Every finding on record at Arbor Manor Rehabilitation and Nursing Center

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 92 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and toxic chemical residue.Findings include:During an observation and interview on 5/05/2026 at 9:07 a.m., of initial kitchen tour, Food Service Manager (FSM) N reported had worked at facility about 10 months. FSM N directed this surveyor to single hand-washing sink located in kitchen with trash can located next to sink with unfunctional lid. After washing hands, foot pedal on trash can was not functioning properly, and lid had to be handled with clean hands to open, and observe several used paper towels in trash can. FSM N reported would replace trash can. Continued tour with staff observed using dish machine. FSM N reported dish machine was low temperature chemical machine and staff monitor temperatures daily and record on log and monitor chemical level in large buckets under the machine. FSM N reported would expect dish machine to be greater than 120 degrees Fahrenheit with cycle. Observed clipboard with dish-machine log hanging on the opposite wall as dish machine with last documented data from 5/1/26. Observed three cycles of dishes from dish machine with temperature gauge that indicated 100 degrees Fahrenheit and FSM N verified temperature and that is how machine in monitored, with no mention of testing chemicals. While the three wash cycles were running, FSM N was observed entering data on dish machine log for 5/2/26 through current date, 5/5/26. FSM N was queried what he was writing on log and stated was completing log with approximate reading for last few days and verified had not been completed since 5/1/26 and other log for monitoring chemical was blank with no entries for May 2026. FSM N placed a digital monitor though the dish machine. Observed digital monitor read 104.9 degrees Fahrenheit and reported was still too low and planned to follow up. Continued kitchen tour on 5/05/2026 at 9:29 a.m., moderate Ice [NAME] were observed protruding from the Walk-In Freezer supply lines. The Walk-In Freezer ceiling surface was also observed with accumulated ice droplets, adjacent to the refrigeration fan unit with two of three fans functioning. Significant amount of solid, pooled ice was noted on at least eight opened cardboard boxes of bread and large pooled area of solid ice was observed on floor about one inch thick and two foot by 4 foot area. FSM N reported had door seal replaced about one month prior and contracted refrigerator company was aware of ice buildup. FSM N reported water pours out of water lines during defrost for past two weeks. The 2022 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.During an observation on 5/06/2026 at 11:31 a.m., entered kitchen for lunch tray service. [NAME] T started to tray meal and this surveyor had asked if food tempertures had already been completed. [NAME] T stated, yes, however was unable to produce completed log. [NAME] T was unable to locate alcohol swab to clean thermometer and another staff member provided one alcohol swab and [NAME] T obtained food temperature for at least six menu items and cleaned thermometer probe with original food caked one inch alcohol swab between items. Observed contracted refrigerator company staff in area of freezer during tray service.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% when 2 of 26 medications for two residents (R7 and R31) were not administered in accordance with physician's orders resulting in a medication error rate of 7.69%.Findings include:R7 Review of the medical record revealed R7 admitted to the facility on [DATE] with diagnoses that included dementia and congestive heart failure. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/27/26 revealed R7 scored 9 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). During an observation on 5/6/26 at 8:35 AM, Licensed Practical Nurse (LPN) I prepared medications for R7. LPN I reported R7 took his medications crushed. LPN I separated a few medications that were not allowed to be crushed. Amongst those medications was ferrous gluconate 324 milligrams (mg). LPN I then used a pill cutter to cut those medications in half, including the ferrous gluconate. In a telephone interview on 05/06/2026 at 9:04 AM, Pharmacist R, from the facility's pharmacy, reported most of the medications LPN I cut in half were allowed to be cut. Pharmacist R reported ferrous gluconate should not be cut or crushed. R7's medical record did not contain a Physician's Order or any instructions from the pharmacy that the ferrous gluconate was okay to cut. In an interview on 05/06/2026 at 10:10 AM, Director of Nursing (DON) B reported each medication cart had a reference sheet that included which medications could not be crushed. DON B reported the reference did not mention the cutting/splitting of pills. DON B reported in that case, staff should reach out to the pharmacy. R31 Review of the medical record revealed R31 admitted to the facility on [DATE] with diagnoses that included congestive heart failure, and hypertension. The MDS with an ARD of 3/3/26 revealed R31 scored 11 out of 15 (moderate cognitive impairment) on the BIMS. Review of the Physician's Order dated 3/11/26 revealed an order for Metolazone 2.5 mg one time per day for congestive heart failure/weight gain. The Physician's Order included the instructions to give the metolazone 30 minutes prior to the bumetanide. During an observation on 05/06/2026 at 8:14 AM, LPN S prepared medications for R31. Amongst those medications were metolazone 2.5 mg and bumetanide 1 mg. LPN S administered both medications at the same time. In an interview on 05/06/2026 at 9:57 AM, when asked about the bumetanide and metolazone being given to R31 at the same time, LPN S reviewed R31's medical record and agreed the order reflected to administer the metolazone 30 minutes prior to the bumetanide. LPN S agreed the metolazone was not administered per the Physician's Order.

Based on observation, interview, and record review, the facility failed to ensure accurate advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for two resident (#12, #78) of two residents reviewed for advance directives.Findings Included:Resident #12 (R12)Review of the medical record revealed R12 was admitted to the facility [DATE] with diagnoses that included Alzheimer's disease, vascular dementia, atrial fibrillation, venous insufficiency (when leg veins [NAME] efficiently return blood to the heart), polyosteioarthritis (a form of arthritis affecting five or more joints), asthma, hypertension, anxiety, hypothyroidism (low thyroid hormone), delusional disorders, and depression. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R12 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. During an attempted interview [DATE] at 09:32 a.m., R12 was observed sitting up in the dining room. R12 was unable to answer verbal questions.Review of R12's medical record revealed a document entitled DO-NOT-RESUSCITATE ORDER which was signed by R12 on [DATE]. The section, of the document listed above, entitled Attestation of Witness revealed one witness signature dated [DATE] and the other witness signature dated [DATE].Resident #78 (R78)Review of the medical record revealed R78 was admitted to the facility [DATE] with diagnoses that included heart disease, osteoarthritis (degenerative joint disease with breakdown of cartilage) of knee, type 2 diabetes, stage 3 kidney disease, atrial fibrillation, hyperlipidemia (high fat content in blood), anemia (low red blood cells), and hypertension. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R78 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15.Review of R78's medical record revealed a document entitled DO-NOT-RESUSCITATE ORDER which was signed by R78 on [DATE]. The section, of the document listed above, entitled Attestation of Witness revealed one witness signature dated [DATE] and the other witness signature had no date.During an interview on [DATE] at 03:35 p.m., Social Worker (SW) E explained that a residents advance directive wishes were obtained upon admission. SW E explained that if the resident did not want to be revived if their heart were to stop, the resident would sign the document entitled DO-NOT-RESUSCITATE ORDER. SW E explained that the document would be signed and dated by two witnesses, which was witnessed at the time of the resident or resident responsible persons. SW E explained that once the DO-NOT-RESUSCITATE ORDER form is completed the attending physician would sign the document and a physician's order would be written. SW E reviewed R12's DO-NOT-RESUSCITATION ORDER, signed by R12 on [DATE], and confirmed the second witness signature of [DATE]. SW E could not explain why the witness date was after the resident signed the document. SW E reviewed R78's DO-NOT-RESUSCIATION ORDER, signed by R78 on [DATE], and confirmed that the second witness signature was not dated. SW E could not explain why the second witness did not date the signature.During an interview on [DATE] at 03:59 p.m., Director of Nursing (DON) B explained that the Nurse Managers were responsible for reviewing the documents entitled DO-NOT-RESUSCITAITON ORDER. DON B explained that during the review, the Nurse Managers were to verify that all portions of the document were completed accurately. DON B reviewed R12's DO-NOT-RESUSCITAITON ORDER, dated [DATE], and confirmed that the second witness signature was dated [DATE]. DON B could not explain why the signature was dated the day after R12's signature. DON b reviewed R78's DO-NOT-RESUSCIATION ORDER, signed by R78 on [DATE], and confirmed that the second witness signature was not dated. DON B could not explain why the second witness did not date the signature.

