENT WAS IN PAIN "ALL THE TIME." HOWEVER, THE RECOMMENDATION AT THE BOTTOM OF PAGE 2 OF THE "PAIN ASSESSMENT" SAID, "...CONTINUE WITH CURRENT PAIN MANAGEMENT REGIMEN." THE ASSESSMENT DOCUMENTED THAT THE RESIDENT (WHO HAD DEMENTIA AND WAS CONFINED TO A WHEELCHAIR) HAD "NO" COGNITIVE OR PHYSICAL IMPAIRMENTS THAT WOULD "ALTER (HIS) ABILITY TO VERIFY OR REPORT PAIN." BASED ON ADDITIONAL REVIEW OF THE RESIDENT'S PAIN CARE PLAN, INITIATED BY THE FACILITY ON 10/6/10, THERE WERE NO REFERENCES TO A PRESSURE ULCER AND/OR FOOT PAIN AS POTENTIAL SOURCES OF PAIN, AND THERE WAS NO MENTION OF THE HOSPICE SERVICES THAT THE RESIDENT RECEIVED. (THAT INFORMATION WAS DOCUMENTED ON A SEPARATE HOSPICE CARE PLAN.) THERE WERE NO REVISIONS OR UPDATES DOCUMENTED ON THE PAIN CARE PLAN SINCE THE ORIGINATION DATE OF 10/6/10. ( )

This citation pertains to intake number MI 245. Based on observation, interview, and record review, the facility failed to provide supervision to prevent the elopement and ensure the safety for 2 (#104 and #105) of 9 sampled residents, resulting in Immediate Jeopardy for (1) Resident #104 when he exited through the front door of the facility, across the parking lot, across a 4 lane 40 MPH road, threw his walker over a fence, then proceed North on an uneven, broken sidewalk, and (2) when Resident #105 exited from the front door of the facility in a wheelchair, across the parking lot, up a 6 inch curb, across a grassy area beside a 4 lane 40 MPH road, to a sidewalk, and continued South away from the facility, placing 17 additional residents are at risk for elopement. Findings include: When a Leave of Absence Policy was requested the Director of Nursing and the Administrator reported that the facility did not have a Leave of Absence Policy. Review of the Nursing Documentation Education dated 1/28/10 reflected, "Leave of Absence" (LOA) documentation; prior to departure, get a physician's order. Review of the "Administrative Policy Manual" dated 3/05 reflected, defined elopement of guest as an unsupervised or unassisted flight from the facility. The policy reported the investigation guidelines for elopement include completion of an "Incident Accident" form, completed interview questionnaires on all staff assigned to the guest at the time, estimation of how long the guest was gone, how they exited the facility, description of any injuries, weather/temperature at time of incident, supervision/staffing levels at time of incident, immediate corrective action... . In an interview on 11/8/10 at 2:30 p.m. the Regional Quality Assurance Registered Nurse (RN #7) reported, she had just found out about the elopements. RN #7 reported that alert and oriented residents have rights and can come and go as they please. RN #7 reported residents are supposed to sign out, and we are suppose to be aware they are leaving. RN #7 reported that no physician's order is required, if a person wants to go, and if they are there own person, they can choose to go. In an interview on 11/8/10 at 4:10 p.m. Physician #1 reported, even if a resident is alert and oriented someone needs to know when they are leaving, where they are going and with whom. In an interview on 11/16/10 at 1:25 p.m. Physician #2 reported that before a resident can leave the facility, the physician must give an order. Physician #2 reported once a resident is admitted to a skilled nursing facility under the care of a physician, an order from the physician is required for the resident to leave the facility. Physician #2 reported that if a resident signs out with no physician's order the resident is leaving against medical. It then becomes the facility's responsibility to go get them. Resident #104: The face sheet in the clinical record reflected that Resident #104 was admitted to the facility on [DATE]. The Physician's Orders dated for 10/1/10 through 10/31/10 reflected [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), a resident assessment tool, dated 8/3/10 reflected that Resident #104 was moderately cognitively impaired, had short and long term memory loss, impaired vision, unsteady balance while standing, and used a walker or wheelchair. The MDS, Resident Assessment Protocol (RAP) dated 8/11/10 reflected Resident #104 triggered for a cognitive loss, had not officially been diagnosed with [REDACTED]. A review of State of Michigan Probate Court document dated 6/30/10 reflected that the court found that Resident #104 did not have a guardian and an emergency existed, so due to