Based on observation, interview, and record review, the facility failed to provide Activities of Daily Living care (showering and shaving) for one dependent resident (#61) of two residents reviewed.Findings Included: Resident #61 (R61)Review of the medical record revealed R61 was admitted to the facility 08/26/20222 with diagnoses that included Alzheimer's Disease, dementia, polyarthritis (arthritis in five or more joints), insomnia, kidney disease, peripheral neuropathy (nerve damage in nerves), gout (high uric acid in joints), urinary retention, sleep apnea, gastro-esophageal reflux, and muscle weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/09/2026, revealed R61 had a Brief Interview for Mental Status (BIMS) of 3 (severe cognitive impairment) out of 15. Section GG- Functional Abilities of MDS, with the same ARD, revealed R61 was dependent for shower/bathe self and dependent for personal hygiene.On 05/05/2026 at 09:12 a.m. during observation and interview, R61 was observed sitting in chair at the side of his bed. R61 was observed to have facial hair covering his face that was approximately 3 cm (centimeters) in length. When R61 was asked about his facial hair he was observed rubbing his face with his hand and explaining that he would like to be shaved. R61 could not recall the last time he had been shaved.Review of R61's Point of Care (POC) documentation (documentation demonstrating care provided by direct care staff) for showers stated: .Shower/Wednesday/Saturday 2nd shift. Review of that previously listed POC revealed shower, for the last 30 days, was completed 04/08/2026, 04/18/2026, 04/22/2026, 04/29/2026. The same POC revealed documentation as not applicable on 05/02/2026. R61's POC documentation and/or progress notes did not reveal that he had received a shower, in the last 30 days, on 04/11/2026 (Saturday), 04/15/2026 (Wednesday), and 04/25/2026 (Saturday).On 05/06/2026 at 08:13 a.m., during observation and interview, R61 was observed sitting in a chair at the side of his bed. R61 was again observed to have facial hair covering his face that was approximately 3-4 cm (centimeters) long. R61 explained that he still had not gotten shaved.On 05/06/2026 at 08:14 a.m., License Practical Nurse (LPN) I explained that residents at the facility received showers/baths two times per week. LPN I explained that showers/baths are usually conducted by the Certified Nurse Aides (CNA). LPN I explained that if a resident refused a shower/bath the CNAs would inform the nurses and then the nurses were expected to try and encourage the resident to take a shower/bath as scheduled. LPN I explained if the resident still had not wanted to take a shower/bath it was expected that the nurse would enter a progress note explaining refusal in the resident's medical record.On 05/06/2026 at 08:18 a.m., Certified Nursing Aide (CNA) J explained that R61 was to have a shower/bath completed twice per week. She explained that R61's shower/bath days were listed in his POC (Point of Care) documentation and then demonstrated a documented that revealed what showers where to be completed on what days and what shifts. CNA J explained that if the resident was male the staff was expected to ask the resident if he would like to be shaved on the days and shifts that the resident was to have a shower.On 05/06/2026 at 08:22 a.m. Director of Nursing (DON) B explained that it was her expectation that residents were to receive a shower/bath at least twice per week and/or according to their plan of care. DON B explained that if residents had facial hair, she expected that the person conducting the shower/bath would ask the resident if they would like to be shaved. DON B also explained that if residents had refused a shower/bath that the Certified Nurse Aides (CNA) would notify the nurse and then the nurse would attempt to have the resident to agree. DON B explained that if the resident still refused it would be documented refusal by the CNA and the nurse are expected to write a progress note in the resident's record. DON B confirmed that R61's Point of Care documentation revealed showers, for the last 30 days, were completed 04/08/2026, 04/18/2026, 04/22/2026, 04/29/2026. DON B could not explain why R61 had not received showers on 04/11/2026 (Saturday), 04/15/2026 (Wednesday), and 04/25/2026 (Saturday). DON B could not explain why staff had documented not applicable on 05/02/2026. DON B could not answer if R61 had been offered shaving on any of his shower/bath days.

Based on observation, record review and interview, the facility failed to ensure proper positioning was in place for one resident (resident #28) of two residents reviewed for positioning. Findings include: Review of the clinical record revealed Resident #28 (R28) was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis that included heart failure. Review of the Minimum Data Set (MDS) dated [DATE] revealed R28 scored 7 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS) and was receiving hospice care. On 05/05/2026 at 9:56 AM, R28 was observed sitting in her room in high back wheelchair. The footrests were on the wheelchair but R28's feet do not touch and were observed dangling. R28 was observed to be sitting on a wheelchair pad, a pillow and the sling to a mechanical lift. R28 was observed in the dining room at the noon meal with her feet dangling from the wheelchair. Observations of R28 were made on 05/06/2026 at 9:35 AM in her room watching television, R28 was sitting in her wheelchair, no footrests in place with R28's feet dangling. R28 was observed again on 05/06/2026 at 11:31 AM sitting in her room visiting with son, the footrests to the wheelchair were on the floor near the bed. Resident #28 feet observed dangling. On 05/06/2026 at 2:41 PM Resident #28 observed in her room sitting in the wheelchair, the footrests were observed on floor not attached to chair, and R28's feet observed dangling. On 05/07/2026 at 8:50 AM R28 was observed in her room, sitting in a high back wheelchair, no footrests in place. R28's feet were pointed down and dangling, toes do not reach floor. On 05/07/2026 at 11:40 AM, during an interview with Director of Nursing (DON) B the above observations were shared. DON B reported due to R28 being under hospice care, hospice provided the wheelchair, DON B reported for comfort the footrests of R28's wheelchair should be in place and was not sure why this was not done or if the chair may be ill fitting as a whole and due to R28's hospice status therapy would not have evaluated R28 for wheelchair positioning.

Based on observation, interview, and record review, the facility failed to provide range of motion (ROM) to one (R11) of two reviewed. Findings include:Review of the medical record revealed R11 was admitted to the facility on [DATE] with diagnoses that included heart failure and polyarthritis (arthritis affecting multiple joints). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/28/26 revealed R11 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had functional limitation in range of motion impairments both sides of the lower extremities. On 05/05/2026 at 1:57 PM, R11 was observed lying in bed. R11 reported she had previously received therapy services, but her insurance no longer covered therapy services. R11 reported during therapy, she did exercises with her arms and legs. R11 reported she knew what exercises she should perform, but reported since therapy services ended, staff did not assist her with any exercises or range of motion. Review of the Occupational Therapy (OT) Discharge Summary revealed R11 received OT services from 2/20/26 through 4/17/26. The discharge recommendations included a home exercise program. Review of the Physical Therapy (PT) Discharge Summary revealed R11 received PT services from 2/20/26 through 3/24/26. The Discharge Summary revealed Staff and patient have been educated on ROM exercises to incorporate into daily routines .Encourage [patient] to participate in ROM exercises daily when providing care. Review of R11's Kardex (nurse aide care guide) and care plan revealed an intervention initiated on 3/27/26 that read please offer to provide ROM of upper and lower extremities daily while providing care to maintain joint mobility, reduce risk of contractures, and reduce painful symptoms. Review of R11's medical record revealed no documentation that ROM was being completed with care. In an interview on 05/07/2026 at 9:16 AM, Occupational Therapist (OT) P reported R11's therapy goals were to sit up in a wheelchair or Broda chair and to gain strength. When asked about the home exercise program mentioned in her discharge summary, OT P reported she believed Physical Therapy set up a passive range of motion program in which staff were trained to provide. In an interview on 05/06/2026 at 10:10 AM, Director of Nursing (DON) B reported the facility did not have a restorative program, but instead Certified Nursing Assistants (CNAs) were to encourage residents to work with them during care. When asked if range of motion was documented, DON B reported it should be in the CNA documentation. DON B agree R11 was care planned to receive ROM but did not have any specific documentation that this task was completed.

Based on interview and record review, the facility failed to ensure that the attending physician documented his/her rationale for not changing medication as requested by the pharmacist for one resident (#6) of five residents pharmacy reviews. Findings Included:Resident #6 (R6)Review of the medical record revealed R6 was admitted [DATE] with diagnoses that included congestive heart failure (CHF), epilepsy (neurological disorder causing seizures), type 2 diabetes, morbid obesity, bladder dysfunction, heart disease, hypothyroidism (low thyroid hormone) atrial fibrillation, restless leg syndrome, insomnia, depression, gout (build-up of uric acid in bone joints), hypertension, and hyperlipidemia (high fat content in blood). The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/27/2026, revealed R6 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) of 15.Review of R6's medial record revealed a Consultant Pharmacist Medication Regimen Review, dated 02/07/2026, which stated: Patient is currently taking Eliquis 2.5mg (milligrams) twice daily for atrial fibrillation. Patient is 74 yo (year old), serum creatinine is 1.41 mg/dl (milligrams/deciliter) and weight is 198.7 kg (kilograms). Based on this information, recommend increase to Eliquis 5mg twice daily. The same document revealed that they physician placed an x near the bock of other and placed a response of continue and the other word was illegible. Review of R6's physician orders had not demonstrated that the Eliquis dosage was increased but had stayed the same.In an interview on 05/06/2026 at 11:07 a.m., Director of Nursing (DON) B explained that R6's Consultant Pharmacist Medication Regimen Review, dated 02/07/2026, was signed by the physician and was documented as, Continue same dose. DON B confirmed that the physician had decided not to change the mediation dosage and had not documented her rationale in the resident's medical record. DON B could not provide an answer why the physician had chosen not to change the dose of Eliquis as the pharmacist had recommended. DON B confirmed that the same document had requested Provide a brief clinical rationale note if the physician disagreed with the pharmacist recommendations.In a telephone interview on 05/06/2026 at 11:16 a.m., attending Physician T explained that she had not followed the recommendations of the pharmacist on 02/07/2026 for R6's dosage of Eliquis because he had a history of urinary bleeding. She explained that it would have been recorded in R6's medical record someplace but she had not provided that rational on R6's Consultant Pharmacist Medication Regimen Review, dated 02/07/2026. Attending Physician T explained that she was not aware that the document Consultant Pharmacist Medication Regimen Review had requested to be Provide a brief clinical rational note if she had disagreed with the pharmacist recommendation.

Based on observation, interview, and record review, the facility failed to maintain infection prevention and control practices during medication administration for one (R31) of two reviewed. Findings include: Review of the medical record revealed R31 admitted to the facility on [DATE] with diagnoses that included congestive heart failure and hypertension. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/3/26 revealed R31 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). During an observation on 05/06/2026 at 8:14 AM, Licensed Practical Nurse (LPN) S prepared medications for R31. LPN S dispensed 11 of R31's 14 medications into her bare hand and then placed each medication in the pill cup. The medications included hydralazine, metformin, bumetanide, colchicine, diltiazem, tamsulosin, duloxetine, eliquis, metolazone, metoprolol, and potassium chloride. LPN S then administered the medications to R31. In an interview on 05/06/2026 at 9:57 AM, LPN S reported she normally dispensed the pills/capsules into her hand before placing them into the medication cup. LPN S was not aware that she was not supposed to touch the medications with her bare hands. In an interview on 05/06/2026 at 10:10 AM, Director of Nursing (DON) B reported nurses should not handle medications with their bare hands and then administer the medications to residents.

Based on interview and record review, the facility failed to maintain documentation that pneumococcal immunization education was provided and whether consent or declination was received for one (R11) of five reviewed. Findings include: Review of the medical record revealed R11 admitted to the facility on [DATE] with diagnoses that included heart failure and atrial fibrillation. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/28/26 revealed R11 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was offered and declined the pneumococcal immunization. Review of R11's medical revealed no documentation of pneumococcal immunization education, consent or declination. On 05/07/2026 at 10:56 AM, Nursing Home Administrator (NHA) A reported the facility was not able to locate a consent or declination for R11's pneumococcal immunization. In an interview on 05/07/2026 at 11:21 AM, Director of Nursing (DON) B reported she was the facility's Infection Preventionist. DON B reported the facility had documentation of R11's education and consent for the influenza immunization and declination of the COVID-19 immunization, but no documentation of education and consent or declination of the pneumococcal immunization.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 84 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 03/03/25 at 07:30 A.M., An initial tour of the food service was conducted with Dietary Aide C. The following items were noted: Ice [NAME] were observed protruding from the Walk-In Freezer Freon refrigerant inlet supply lines. The Walk-In Freezer ceiling surface was also observed with accumulated ice droplets, adjacent to the refrigeration fan unit. The Can Opener Assembly was observed soiled with accumulated and encrusted food residue. The 2022 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 Microwave Oven door face plate was observed (etched, scored, particulate, corroded). The damaged face plate surface measured approximately 0.5 - inches-wide by 4-6 inches-long. The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. On 03/03/25 at 08:35 A.M., An initial tour of the food service was continued with Director of Food Services D. The following items were noted: The three-compartment sink rinse and sanitizer basin faucet assembly was observed leaking water from the chemical diversion valve. Director of Food Services D indicated he would contact Ecolab for necessary repairs as soon as possible. The 2022 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 of two Dish Machine Room overhead spray arm valve assemblies were observed soiled with accumulated and encrusted food residue. Director of Food Services D indicated he would have dietary staff thoroughly clean and sanitize the soiled spray arm valve assembly as soon as possible. West Wing Dining Room: The microwave oven interior and exterior surfaces were observed soiled with accumulated and encrusted food residue. Director of Food Services D indicated he would have dietary staff thoroughly clean and sanitize the soiled microwave oven as soon as possible. The 2022 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. On 03/05/25 at 08:30 A.M., Record review of the Policy/Procedure entitled: Equipment dated 5/2014 revealed under Policy Statement: It is the center policy that all food service equipment is clean, sanitary, and in proper working order. Record review of the Policy/Procedure entitled: Equipment dated 5/2014 further revealed under Action Steps: (1) The Food Services Director will ensure that all equipment is routinely cleaned and maintained in accordance with manufacturer directions and training materials. (4) The Food Services Director ensures that all non-food contact equipment is clean. On 03/05/25 at 08:45 A.M., Record review of the Policy/Procedure entitled: Environment dated 5/2014 revealed under Policy: It is the center policy that all food preparation areas, food services areas, and dining areas will be maintained in a clean and sanitary condition. Record review of the Policy/Procedure entitled: Environment dated 5/2014 further revealed under Action Steps: (1) The Food Service Director will ensure that the physical plant is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation.

Based on observation, interview, and record review, the facility failed to provide a homelike environment for up to 84 residents residing at the facility, resulting in residents being subjected to numerous loud overhead paging throughout the day. Findings: During an observation on 3/3/25 at 8:31 AM on North 2 unit, during initial resident screening heard very loud overhead speaker announcement made through facility, [named staff] to dietary. During an observation on 3/3/25 at 8:41 AM, overheard very loud overhead announcement, Maintenance to back hall for delivery. During an observation on 3/03/25 at 9:12 AM, overheard very loud overhead announcement throughout facility. During an observation on 3/03/25 9:at 21 AM , overheard very loud overhead announcement throughout facility, Wander risk front lobby. During an observation on 3/03/25 at 9:34 AM, resident # 35 granted permission to enter room and reported door was closed because overhead paging was so loud and was annoying to her. During an observation on 3/03/25 at 9:39 AM, overheard very loud overhead announcement throughout facility, [name] to front office. During an observation on 3/03/25 at 9:45 AM, overheard very loud overhead announcement throughout facility. During an observation on 3/03/25 at 10:02 AM, overheard very loud overhead announcement throughout facility, Doctor call . During an observation on 3/03/25 at 12:12 PM, overheard very loud overhead announcement throughout facility, beep noise, followed by sound of phone hanging up. During an interview on 3/03/25 at 12:52 PM, R20 family reported visits facility often and reported have observed R20 startled by overhead announcement because they are so loud. During an observation on 3/03/25 at 1:07 PM, overheard very loud overhead announcement throughout facility. During an observation on 3/03/25 at 1:57 PM, overheard very loud overhead announcement throughout facility. During an observation on 3/03/25 at 2:02 PM, overheard very loud overhead announcement throughout facility. During observations on 3/4/25, overheard several overhead announcements. During an observation on 3/05/25 at 9:09 AM, overheard very loud overhead announcement throughout facility, [stated name] to front office. Review of the, Phone extentions for ., provided to survey team 3/3/25, also included staff contact information. The Document indicated in bold, red print, TO PAGE OVERHEAD - DIAL *460 . During an interview on 3/05/25 at 9:30 AM, Nursing Home Administrator (NHA) A reported reviewed General Maintenance Policy yesterday that spoke about, Homelike Environment that included limiting overhead announcements and verified facility paged too frequently overhead and should limit to emergencies only. NHA A reported planned to limit overhead announcements starting today (3/5/25). NHA A reported he had just tuned out noise but agreed that frequent overhead paging was not homelike.

Based observation, interview, and record review the facility failed to ensure proper storage of medication in one of three medication carts and one medication room of three reviewed for medication storage. Findings include: During an observation and interview on 3/04/25 at 12:32 PM, Licensed Practical Nurse(LPN) R unlocked the South 1 medication cart. Located in the medication cart was an open resident Albuterol 90mcg, dated on box 2/21/24. LPN R verified date and inhaler was open and reported should have been discarded 12 months after open date. LPN R verified the LOT#(batch number) on the inhaler and the box were not the same and reported should match. Observed open bottle of Timolol Mateate eye drops with no open date. LPN R verified eye drops open and should have been labeled with open date. Observed Glucose Gel in cart with manufacturer expiration date of 7/2024. LPN R reported planned to discard. During an interview on 3/05/25 at 11:45 AM, Director of Nursing (DON) B reported would expect nursing staff to date medications when opened. DON B reported Pharmacy and Unit Managers routinely check medications carts for outdated items. During an observation and interview on 3/05/25 at 1:27 PM, Registered Nurse (RN) S unlocked the South 2 medication room. Several (more than 20) yellow Heparin 100units/1 ml syringes were observed in bin with manufacturer expiration date of 6/30/23. RN S reported was unsure what they were used for and reported plan to dispose. Unit Manager T arrived and verified Heparin syringes should have been discarded according to manufacture date 6/30/23.