reason of physical illness and mental incompetence, a temporary guardian was appointed. A review of State of Michigan Probate Court document, dated 9/30/10 reflected that Resident #104 by reason of physical illness and mental incompetence, was totally, without the capacity to make medical decisions or care for himself. The petition for appointment of guardian was granted. Review of the Psychosocial assessment dated [DATE] reflected, Resident #104 had a court appointed guardian. Section L, Mental/Cognitive Status reflected Resident #104 did not understand what was happening to him, had problems with short-term memory, and did not remember questions asked 3 hours prior. The summary of the assessment reflected Resident #104 has a court appointed guardian as he is no longer able to make safe decisions for himself, would fixate on subjects, would not be redirected, and was alert with confusion. In an interview on 11/5/10 at 1:07 p.m., Licensed Practical Nurse (LPN #2) reported an elopement of Resident #104 a couple weeks ago, she could not recall exact date. LPN #2 stated she had filled out an Incident Report. Review of the Facility Incident Report dated 10/10/10 at 11:15 a.m. reflected, Resident #104 "left building without telling the staff, found 2 1/2 blocks away without walker, walker was found abandoned across the street, staff located resident (Resident #104) and convinced him to come back, resident was cooperative, stated "out numbered"". It was noted in the Incident Report that Resident #104 was not authorized to be out of the facility at the location where he was found. Immediate interventions to prevent recurrence included placing Resident #104 on 15 minute checks and to place a WanderGuard on his walker. Resident #104 refused to have the WanderGuard placed on his ankle stating "I will cut it off and leave". The cause of the occurrence was documented , as elopement on the 10/10/10 Incident Report. The 10/10/10 Incident Report was documented as reportable to Risk Management; there is no documentation that the Risk Management was notified. Review of the Nursing Admission assessment dated [DATE] at 4:30 p.m. reflected Resident #104 was a risk for wandering and elopement. In bold lettering after the wandering and elopement assessment stated a "yes" answer to question #1 and any other question means the resident is a high risk; apply bracelet and Care Plan". Resident #104's documented answer to #1 and #2 were yes. Review of the Clinic Records for Resident #104 reflected, there was no care plan in place for elopement. Review of the Nursing Progress Notes dated 10/10/10 at 11:30 a.m. read; "Alert and oriented, able to voice needs, states "want to go home and cook a good meal". employee's able to convince to stay. Resident cooperative. Placed on 15 minute checks for safety. refused wanderguard, states "will cut off" guardian and physician notified. Will continue to monitor". The surveyor re-reviewed all the Incident Reports presented to her on entrance and did not locate an Incident Report for Resident #104 on 10/10/10. In in interview on 11/5/10 at 2:00 p.m., Registered Nurse (RN #1) reported that the surveyor would need to check with the Director of Nursing (DON) as to the location of the 10/10/10 Incident Report for Resident #104. RN #1 was shown Resident #104's Nursing Admission Assessment and ask if Question #1 and #2 were "yes", indicating an elopement risk, she stated they were. RN #1 was then asked why Resident #104 was not care planned for elopement, she stated Resident #104 did not qualify as an elopement risk. In an interview on 11/5/10 at 2:20 p.m., the DON was asked for the 10/10/10 Incident Report for the elopement of Resident #104, the investigation, and all witness statements. The DON stated "it wasn't a true elopement, because Resident #104 did sign out, and that is why it was not reported. Resident #104's guardian was made aware of the incident and Resident #104 was reprimanded by the guardian. Resident #104 usually goes out with someone, not by himself. Resident #104 is alert and oriented, but makes poor decisions". In an interview on 11/5/10 at 2:50 p.m., the Administrator reported the 10/10/10 incident with Resident #104 was not reported to the State, because he is alert and oriented and his guardian lets him go Leave of Absence (LOA), "usually with someone". The Administrator reviewed Resident #104's chart and was unable to locate a physician's order or guardian permission for Resident #104 to sign