Based on observation, interview and record review, the facility failed to ensure appropriate use of Personal Protective Equipment (PPE-protective garments or equipment designed to protect the wearer from injury or infection) and hand hygiene for Transmission-Based Precautions (TBP-used for patients known or suspected to be infected or colonized with infectious agents) for one (Resident #4) of two reviewed. Findings include: Review of the medical record reflected Resident #4 (R4) admitted to the facility on [DATE], with diagnoses that included congestive heart failure and carrier of Carbapenem-resistant Acinetobacter baumannii (a multi-drug resistant bacteria). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/9/24, reflected R4 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). A Physician's Order, dated 12/5/24, reflected R4 was on Contact Precautions (a type of TBP) for a multi-drug resistant organism (MDRO). According to the Centers for Disease Control and Prevention (CDC), .Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission .Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning [putting on] PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens . (https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html) On 03/03/25 at 9:34 AM, PPE was observed hanging on the exterior of R4's room door. A sign for Contact Precautions was posted on the exterior of the door, which reflected two STOP signs and notation of, CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit . On 03/03/25 at 9:34 AM, Licensed Practical Nurse (LPN) I reported R4 was on Contact Precautions for methicillin-resistant Staphylococcus aureus (MRSA-an infection caused by a type of staph bacteria that is resistant to many antibiotics) in their urine, and a gown and gloves were to be worn into R4's room. During an observation on 03/03/25 at 12:02 PM, Certified Nurse Aide (CNA) J entered R4's room with a lunch tray. CNA J did not wear PPE into the room and closed the door behind them. CNA J exited the room at 12:02 PM and proceeded to the meal cart in the hallway. On 03/03/25 at 12:04 PM, CNA J reported they would wear gloves when going into R4's room and would wear a gown and gloves if doing perineal care for R4 or anything related to toileting. CNA J stated they were supposed to wear gloves to pass the room tray due to an MDRO in R4's urine. CNA J indicated they forgot to put PPE on prior to passing R4's lunch tray. CNA J also reported they did not perform hand hygiene upon exiting R4's room. On 03/03/25 at 2:30 PM, R4 was observed seated in a recliner, in their room. R4 stated staff only wore a gown and gloves when assisting them in the bathroom. A box of empty pop cans was observed on the lid of the trash can, near the inside of R4's room door, which was designated for disposal of PPE. In an interview on 03/05/25 at 9:36 AM, Director of Nursing (DON) B reported if a resident was on Contact Precautions, a gown and gloves should have been worn any time someone entered the resident's room. In an interview on 03/05/25 at 11:21 AM, Unit Manager (UM) Q reported R4 had a history of an MDRO in their urine, for which staff was to wear a gown and gloves for any care. UM Q indicated they were attempting to determine if R4 was to be on Enhanced Barrier Precautions (EBP-use of gowns and gloves during high-contact resident care activities for residents known to be colonized or infected with a MDRO and/or residents at an increased risk of acquiring an MDRO). 34705 During an observation and interview on 3/04/25 at 11:51 AM, Licensed Practical Nurse (LPN) F was preparing medications for resident on North 1 unit. LPN F reported plan to administer insulin via insulin pen. LPN F removed the cap from the Humalog insulin pen and twisted needle on the end of the pen without cleaning rubber tip first with alcohol wipe. During an interview on 3/05/25 at 11:45 AM, Director of Nursing (DON) B reported would expect nurse to clean tip of insulin pen prior to attaching new needle every time.

Based on observation, interview and record review, the facility failed to maintain complete and accurate medical records for one (Resident #90) of 18 reviewed. Findings include: Review of the medical record reflected Resident #90 (R90) was admitted to the facility on [DATE], with diagnoses that included atrial fibrillation, retention of urine and urinary tract infection. R90's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/4/25, was in progress (not complete). On 03/03/25 at 9:56 AM, R90 was observed seated in a recliner, in their room. R90 reported they had open areas on their buttocks, since admitting to the facility. R90 believed cream and a bandage were being applied to the open areas. A Progress Note for 2/26/25 at 5:54 PM reflected R90 admitted from the hospital following a urinary tract infection and atrial fibrillation. Open areas were noted to R90's bilateral (both sides) buttocks, according to the note. The admission skin assessment for 2/26/25 reflected R90 had pressure ulcers to their bilateral buttocks. There was no further documentation pertaining to the pressure ulcers, including wound measurements, wound staging or wound characteristics. A Physician's Order with a start date of 2/26/25 reflected the open area on the bilateral buttocks was to be cleansed with normal saline and patted dry. Barrier cream was to be applied, then covered with a sacral dressing, every shift and as needed. In an interview on 03/04/25 at 3:52 PM, Licensed Practical Nurse (LPN) N reported being unsure of the appearance of R90's pressure ulcers, stating R90's treatment was not scheduled on their shift. Upon review of the treatment order, LPN N reported R90's treatment was for cream only. LPN N then identified the treatment order included application of a dressing. LPN N stated they had not yet performed R90's treatment that day. The March 2025 Treatment Administration Record (TAR) reflected R90's bilateral buttocks treatment was signed out as completed for the 6 AM to 6 PM shift on 3/4/25 by LPN N. The Medication Administration Audit Report reflected LPN N signed the treatment out as being completed on 3/4/25 at 8:24 AM. During an interview on 03/05/25 at 10:45 AM, Unit Manager (UM) P reported assessing R90's skin upon admission to the facility. UM P stated R90's pressure ulcer presented as a stage two (partial-thickness loss of skin, presenting as a shallow open ulcer) upon admission. UM P reported they assessed R90's pressure ulcer on 3/4/25, and it was healed. UM P reported when completing their weekly wound assessments, they compared their assessment from the week prior. A late entry Progress Note for 2/26/25, entered by UM P on 3/4/2025 reflected R90's buttocks was assessed upon admission to the facility. The note reflected there were peeling areas, open areas and several scattered, small open areas, which were in different stages of healing. According to the note, stage two pressure ulcers were present upon admission.

Based on interview and record review, the facility failed to provide a written notice of bed hold policy upon transfer for one (R92) of two reviewed. Findings include: Review of the medical record revealed R92 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, and multiple rib fractures. Review of the Health Status Note dated 12/31/24 revealed R92 was transferred to the emergency room for evaluation due to behaviors and refusals of care. R92 did not return to the facility. Review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/24 revealed R92 had an unplanned discharge with return not anticipated. The medical record did not indicate a written notice of bed hold policy was provided upon transfer. In an interview on 03/05/25 at 10:20 AM, Director of Nursing (DON) B reported they were not able to locate a written notice of bed hold policy upon transfer for R92.

Based on observation, interview, and record review the facility failed to ensure enteral nutrition was administered as ordered and weights were monitored for two (R33 and R41) of four reviewed. Findings include Resident #33 (R33) Review of the medical record revealed R33 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/3/24 revealed R33 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of Physician's Order dated 11/27/24 revealed an order for Jevity 1.5 cal (tube feeding formula) run at 55 milliliters (mL) per hour continuous via PEG tube (percutaneous endoscopic gastrostomy/feeding tube) for total of 1320 mL of formula per day. On 03/03/25 at 09:27 AM, R33 was observed lying in bed. An empty bottle of Jevity 1.5 cal was hanging from the tube feeding pump. The pump was off. At 9:43 AM, a new bottle of Jevity 1.5 cal was observed sitting on R33's nightstand. The empty bottle had been discarded. R33 did not have the tube feed formula running as ordered. At 10:23 AM, the new bottle was still on the nightstand and R33 did not have the tube feed formula running as ordered. On 03/03/25 at 11:41 AM, R33's Jevity 1.5 cal was started after not receiving the tube feed for over 2 hours. Review of the Weight Change Note dated 2/28/25 revealed R33's weight was 150.5 pounds which was a significant weight gain and was over R33's usual body weight of approximately 140 pounds. The note revealed new weight to be obtained for confirmation .Possible need for reduction to total formula pending confirmation of weight gain .Will reassess for quarterly next week and make updates. R33 did not have another weight obtained to confirm the significant weight gain. In an interview on 03/05/25 at 10:32 AM, Registered Dietitian (RD) E reported R33 receives enteral nutrition continuously and they were not aware of any reason as to why R33 would have not received their nutrition for over two hours on 3/3/25. RD E reported R33's last weight obtained was on 2/27/25. RD E reported they asked for a re-weigh which they would have expected to be obtained by now. RD E reported they were completing R33's quarterly evaluation today and would ask staff to weigh R33. In an interview on 03/05/25 at 11:22 AM, Director of Nursing (DON) B reported re-weights should be completed the same day or next day. Resident #41 (R41) Review of the medical record revealed R41 admitted to the facility on [DATE] and readmitted [DATE] with diagnoses that included dysphagia and moderate protein-calorie malnutrition. The Minimum Data Set (MDS) with an Assessment Reference date (ARD) of 11/23/24 revealed R41 scored 11 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and had a feeding tube. Review of the Physician's Order dated 10/8/24 revealed an order for monthly weights. R41's last documented weight was on 1/6/25 at 123.5 pounds. Review of the Physician's Order dated 12/31/24 revealed an order to run Jevity 1.5 cal at 70 mL per hour continuous for 16 hours for a total of 1120 mL of formula daily. The tube feeding was scheduled to begin each day at 6:00 PM and end at 10:00 AM. On 03/03/25 at 09:46 AM, R41 was observed in bed with a 1000 mL bottle of Jevity 1.5 cal hanging and running at 70 mL per hour. The bottle was not dated or timed. On 03/03/25 at 10:27 AM, R41's tube feeding pump indicated they had received 930 mL total of Jevity 1.5 cal. On 03/03/25 at 11:38 AM, R41 was observed awake in bed. The tube feeding was turned off. At this point, R41 would have received approximately 1010 mL of Jevity 1.5 cal which was not the ordered 1120 mL . On 03/04/25 at 09:23 AM, R41 was observed asleep in bed with a 1000 mL bottle of Jevity 1.5 cal running at 70 mL per hour. The bottle was dated 3/3/25 at 6:00 PM. The tube feeding pump reflected a total amount fed as 1820 mL, indicating the pump most likely was not reset when the tube feeding was started on 3/3/25 at 6:00 PM In an interview on 03/04/25 at 09:43 AM, Licensed Practical Nurse (LPN) F reported R41 started their tube feeding each day at 6:00 PM and then stopped the tube feeding the next morning at 10:00 AM. When asked about the total amount administered during that time, LPN F calculated the total to be 880 mL. When asked if the pump indicated the total milliliters administered, LPN F stated I don't think so. LPN F then entered R41's room to observe the pump. LPN F reported the pump indicated R41 had received 1858 mL and reported the pump must not have been reset when the tube feeding was started the prior evening. LPN F reported R41 was due to come off the tube feeding at this time. LPN F reported it appeared R41 had received approximately 820 mL because there was a little less than 200 mL left in the bottle that was dated 3/3/25 at 6:00 PM. LPN F reported R41 usually only received one bottle of Jevity 1.5, but they usually had to discard some when the tube feeding was disconnected each day at 10:00 AM. On 03/04/25 at 10:32 AM, LPN F reported R41 was taken off the tube feed already. LPN F reported they left the bottle hanging on R41's pump. The 1000 mL bottle of Jevity 1.5 cal was observed with approximately 180 mL left in the bottle. On 3/4/25 at 12:58 PM, R41's tube feeding bottle was still hanging with approximately 180 mL of formula left in the bottle. R41 did not receive the ordered 1120 mL of feeding formula. On 03/05/25 at 09:15 AM, R41 was observed asleep in bed. R41's tube feed was observed as a Jevity 1.5 cal 1000 mL bottle (33.8 ounces/1.05 quarts/1 liter) dated 3/4/25 at 6:00 PM. The tube feed was running at 70 mL/hour. According to the pump, the total administered at that time was 815 mL. In an interview on 03/05/25 at 09:17 AM, LPN F reported they usually turned off R41's tube feeding between 9:45 AM and 10:00 AM. LPN F reported at that time, R41 would have received just under 880 mL of tube feeding formula, which is what LPN F calculated as being needed. On 03/05/25 at 09:53 AM, LPN F reported they hung R41's tube feed formula on 3/4/25 at 6:00 PM and cleared the pump to zero. LPN F reported the tube feeding formula bottle hanging was the one that they personally hung on 3/4/25 at 6:00 PM. LPN F was observed turning off R41's tube feeding as scheduled for 10:00 AM. The pump was observed to have administered 861 mL of feeding formula. The feeding formula bottle had approximately 200-250 mL of formula remaining in the bottle. R41 did not receive the ordered 1120 mL of feeding formula. In an interview on 03/05/25 at 10:32 AM, RD E reported R41 should be weighed monthly and agreed the last documented weight for R41 was 1/6/25 at 123.5 pounds. RD E reported R41 was ordered to receive a total of 1120 mL of Jevity 1.5 cal over a period of 16 hours. RD E reported the facility previously had 1500 mL bottles of Jevity 1.5 cal, but if they were currently using the 1000 mL bottles, R41 would require a second bottle to receive the ordered total of 1120 mL. RD E went to R41's room and confirmed there was still approximately 200-250 mL of formula remaining in the bottle. On 03/05/25 at 10:44 AM, Jevity 1.5 cal was observed in the medication room. There were 1000 mL bottles available. LPN F reported they did not have 1500 mL bottles in the medication room.

Based on interview and record review, the facility failed to provide a written notice of transfer/discharge for one (R92) of two reviewed. Findings include: Review of the medical record revealed R92 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, and multiple rib fractures. Review of the Health Status Note dated 12/31/24 revealed R92 was transferred to the emergency room for evaluation due to behaviors and refusals of care. R92 did not return to the facility. Review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/24 revealed R92 had an unplanned discharge with return not anticipated. The medical record did not indicate a written notice of transfer/discharge was provided. In an interview on 03/05/25 at 10:20 AM, Director of Nursing (DON) B reported they were not able to locate a written notice of transfer/discharge for R92.

Based on observation, interview and record review, the facility failed to ensure monitoring of psychotropic medications was completed as ordered for one (Resident #74) of five reviewed. Findings include: Review of the medical record reflected Resident #74 (R74) admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included bipolar disorder, schizophrenia, anxiety disorder, other recurrent depressive disorders and bipolar type schizoaffective disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/9/25, reflected R74 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). A Physician's Order, dated 4/10/24, reflected orthostatic blood pressures (monitoring for blood pressure changes that occur when transitioning from lying down to standing) were to be obtained monthly for psychotropic medication monitoring. Further review of Physician's Orders reflected R74 routinely received Buspirone (medication used to treat anxiety), Venlafaxine (antidepressant medication) and Risperidone (antipsychotic medication). A Progress Note for 10/11/24 reflected R74's blood pressure was obtained while lying down, sitting and standing. A Progress Note for 12/11/25 reflected R74's blood pressures were obtained while lying down and after standing for one minute and two minutes. A Progress Note for 2/11/25 reflected R74's blood pressures were obtained while sitting down and while standing. The medical record was not reflective of orthostatic blood monitoring for 11/2024 or 1/2025. On 03/05/25 at 1:39 PM, a request was made for R74's orthostatic blood pressures for the previous six months. During an interview on 03/05/25 at 1:55 PM, Director of Nursing (DON) B reported there was documentation of R74's blood pressures but not while lying, sitting and standing. DON B reported R74 was able to stand, but it was possible they were refusing to stand (for blood pressures). DON B stated there was no documentation of refusals. On 03/05/25 at 2:10 PM, DON B reported they located orthostatic blood pressures for 10/11/24 and 12/11/24 but were not able to locate any additional. DON B reported the purpose of orthostatic blood pressures was for medication monitoring.

This citation pertains to intake number MI00149135. Based on observation, interview, and record review the facility failed to ensure for one out of three residents (Resident #1) proper and safe transfer with an assistive device was conducted resulting in harm to the resident. Findings Included: Review of Resident #1's (R1) electronic medical record (EMR) revealed R1's had resided at the facility since 2013; Diagnosis included multiple sclerosis and muscle weakness. Review of a progress note dated [DATE], revealed R1 had a fall. The note revealed R1 was noted to be on the floor with her back to the bed, and the assistive device (sit to stand-a device that lifts a person from a sitting to a standing position) in front of her. The note revealed that R1 made a statement that her legs gave out. This was noted in the note to have occurred while the sit to stand was in use on R1. Further review of R1's progress notes revealed that on [DATE] at R1 had complained of pain to both lower legs. The note revealed R1's pain was more so in the right hip and knee so the Physician was notified, and X-rays were ordered. Review of the X-rays dated [DATE], revealed R1 had a fracture to the top area of the right femur (top leg bone). R1's progress notes dated [DATE], revealed R1 was transferred to the hospital related to the right femur fracture. Continued review of R1's progress notes revealed R1 returned to the facility on [DATE] with a surgical incision to her right hip. Review of progress notes revealed that on [DATE], the Interdisciplinary Team (IDT) documented the circumstances of R1's fall on [DATE]. The notes revealed R1 was seated on the edge of the bed, the lift (assistive device) had been lowered to the mattress. Staff were disconnection R1 from the lift after R1 had been placed on the bed, R1 was not able to follow directions, and would not let go of the lift handle bars after being seated, staff had attempted to assist R1 to remain safely on the bed but had to lower R1 to the floor. The note did not document a reason R1 had to be lowered to the floor instead of being assisted to scoot back onto the bed. The note also revealed R1 was sent to the hospital due to a fracture. Review of a documented interview with Nurse Aid (NA) C and D dated [DATE], that was not signed but provided by Nursing Home Administrator (NHA) A, revealed R1 was transferred with a sit to stand lift, placed on the bed, the lift belt was disconnected, R1 was at the edge of the bed, R1 was directed to let go of the lift bars so NA C and D could move R1 back further onto the bed, but R1 would not let go so R1 started to slide off the bed, which caused NA C and D to grab onto the lift belt and lower R1 to the floor. In an interview on [DATE] at 2:35 PM, NA D stated that she and NA C were transferring R1 from wheelchair to bed with a sit to stand device. NA D said the sit to stand device was R1's personal sit to stand that R1 owned. NA D said the battery to the sit to stand died so NA C left R1's room to find another battery, but when NA C returned she was not able to find another battery. NA D said the battery had worked fine when her and NA C had taken R1 to the bathroom, but said on the way back the battery stopped working once they got R1 to the bed. NA D stated that there was no indicator on the lift that showed the amount of battery power left in the battery. NA D said she was not able to hold R1 up any longer by herself so when NA C returned from looking for a battery the two of them guided R1 to the floor. NA D said she was the only one in R1's room when NA C left to get another battery that was why she could not hold R1 up by herself any longer. In an interview and observation on [DATE] at 3:10 PM, R1 stated that she did not really recall the fall, but was aware that she had a fracture to her right femur. While in R1's room a sit to stand was observed to be in her room, and had a label that had her name typed on it. Two batteries were also observed with R1's name on them. One battery was in place on the charger, and the other on the floor next to it. A battery that did not match the two batteries was observed to be plugged into the lift. In an interview on [DATE] at 2:04 PM, NA C stated R1 was sit to stand lift for transfers. NA C said her and NA D were transferring R1 from her wheelchair to the bed when R1 said her legs were giving out. NA C said they were able to get R1 to the bed, but R1 was only sitting on the edge of the bed, they removed the lift straps from the lift, but stated R1 would not let go of the bars on the lift. NA C said she tried to scoot R1 back onto the bed further, but stated that herself and NA D had not placed a gait belt (belt that goes around the waist for staff to hold onto for guidance and safety of the resident) on R1, and R1 would not let go of the lift bars so her and NA D had to lower R1 to the floor. NA C stated that she was supposed to have placed a gait belt on R1 prior to transferring R1. In a further interview NA C stated she had left R1's room when R1 was up in the lift at the bed to find another battery because the one in the lift had died . NA C said when the battery died the lift lowered to approximately one inch above the bed mattress. NA C said she got another battery then her and NA D lower R1 to the floor. NA C stated that she did not believe there was a battery indicator on R1's sit to stand lift. NA C: said that was the first time she had ever used R1's sit to stand lift. In an observation with NA C at 2:25 PM on [DATE] of R1's room, R1's lift was not in the room at the time. The battery charger and the extra battery were in the room. NA C stated that neither herself nor NA D knew that those were the batteries for R1's sit to stand lift, but knew they were there, just did not know what they were. NA C said that when she left R1's room to get a battery, R1 was standing up in the sit to stand until she returned and changed the battery, but by that time said R1's legs had given out so her and NA D guided R1 to the floor. NA C was asked if the window that was observed underneath the battery on the lift, which showed rectangular bars, was the battery power indicator window, NA C said no she did not think so nor did she know. NA C was not able to identify how to know when the battery needed to be changed on the lift prior to the battery running out of power completely. In an interview on [DATE] at 1:35 PM, Licensed Practical Nurse (LPN) E stated she was called to R1's room by NA D, and she got there she saw NA C standing next to the sit to stand, and R1 was on the floor. NA C or D told me the battery had dead, and neither of them seemed to know there were two batteries in R1's room, LPN E said she asked both NA C and D where the gait belt was and why there was not gait belt on R1. LPN E said she was livid, and both NA C and D had just been trained on the use of lifts, and said she scolded them for not using a gait belt. In an interview and observation on [DATE] at 3:18 PM, Certified Nurse Aid (CNA) F stated that all the sit to stands and hoyers lifts (full lifts) had a window that show the battery life that remained in the battery. R1's lift was observed with CNA F, and CNA F stated that the battery indicator window was the window with the bars which was right underneath the battery. Record review of a care plan with a Focus of ADL (activities of daily living)-I (R1) have impaired mobility r/t (related to) my dx (diagnosis) of MS (multiple sclerosis) and dementia. The care plan was initiated on [DATE] and revised on [DATE]. The care plan included an intervention for R1 to have, TRANSFERS: EZ Stand (sit to stand) with assist x3 (3 person to assist with transfer) . This intervention was dated [DATE], and was not resolved nor canceled therefore the intervention remained active. Review of the CNA Kardex (a document that list how to care for a resident that a CNA uses) revealed under the Transfers section, TRANSFERS: EZ Stand with assist x3 .