himself out of the facility LOA. The Administrator stated "we do not keep him prisoner. He is alert and oriented and can sign out". In an interview at 4:00 p.m. on 11/5/10 the Administrator stated only a WanderGuard (a monitoring device used to alert staff) alerts us of residents exiting out the front door of the facility. Resident #104 did not have a WanderGuard. On 11/5/10 the surveyor reviewed the 10/10/10 Incident Report, "Post Incident Follow Up" that reflected the Director of Nursing and the Administrator did not sign the Incident Report and no changes had been made to the immediate interventions put in place by the nurse who had completed the Incident Report on 10/10/10. The care plan was not updated. The Incident Report did not document a complete assessment of Resident #104 or indicate where the complete assessment was charted. Review of the leave of absence (LOA) book at the skilled hall nursing desk reflected, that on 10/10/10 at 10:55 a.m. Resident #104 had signed out to go home. In an interview on 11/19/10 at 1:00 p.m., Staff Member #1 reported that Resident #104 "presents as being alert and oriented, but has very limited short term memory capacity". Staff Member #1 reported that Resident #104 would come to her office 4 to 5 times a day with the same question, would not follow simple basic instructions, and was not safe to be out of the facility alone. In an interview with Resident #104 on 11/5/10 at 1:20 p.m., Resident #104 reported that he did leave the facility a few weeks ago, after he signed himself out in the LOA book at the skilled hall nursing desk, then went down the hall past the center nursing station and out the front door. Resident #104 stated, "facility staff came and got me, and said I wasn't suppose to leave like that, they wanted to put a thing on my ankle but I told them I would cut it off". Resident #104 reported facility staff called his guardian after bringing him back into the facility and he was told he couldn't leave without her knowing and that someone should be with him. In an interview on 11/8/10 at 10:30 a.m. Resident #104's guardian reported, Resident #104 needed a guardian because of mental incapacity, and that he "cannot leave the facility by himself as she would worry where he would end up". The guardian reported Resident #104's short term memory was bad. In interviews on 11/05/10 at 1:07 p.m. and 11/17/10 at 12:01 p.m. LPN #2 reported, that she was paged overhead by the Director of Maintenance (DOM) and found out Resident #104 was seen across the road in front of the facility) a 4 lane 40 MPH road). LPN #2 reported Resident #104 must have gone out the front door because no alarms went off. LPN #2 reported Resident #104 was found North and East of the facility and was brought back to the facility in a car by a facility staff member. LPN #2 stated Resident #104 had threatened to leave the facility against medical advice in the past. LPN #2 could not recall Resident #104 ever leaving the facility by himself, someone always accompanied him. LPN #2 reported she called the DON and informed her about Resident #104 leaving the facility and the DON guided her on how to do the narrative chart for the incident, "I did what I was told to do". LPN #2 reported calling Resident #104's guardian to inform her that he had left the facility and the guardian spoke to the Resident #104. LPN #2 stated she had always called to get permission prior to Resident #104 leaving the facility in the past. In interviews on 11/5/10 at 1:40 p.m. and 11/09/10 at 1:40 p.m. LPN #1 reported, going outside on a break and noticed a man on the sidewalk across the 4 lane 40 MPH road in front of the facility with his back to her. LPN #1 did not realize it was a resident from the facility until she witnessed the resident throw a walker over a 4 foot chain link fence. When the resident turned, LPN #1 noticed it was Resident #104, and yelled for the Director of Maintenance (DOM) who was coming out of the facility employee entrance to get Resident #104's nurse. LPN #1 reported she was concerned when Resident #104 continued North on the uneven, broken sidewalk without his walker as Resident #104 was not steady on his feet. LPN #1 stated, to go LOA a resident needs to have permission from the physician and guardian to ensure the resident was safe to go out alone. LPN #1 reported having education since employed in the facility on the procedure for LOA. Review of the Physical Therapy Evaluation date 10/5/10 reflected, Resident #104 transferred with a stand-by-assist due to decreased safety, decreased left knee range of motion, and balance. The gait of Resident #104 was documented as unsteady. The surveyor was unable to interview Resident #104's physical therapist during the course of the investigation. In interviews on 11/5/10 at 3:30 and 11/16/10 at 12:05 p.m. the DOM reported, going out the employee entrance/exit and LPN #1 yelling for him to go find LPN #2 to ask if it was okay for Resident #104 to be out of the facility. The DOM reported seeing Resident #104 on the sidewalk across the 4 lane 40 MPH road from the facility. The DOM went back in the facility and paged on the overhead public address system for LPN #2. LPN #2 said it was not okay for Resident #104 to be out of the facility. The DOM reported that he, LPN#2 and maybe two Certified Nursing Assistants (CNA's) then left the facility to get Resident #104. The DOM measured the distance and visually reported the path Resident #104 took from the facility for the surveyor. The DOM reported Resident #104 left from the front door of the facility, to the parking lot, across the parking lot to the facility entrance off the 4 lane 40 MPH road, across the 4 lane 40 MPH to the sidewalk, where Resident #104 was seen throwing his walker over the 4 foot high chain link fence. Resident #104 then preceded North on an uneven, broken sidewalk without his walker, across a side street off the 4 lane 40 MPH road, then East down the side street 1043.11 feet from the front door of the facility, where Resident #104 was stopped by CNA #7. The DOM reported RN #8 who drove over from the facility, and CNA #7 were with Resident #104 when he and LPN#2 reached Resident #104. Observations on 11/5/10 and 11/16/10 by the surveyor of the route Resident #104 took from the front door of the facility confirmed, that the sidewalk across the 4 lane 40 MPH road had broken and uneven sections, and the 4 lane 40 MPH could be difficult to cross due to traffic volume. In an interview on 11/24/10 at 10:56 a.m., CNA #7 reported hearing that Resident #104 had left the building and didn't have his walker. CNA #7 reported leaving by the front door as she was concerned because Resident #104 did not have his walker and CNA #7 knew he was to have the walker in the facility. CNA #7 reported catching up with Resident #104 on a side street across the 4 lane 40 MPH road in front of the facility, then RN #8 drove up and they helped Resident #104 into her car. In an interview on 11/8/10 at 12:30 p.m., CNA #4 reported hearing that Resident #104 had left the building and someone yelled to get his wheelchair. CNA #4 reported leaving the facility with the wheelchair, crossing the 4 lane 40 MPH road and hurrying to where Resident #104 was. CNA #4 stated, I asked Resident #104 about his walker and he said "it wouldn't roll well, so I threw it over a fence". In an interview on 11/24/10 at 12:18 p.m., RN #8 reported she had lunch in her car and heard a nurse yelling, then saw LPN #1 run to the middle of the parking lot. RN #8 reported that she then drove her car in the direction staff was running, which was about 2 blocks away from the facility and a CNA and RN #8 put Resident #104 in my car and RN #8 transported Resident #104 back to the facility. RN #8 asked Resident #104 if he had told anyone he was leaving and Resident #104 said no. RN #8 reported receiving education about LOA procedures for the facility, which included getting a physician's order for resident's to leave the facility. In an interview on 11/8/10 at 1:16 p.m., LPN #8 reported Resident #104 did not make intelligent, rational decisions. In an interview on 11/9/10 at 8:00 a.m., LPN #7 reported Resident #104 was not alert and oriented, he is forgetful as to where he is or what he is doing. Resident #105 The face sheet in the clinical record reflected Resident #105 was admitted to the facility on [DATE]. The Physician's Progress Note dated for 10/9/10 reflected [DIAGNOSES REDACTED]. The MDS (Minimum Data Set), a resident assessment tool dated 8/3/10 reflected, Resident #105 had some difficulty making decisions in new situations, had short term memory loss, impaired vision, and used a wheelchair as his primary mode of locomotion. Review of the Geriatric Psychiatry physician progress notes [REDACTED]. Review of the Psychiatry physician progress notes [REDACTED]. Review of the Nursing Admission assessment dated [DATE] at 3:00 p.m. reflected that Resident #105's Risk for Wandering