This citation pertains to MI00147519 Based on observation, interview and record review, the facility failed to initiate new interventions to prevent falls for one resident (Resident #4) of two reviewed for falls, from a total sample of 5, resulting in continued falls and hospitalization for major injury. Findings include: Resident #4 (R4) Review of the medical record reflected R4 was an initial admission to the facility on [DATE]. Diagnoses of [NAME] Matter Disease, Dementia with behavioral disturbance, Anxiety, Delusional Disorder, Restlessness and Agitation, Muscle Weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/09/2024, revealed R4 had a Brief Interview of Mental Status (BIMS) of 06 (severe cognitive impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R4 requires substantial assistance with personal care. During an interview and observation on 10/18/24 at 11:46 AM, R4 was sleeping in his bed fully dressed, hair was matted, face was scruffy from not being shaved. Noted the call light was out of reach for him, water glass on the over the bed table was room temperature with no date or time on the cup. Writer tried waking R4 up with verbal stimulation and tactile, he opened his eyes and then went back to sleep. During an interview and observation on 10/18/24 at 1:34 PM, Licensed Practical Nurse (LPN) O stated R4 was safe sitting in his wheelchair with an alarm under him. Writer observed R4 sitting in his wheelchair sitting in the hallway. Writer asked LPN O who provides the one-on-one supervision as documented in the progress notes. LPN O stated she didn't know they provided that because they do not have enough staff to provide that. Writer asked when R4 had his last shower, LPN O stated on 10/14/24, and blamed R4's behaviors made it hard to provide. Writer asked LPN O what other interventions they had tried to get him to take a shower. LPN O stated they just left him alone for a while and then try again. Writer asked if R4 would be getting a shower today as he appeared dirty. LPN O stated I am sure the CNA washed him up this morning. During an interview on 10/22/24 at 1:08PM, Social Worker (SW) L stated with R4's falls, they met every week to review falls and go over the interventions in place. SW L also stated they had him on psych services and increased the involvement of activities. Also stated R4 was in the military service and the sound of alarms increases his anxiety. SW L stated that the family of R4 are the ones who initiated the discharge planning process. SW L also stated that the family were upset that R4 had had so many falls at this facility. SW L also added that the facility did not have enough staff to be with him 24/7 to watch him. SW L stated that the staff did every 15 minutes checks on him and periods of one on one, and ensuring the alarms were on him and working well and continued to observe. Writer asked who provided the one-on-one for him, SW L stated to check with the Director of Nursing (DON) B as SW L did not provide that. SW L stated that nursing was the discipline that addresses falls, and she only addressed cognition. Record review of activity log for one-on-one visits, revealed no interactions for the last 30 days. During an interview on 10/22/24 at 1:38 PM, DON B was asked who puts interventions in place following a fall. DON B stated the reason the writer could not see them is because the family was not on board. DON B then stated they were using alarms, offering snacks, brought down to the nurse's station, brought out in the day room, was very common for them, not specific. DON B stated she talked to the family of R4 about his anxiety and was not in agreement to psych medications. DON B also stated that care conferences were not productive as family would yell at them and hang up the phone on them. DON B added that several suggestions, but family did not want them. Writer asked for documentation of the suggestions and where family refused. DON B was looking for documentation in the medical record that family were not in agreement to the suggestions. DON B was unable to find any, she stated she thought Unit Manager J put them in her notes. During the phone call from DON B to Unit Manager J, stated the last care conference on 08/29/24 did not include any documentation that family were in agreement or not in agreement with suggestions. Unit Manager J came into DON B office. Writer asked for the care conference notes for 10/10/24. DON B provided the documentation which showed that social work section was the only section completed, nursing did not have anything documented, area was blank. Writer asked for the 15-minute check log for R4, Unit Manager J stated she had paper copies and went to get them. Writer asked DON B for the one-on-one log as it was documented they would provide if R4 got anxious or restless. DON B stated they would have someone watching him, not like a 24/7 thing, staff just knew if R4 got anxious, like taking him to the nursing station, have staff follow him around, but it wasn't documented or tracked. Unit Manager J provided the 15-minute checks log. The 15 minutes checks were from the date 10/19/24 at 15:45 (3:45 PM) through 10/19/24 at 2000 (8:00 PM). The 15 minutes started back up on 10/20/24 at 6:00 AM until R4 was hospitalized on [DATE] at 1530 (3:30 PM). No 15-minute checks following any of the other falls. Writer asked DON B again about not updating the care plan with new interventions or revisions following each fall. DON B stated the fall on 10/12/24, alarm was alerting them, but they could not get to him in time to prevent the fall. Unit Manger J stated it was her responsibility to update the care plans. Unit Manager J also stated she didn't have anything more to put on it. Writer asked DON B and Unit Manager J why there wasn't anything added to the fall section on the care plan or Kardex since admission of 07/05/24, no response. During an interview on 10/23/24 at 0800 AM via email to DON B requested to see the incident reports on the falls for R4 since admission in July 2024. Record review revealed that the incident reports for the falls on R4 included 8 separate falls from 07/19/24 through 10/19/24 which resulted in a hospitalization with a femur fracture. Fall on 07/19/24 at 18:45 PM, R4 found sitting on the floor beside his recliner, no injuries. Fall on 08/30/24 at 03:30 AM, R4 found sitting on the floor on buttocks in his room leaning up against the bathroom door. Bed alarm was alerting, staff did not get there in time to prevent the fall. Fall on 09/22/24 at 20:20 PM, R4 got out of bed, bed alarm was alerting, he was walking to the bathroom, was assisted by CNA to the toilet, CNA stepped out and R4 slid off the toilet. Found in a seated position in front of the toilet. Fall on 09/30/24 at 00:19 AM, fell to the floor,skin tear to the right knee. Fall on 10/9/24 at 21:41 PM, R4 became aggressive towards staff and lost balance and fell on to his knees. Fall on 10/12/24 at 14:36 PM, fell to the floor and hit his head on the floor resulting in a small lump forming to the right side of his head. Fall on 10/13/24 at 01:58 AM, fell to the floor, hit his forehead, was bleeding, R4 was unable to give a pain level, sent out to emergency department. Fall on 10/19/24 at 03:53 AM, fell to the floor in front of his bed, bed alarm did not alert staff that R4 got out of bed, wheelchair was beside R4 with the brakes unlocked. Record review revealed on 10/19/24 at 10:30 AM, R4 complained of left hip/femur pain, not able to lift left leg, would cry out when the left leg was moved. R4 sent out to emergency department for X-rays. Review of the X-ray results, R4 did not get his left hip or femur X-rayed, only head to lower spine was X-rayed. On 10/21/24 at 10:47 AM, R4 was still complaining of pain in his left hip/leg. On 10/21/24 at 12:35 PM, Nurse Practitioner (NP) Q assessed R4, ordered a stat X-ray of his left hip, pelvis and femur. On 10/21/24 at 15:28 PM, Stat X-ray results for R4's left hip, pelvis and femur came back with R4 having a left subcapital fracture (neck of femur fracture) and fracture involving the left proximal femur (break in the upper quarter of the thighbone, near the hip joint). R4 was sent to the hospital and admitted with a hip fracture. Record review revealed the care plan for falls, were not updated with any changes or additions to the interventions after these 8 falls. Record review did not reveal any changes to R4's care plan, Kardex or task sheet in effort to prevent these falls from admitted [DATE] to being hospitalized for fractures on 10/21/24.