and Elopement was not completed by the Admitting Nurse. Review of the Facility Incident Report dated 9/18/10, Sunday at 5:30 p.m. reflected, the facility was notified by an unidentified woman that a resident was walking down the road pushing a wheelchair. A staff member driving by on the road, also observed Resident #105 and stopped to assist him back to the facility. The Incident Report indicated that Resident #105 was not authorized to be at the location of the incident. Immediate interventions put in place to prevent recurrence were to apply a wanderguard and initiate a 1:1 (1 resident with 1 CNA). Review of the LOA book at the skilled hall nursing desk reflected, that Resident #105 did not have a sign out sheet in the book. In an interview on 11/23/10 at 1:40 p.m., Resident #105's conservator reported that she had been Resident #105's conservator since October of 2009. The conservator reported that after Resident #105's stroke when he was placed in the facility, he was not making sound decisions. The conservator stated that if Resident #105 was outside of the facility in a wheelchair by himself she would be scared for him. The conservator stated Resident #105 was becoming more disoriented and forgetful, even before he suffered a stroke. In an interview on 11/8/10 at 1:07 p.m., CNA #5 reported Resident #105 was found out of the facility, pushing his wheelchair like a walker. In an interview on 11/9/10 at 11:25 a.m., CNA #8 reported receiving a phone call between 5:15 and 5:20 p.m. from a neighbor asking if the facility was missing a resident. CNA #8 asked the caller what she meant, and the caller stated, there was an elderly gentleman going down the sidewalk in a wheelchair, "you might want to count your residents and see if they are all in the building". CNA #8 reported the caller then hung up and she reported the information to LPN #6. CNA #8 reported leaving the building and getting in her car to go find the resident, and when she located the resident there were cars coming up to the stop sign on the side street, so she told Resident #105 to stop, parked her vehicle, and went to assist Resident #105. CNA #8 reported Resident #105 had a bowel and bladder movement, "was soaking wet with urine and had soiled himself". CNA #8 reported the tab alarm was sounding, and Resident #105 did not know where he was, but Resident #105 stated he "just went out the front door". CNA #8 reported Resident #105 did not have a WanderGuard on. CNA #8 reported that an off-duty employee drove by and stopped to assist and while the off duty employee put the wheelchair in her vehicle, CNA #8 had to hold on to Resident #105 because he was not steady on his feet. CNA #8 reported there was no alarm, accept for a WanderGuard alarm on the front door, and on the weekends there was no one who monitored the front doors. In an interview on 11/9/10 at 9:45 a.m., LPN #6 reported hearing about a phone call from a neighbor asking if the facility was missing any residents. LPN #6 reported immediately calling a Code White (possible missing resident) and had CNA #8 go outside to look, prior to receiving confirmation that any residents in the facility were missing. LPN #6 reported that another call came in from an off duty employee who saw Resident #105 going South on the sidewalk on the 4 lane 40 MPH road the facility was located on. In an interview on 11/8/10 at 2:05 p.m., staff member #10 reported driving North on the 4 lane 40 MPH road and seeing Resident #105 pushing his wheelchair on the sidewalk going South from the facility. Staff member #10 reported calling the facility to inform them that she had seen Resident #105 and was going back to get him. Staff member #10 reported that CNA #8 from the facility was with Resident #105 when she drove up and the tab alarm on Resident #105's wheelchair was sounding. Staff member #10 reported that she and the CNA #8 put Resident #105 and the wheelchair in her vehicle and took him back to the facility. Staff member #10 reported Resident #105 was confused at times and had not been at the facility long. In an interview on 11/9/10 at 1:25 p.m., CNA #9 reported last seeing Resident #105 in his wheelchair in the hallway by his room going toward the center nursing station sometime before 5:00 p.m. CNA #9 reported that during dinner (which begins at 5:00 p.m.), the center hall nurse called the skilled hall and told us to check our residents. CNA #9 reported not finding Resident #105 in his bed eating dinner like