Based on observation, interview and record review the facility failed to: 1) accurately assess, monitor and prevent the development and worsening of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; 2) follow physician orders including wound treatment orders; 3) implement care-planned and non-care-planned interventions; and 4) ensure that those interventions were functional and in place for nine residents (R5, R13, R22, R24, R28, R39, R43, R47, and R218) reviewed for pressure ulcers, from a total sample of 16 residents, resulting in an Immediate Jeopardy, beginning on 03/30/23 when facility staff did not follow facility policy and procedure or physician's orders for pressure ulcer prevention and/or treatment. This deficient practice resulted in worsening of pressure wounds. Additionally, this deficient practice placed all residents residing in the facility at risk for the development of avoidable pressure ulcers, the delay in wound treatment, the potential for delayed wound healing, infection, and the high likelihood for overall deterioration in health status. Findings include: Review of the facility, Pressure Injury Prevention Guidelines, dated 02/19/20, reviewed on 11/08/22, reflected, Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Policy explanation and compliance guidelines: 1) Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessments (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 2) The goal and preferences of the resident and/or authorized representative will be included in the plan of care. 3) Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. 4) Prevention devices will be utilized in accordance with manufacturer recommendations (e.g., heel floatation devices, cushions, mattresses). 5) Guidelines for prevention may be utilized in obtaining physician orders. a. The guidelines are to be used to assist in treatment decision making. b. Due to the unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. c. When physician orders are present, the facility will follow the specific physician orders. 6) Interventions will be documented in the care plan and communicated to all relevant staff. 7) Compliance with interventions will be documented in the medical record. a. For at-risk residents: Treatment or medication administration records. b. For residents who have a pressure ulcer present: treatment or medication administration records; weekly wound summary charting. 8) The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a. Development of a new pressure injury. b. Lack of progression towards healing or changes to the wound characteristics. c. Changes in the resident's goals and preferences, such as end of life or in accordance with his/her rights. Preventive Skin Care 1) Inspect skin while providing care, paying close attention to bony prominences. 2) Inspect skin underneath medical devices at least twice daily. Keep skin clean and dry underneath . 3) Avoid positioning the resident on an area of redness whenever possible. 4) Keep the skin clean and dry . 5) Use positioning devices or folded linens to keep body surfaces from rubbing against one another. Nutrition/Hydration: 1) Consult dietician for nutritional screen for each resident who is at risk for a pressure injury or has a pressure injury present. 2) Develop an individualized nutrition care plan for each resident with or at risk for a pressure injury, considering the recommendations made by the dietician. Repositioning: 1) Reposition all residents at risk of, or with existing pressure injuries, unless contraindicated due to medical condition. Utilize small shifts in repositioning, if otherwise contraindicated. 2) Routinely and frequently reposition, using both side-lying and back positions. Reposition when in bed, and out of bed . 3) Considerations for alternative repositioning schedule . 4) Teach residents to do pressure relief lefts or other pressure relieving maneuvers as appropriate. 5) Repositioning techniques: a. Avoid positioning the resident on bony prominences/turning surfaces with existing pressure injuries, including stage 1. b. Utilize left sheet or pads to reduce shear force. Avoid dragging the resident when repositioning. c. Limit head of bed to 30 degrees, if not contraindicated. d. When floating heels, ensure heels are floated off the surface of the bed, using pillows or devices to elevate and offload the heel . e. Minimize seating time/out of bedtime to promote ischial and sacral wound healing. Pressure Relieving Devices: 1) Support surfaces do not eliminate the need for turning and repositioning. 2) Pillows and wedges may be utilized to maintain proper positioning. 3) Apply heel suspension devices according to the manufacturer's instructions. a. For prevention, stage 1 or stage 2: Use pillows or heel suspension devices . 4) For stage 3, 4, unstageable or deep tissue injury: Place foot and leg into a heel suspension boot that elevates the heel from the surface of the bed, completely offloading the pressure injury . The standard mattress for all facility beds are pressure redistribution mattresses (i.e. high specification reactive foam). 5) The standard seat cushion for wheelchairs are pressure redistributions seat cushions. 6) Provide alternative support surfaces as needed. Considerations for utilizing specialized support surface. a. Cannot be positioned off existing pressure injury. b. Has pressure injuries on two or more turning surfaces (e.g. the sacrum and trochanter) that limit turning options. c. Failure to heal or deterioration in wound status despite appropriate comprehensive care. d. Stage 3, 4, unstageable or deep tissue injury on trunk . Resident #24 (R24) Review of the medical record reflected R24 was an initial admission to the facility on [DATE], then admitted to hospice on 11/5/21. Diagnoses of Transient Cerebral Ischemic Attack (CVA), Dysphagia (difficulty swallowing), Vascular Dementia, anxiety, Depression, weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/06/2023, revealed R24 had a Brief Interview of Mental Status (BIMS) of 03 (severe impairment) out of 15. Under section G0110, Activities of Daily Living (ADL) Assistance reveals R24 is dependent on all care provided. Under section M0100. Determination of Pressure Ulcer/Injury Risk, section A revealed R24 did not have a pressure injury. Section B, R24 was assessed is at risk for developing them. During an interview on 03/28/23 at 12:22 PM, Licensed Practical Nurse (LPN) M stated R24 received wound care on scheduled shower days, Monday and Thursdays. LPN M Also stated the hospice CNAs provided the showers then would let us know when they were done, and nursing would provide wound care to the pressure ulcer. During record review on 03/28/23, revealed a physician's order to apply barrier cream to coccyx every shift and as needed for skin integrity dated 03/25/23. Place protective dressing to right hip for protection. Assess for any open areas. Reviewed physician orders dated 12/29/22, Change every 3 days, every day shift every 3 day(s) and as needed for loose, soiled or saturated dressing. Nurse to assess skin on the first shower of the week. Record review of hospice care plan and monthly schedule, hospice CNAs provide R24 bathes. Electronic medical record (EMR) revealed no weekly skin assessments were completed to assess the wound measurements, characteristics, tunneling, and any changes in dressing treatments with changes in the size of pressure ulcers. Interview and observation on 03/29/23 at 10:47 AM, CNA N was providing Am care. Long pillow was placed under the bottom sheet along the outer edge of the bed to prevent from rolling out of bed. Bowel movement present, CNA N cleaned the area up, the dressing over coccyx was soiled with stool, CNA N pushed the call light for the nurse to perform wound care. Unit manager/ LPN O came into R24 room, she washed the wound bed and surrounding area. Applied a barrier cream over the wound as well as the surrounding areas. LPN O did not put a dressing back over the wound, she stated the regular nurse was on break so she would finish up the dressing when she comes back. Observation of one pressure ulcer open area in the coccyx, size of a quarter covered with slough (white layer of dead skin), additionally two small areas under the coccyx were scabbed over, approximately the size of a dime. Review of the care plan was not updated to include open pressure ulcer wounds on 03/29/23. Original care plan in place dated 07/19/19, documented that R24 had the potential for skin breakdown. During an interview on 03/29/23 at 03:37 PM, DON B stated the pressure ulcers interventions should include a gel cushion in wheelchair, low air loss mattress. When asked about current dressing change order, DON B stated current physician order discontinued on 3/25/23, and new physician order of barrier cream only to area on 03/25/23. Asked DON B if there was a nursing progress note to clarify healing of pressure ulcer to discontinue physicians' orders prior to 03/25/23, in which DON B stated no. DON B stated it didn't look like a weekly skin assessment was documentation at the time the wound care order was discontinued. DON B reviewed R24 care plan and noted the care plan was not updated to include open wounds. During an interview on 03/30/23 at 01:50 PM, Minimum Data Set (MDS) Coordinator V, in regard to MDS assessments. MDS V stated that the pressure ulcers might have not been present during the two weeks look back time if it was not open wound, she would not have coded skin alteration. MDS Coordinator V also stated, it was about what happened in the last 2 weeks and would not change the assessment reference date (ARD) date to reflect changes in skin condition. Record review of the nursing progress note dated 10/26/22 revealed R24 had a pressure ulcer measuring 1.3cm x 1.0cm x no depth noted. Peri-area pink with minimum to no drainage noted on dressing. Wound bed showed some areas that had scabbed appearing in the middle bed. Some pink tissue noted in other areas. Assessments and dressing change would continue, orders were updated to reflect any changes. This progress note did not reveal where this wound was located on the body and staging of this pressure ulcer. Record review of nursing progress notes dated 11/04/22 at 15:55PM (3:55PM) revealed an open area on the right hip measuring 1.5cm x 2.5cm with no depth reported. Also reflected wound bed had slough firmly adhered to wound