he usually does, and asked his roommate if he had seen him. The roommate stated Resident #105 was talking earlier about going outside. CNA #9 reported to the center nursing desk that it was probably Resident #105 who was missing, the center hall nurse said she already knew and that they were bringing Resident #105 back to the facility. CNA #9 reported that when Resident #105 was returned to the facility he'd had a bowel and bladder movement, "his pants were soaked through". CNA #9 reported Resident #105 had a tab alarm on his wheelchair because he was not steady on his feet and had a tendency to get up unassisted. CNA #9 reported doing 1:1 with Resident #105 until 11 p.m. Per the Facility Incident Report dated 9/18/10 at 5:30 p.m. the facility was unaware of the location of Resident #105 for approximately 30 minutes, from between 5:00 p.m.-5:30 p.m. In interviews on 11/8/10 at 3:10 p.m. and 11/9/10 at 1:20 p.m. RN #4 reported hearing an announcement on the overhead public address system to check for missing resident, and that was when it was discovered Resident #105 was gone. RN #4 reported witnessing CNA #8 leave the facility in a vehicle and seeing CNA #8 and another person push Resident #105 in his wheelchair back into the facility. RN #4 reported Resident #105 was not safe to be out of the facility by himself, he was very forgetful, and not safe by himself. In an interview on 11/9/10 at 2:25 p.m., LPN #3 reported, being called by a staff member who was off duty about Resident #105 being seen up the road from the facility pushing his wheelchair. LPN #3 reported Resident #105 was pushed back in the facility in his wheelchair and he had stated he was" headed to the corner to the bank to get money". LPN #3 reported that Resident #105 was alert but not orientated or safe to be out of the facility alone. LPN #3 reported that the LOA education reviewed during orientation was to get permission from a physician for a resident to be out of the facility. In an interview on 11/8/10 at 4:00 p.m., RN #1 reported Resident #105 had a tab alarm on his wheelchair so staff would know when he got up, Resident #105 needed supervision to keep him safe. RN #1 reported if a resident wants to go LOA an order from the doctor was always needed. RN #1 stated, "if the residents don't tell us they are leaving we can't get an order". In an interview on 11/8/10 at 4:25 p.m., RN #3 reported Resident #105 was not alert and oriented times 3(person, place, and time), he was not safe to be out of the facility alone. In an interview on 11/9/10 at 8:00 a.m., LPN #7 reported Resident #105 was alert and oriented to his own world, and was not safe to be outside on his own. LPN #7 reported that Resident #105 had a tab alarm on his wheelchair because he was unsafe to transfer or ambulate without help. In an interview on 11/8/10 at 3:10 p.m,. Resident #105 reported that he went out the front door, pushing the door open by twisting the handle. Resident #105 reported he was in his wheelchair and did not remember telling anyone he was leaving. Resident #105 stated "when they brought me back they put this band on my ankle". Observation on 11/16/10 at 12:45 p.m., while this surveyor walked toward skilled hall nursing station revealed, Resident #105 was sitting on the edge of his bed. The surveyor asked "how are you", Resident #105 stated "I'm a little confused about who and where I am". In an interview on 11/8/10 at 4:10 p.m. Physician #1 reported that is was common sense that people need to know if Resident #105 was going out of the facility and who he was going with. Review of the Nursing Progress Notes dated 9/18/10 at 7:50 p.m. reflected LPN #8, who was not Resident #105's assigned caregiver documented, "Resident (Resident #105) talk to this nurse (LPN #8) after returning from walk stated he (Resident #105) thought he should have gotten farther down the road, I (LPN #8) have instructed this resident (Resident #105) to in the future notify staff that he would like to leave building we would get Dr's (doctor's) permission and we would help in getting him there and back". Review of the Nursing Progress Notes dated 9/18/10 at 8:40 p.m. reflected Resident #104's assigned caregiver documented,"facility made aware that a resident was ambulating down the street pushing his wheelchair (w/c). Resident (Resident #105) returned to facility by staff. Wanderguard placed on Resident. Resident educated per other Nurse. Nurse Manager aware as well as DON (Director of Nursing)". In an interview on 11/9/10 at 3:15 p.m., a neighbor by the facility reported seeing a guy in a wheelchair going South from the facility, he was going fast. The neighbor stated it is a busy road in front of the facility. In an interview on 11/16/10 at 12:05 p.m., the DOM measured the distance and visually reported the path Resident #105 took after exiting the facility on 9/18/10 to the surveyor. Resident #105 exited his room in his wheelchair, went down the hall past the center nursing station and out the front door of the facility; to the parking lot, across the parking lot, up a 6 inch curb, across a grassy area to a driveway, crossed the driveway and continued on the narrowing grassy area next to the 4 lane 40 MPH road to a sidewalk, down the sidewalk crossing one more residential side street 1304.1 feet from the front door of the facility where Resident #105 was stopped by CNA #8. Observations on 11/16/10 this surveyor of the route Resident #105 took from the front door of the facility confirmed, that Resident #105 had to get his wheelchair up a 6 inch curb, over a grassy area that sloped downhill in sections, then narrowed due to a fence to the left side of the 4 lane 40 MPH road, the grassy area was sparse and rutted with occasional trees noted next to the road to maneuver around, then onto a sidewalk, pushed his wheelchair 81 feet across a side street off the 4 lane 40 MPH road, to the next side street, Resident #105 either propelled or pushed his wheelchair 1304.1 feet from the front door of the facility where he was stopped by CNA #8. On 11/10/10 at 2:09 p.m., the Administrator and the Director of Nursing were notified of an Immediate Jeopardy that began on 9/18/10 at 5:30 p.m. when Resident #105 eloped from the facility, followed by the elopement of Resident #104 on 10/10/10 at 10:55 a.m.. On 11/16/10, at 7:45 a.m. the surveyor confirmed that the facility implemented the following to remove the immediate jeopardy. 1. On 10/10/10 Resident #104 was assisted back to the facility, assessed by the nurse, and placed on 15 minute checks upon return, the resident refused the application of a WanderGuard to his walker or person. The guardian was in agreement with not applying the device and the resident agreed to notify staff and continue to sign out when he wanted to leave the facility. Due to an acute change in condition on 11/6/10 Resident #104 was transferred to the hospital. 2. On 9/18/10 Resident #105 was assisted back to the facility, assessed by the nurse, and a WanderGuard was placed on the ankle of Resident #105. 3. On 11/5/10 the Administrator demonstrated the use of a WanderGuard to set an alarm off at front door. 4. On 11/8/10 and 11/10/10, in-servicing was completed with all 132 employees relating to the procedures and requirements for residents to leave the facility. 5. On 10/10/10 a written notification on the procedures for signing out of the facility and notification of staff when a resident desires to leave the facility, will be added to the resident's admission information. The information will be reviewed during the admission process with the resident and/or legal representative. 6. On 11/11/10 residents are assessed upon admission to determine if they are at risk for exiting the facility. Additionally, residents are re-assessed when behaviors are exhibited or a change of condition may increase their risk for exiting. Interventions are implemented which may include the application of a WanderGuard device and may include frequent checks and/or 1:1 supervision until the change in condition is resolved. 7. On 11/11/10 residents with WanderGuard devices are assessed for placement and function every shift, this assessment is documented in the treatment administration record. 8. On 11/11/10 the Director of Maintenance checked all door alarms and does this at least weekly. 9. On 11/9/10 all WanderGuard devices were checked for placement and functioning. 10. On 11/9/10 the 12 ambulatory residents identified by the facility were assessed for exiting behaviors and risks. 11. On 11/11/10 the facility will review all residents upon admission and as indicated to identify potential risks for identified residents. Although the Immediate Jeopardy was removed 10/16/10 the facility remained out of compliance at a scope of isolated and severity of no actual harm, but potential for more than minimal harm, that is not Immediate Jeopardy, due to the State Agency not being able to verify sustained compliance. #