bed. Small amount of drainage on dressing in note. Description of wound did not include staging or treatment for slough in the wound bed. Record review of nursing progress note dated 11/06/23 at 9:16 AM revealed an open area on coccyx at the apex of R24 buttocks. Measurements of open area 1.0cm x 0.4cm x 0.1. Nursing note did not include staging, description of the wound or treatment that would be used. Record review of R24, MDS assessment, section M0300 dated 11/10/22, did show alterations in skin, pressure ulcers or open areas. Identified one pressure ulcer stage 2 with no slough. Also revealed R24 had a pressure reducing device for her bed but was not on a turning schedule. Record review of skin/wound note dated 11/11/22 at 11:38 AM revealed assessment of two pressure ulcers. Coccyx pressure ulcer measured 0.5cm x 0.3cm with no depth. Right hip pressure ulcer measurements of 2.0cm x 1.0cm with no depth. Wound bed had varied white/pink areas throughout. Note did not include staging, identification of white tissue as slough or ordered treatment. Record review of health status note dated 11/15/22 at 15:46 (3:46 PM) revealed an open area to the coccyx and a suspected deep tissue injury to the left buttocks measuring 3.0cm x 1.0cm, did not document if depth was present, nor was staged. Note revealed a barrier cream was applied to the open areas and buttock. Record review of a skin/wound note dated 11/18/22 at 12:30 PM revealed open area on the right hip measured 2.0cm x 1.5cm with no depth documented. Wound based described with pink and white tissue, no staging included. Coccyx wound measuring 1.0cm x 0.8cm, no depth documented. Wound bed was pink. Note included that new wound care orders. Review of Physician orders dated 11/18/22, did not reflect new wound care orders. Record review of skin/wound note dated 12/02/22 at 11:00AM revealed open area measuring 1.2cm x 0.7cm with no depth documented. Included the top area of the wound remains with slough. Location of this wound was not documented. Continued treatment of barrier cream on this wound. Further in the note, revealed the coccyx wound was closed, no longer an open wound. Record review of skin/wound note dated 12/09/22 at 15:04 (3:04PM) revealed right hip open area measured1.0cm x 0.5cm, no depth documented. Wound bed covered pink and white tissue. No change in treatment noted. No staging documented to include white tissue slough. Record review of skin/wound note dated 12/16/22 at 11:50AM revealed right hip wound is partially healed in the middle, now leaving two open areas. Top open area measured 0.5cm x 0.7cm, no depth documented. Bottom open area measured 0.5cm x 0.5cm, no depth documented. No staging documented. No treatment noted. Record review of skin/wound note dated 12/29/22 at 10:30AM revealed one area is scabbed over, 0.5cm x 0.5cm. No location identified of this wound. No staging noted. Record review of physician's orders dated 12/29/22. Place protective dressing to right hip for protection. Assess for any open areas. Change every 3 days. Record review of skin/wound note dated 02/10/23 at 9:31AM revealed coccyx, gluteal, left and right hip are clear of any skin impairment. Record review reflected MDS assessment section M0300 dated 02/06/23 did not show any alterations in skin, pressure ulcers or open areas. Section M1200 revealed a pressure reducing device for the chair and the bed. No turning/repositioning program. Record review of nursing progress note dated 03/20/23 at 17:02 (5:02) revealed an open area on the coccyx measuring 0.6cm x 0.4cm x 0.3cm. No staging documented. Treatment was to clean area with normal saline and apply a piece of calcium alginate then cover with proximal dressing. Change every other day and as needed. Record review of physician orders on 03/20/23, did not reflect a physician order written for treatment of clean area with normal saline and apply a piece of calcium alginate then cover with proximal dressing. Change every other day and as needed. Manufactures instruction for use of calcium alginate indicates this dressing should be used on moderate to heavy exudative wounds. Dry wounds should not be treated with this product. This dressing is also designed to stay on the wound bed for 5-7 days, not to be changed every other day. Also noted this treatment was for stage 3 and above. Record review of physician's orders dated 04/03/23 at 6:00AM, Cleanse coccyx and pinpoint open area just below coccyx with soap and water, pat dry, apply calcium alginate to wound bed only, then cover with proximal. Change every day and PRN. Record review of the care plan for R24, the focus on skin integrity was initiated on 07/19/2019, revision on 11/04/22. Goal was to keep R24 skin intact and free of pressure ulcers/injuries and other skin impairments dated 07/19/2019, revision on 02/02/2022 and revision on 03/30/23. Interventions were put in place on 07/19/2019, however no intervention after 07/19/19. On 3/30/23 at 4:30 PM, DON B was notified of the Immediate Jeopardy that was identified on 3/30/23 due to the facility's failure to accurately assess, monitor and prevent the development and worsening of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; On 04/03/23 it was verified that the facility implemented the following to remove the Immediate Jeopardy: 1. Total of 63 current residents had a Skin Assessment conducted by Director of Nursing and/or designee on 04/03/2023. 2. Skin assessments were compared to current orders and treatments and validated as appropriate on 04/03/2023. 3. Total of 7 current residents with pressure wounds have validated appropriate orders and treatment plans are in place as of 04/03/2023. 4. Immediate education with licensed nurses and certified nursing assistants on skin effective 04/03/2023 on Pressure Injury Prevention and Management policy, to ensure new wounds, including admissions, have been assessed to include orders and care plans by Staff Development Coordinator and MDS Coordinator. Nurses were provided education on new policy on notification of skin impairment and reviewed policy on pressure injury prevention guidelines, documentation of wound treatment, and wound treatment management on 03/31/23. Any licensed nurse not completing education will be educated prior to next scheduled shift. Certified nursing assistants were educated on notification of skin impairment. Any CNA not completing education will be educated prior to next scheduled shift. CNAs were re-educated by Staff Development Coordinator on Routine Resident Checks policy. Education includes reporting changes in the resident's condition and medical needs that cannot be performed by the person conducting the routine check must be reported to the Nurse Supervisor/Charge Nurse at once. 5. Effective 03/31/2023, new wound care policy developed on notification of skin impairment. Continue using the policy on pressure injury prevention guidelines, documentation of wound treatment and wound treatment management. Although the Immediate Jeopardy was removed on 04/03/23, the facility remained out of compliance at a scope of widespread and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency. 30337 Resident #13 (R13) On 3/28/23 at 9:00 AM, R13 was observed sitting in a recliner chair in her room eating breakfast, wearing blue socks on both feet. R13's Minimum Data Set (MDS) assessment dated [DATE] introduced a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score of 15 (13-15 cognitively intact). The same MDS indicated R13 required extensive assistance (staff provided weight bearing support) in bed mobility, was at risk for pressure ulcers, had a Stage 2 pressure ulcer (partial thickness loss of dermis [inner layer of the two main layers of the skin] presenting as a shallow open ulcer with a red-pink wound bed, without slough [Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed.] or bruising) that was facility acquired, and a turning/re-positioning program (specific frequency for changing position) was not implemented. R13's medical record revealed she had the diagnoses of heart failure, depression, high blood pressure, and chronic kidney disease. Progress Note dated 1/16/23 at 7:41 PM indicated R13 denied pain except with ambulation. R13 had plus 2 edema (swelling assessed by pressure to area and rebound time, plus 2 was 3 to 4 millimeters of depression, rebounding in 15 seconds or less) to right lower leg-chronic per resident from previous injury. In review of R13's care plan, there were no interventions to elevate feet due to swelling or to float her heels. Progress Note dated 1/22/23 at 3:33 PM indicated two wounds were noted on R13's right foot. The lateral foot ulcer measured. 2 centimeters (cm) by 2 cm, had a red wound base with blanchable redness surrounding the wound. R13's heel ulcer measured 1.5 cm by 1 cm with a small amount of bleeding. The same note did not include the stage of the pressure ulcer. In review of R13's care plans, there was no care plan that indicated she had a pressure ulcer or actual impaired skin integrity. 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. R13's progress note dated 1/23/23 at 9:15 AM indicated her right heel had an open area on the right side of the heel that measured 1.0 cm in diameter. The edges were slightly macerated, wound bed was pink. Wound was draining small to moderate amounts of serous (clear to pale yellow, watery) fluid. R13 stated she did not bump her foot or rub her foot in her bed. R13 stated her right ankle was always swollen since she fell and fractured it. R13's right ankle had some edema present compared to the left foot. The same note indicated R13 sat in her recliner chair with her feet elevated, and was observed turning her right foot slightly to the side, lying on the area that was now open. In review of R13's risk for impaired skin integrity care plan dated 6/07/21 indicated to wear a green boot to right foot at all times, may remove with ambulation; was initiated on 1/27/23, 5 days after wounds were noted. R13's March 2023 treatment record revealed a green boot to the right foot was to be on at all times, may take off when ambulating and for personal hygiene was initiated on 1/27/23. Documentation that R13's green boot was in place was to be documented every AM and PM. There were 6 holes in R13's March 2023 treatment record that the boot was verified in place in the AM on 3/01/23, 3/05/23, and 3/29/23; and in the PM on 3/02/23, 3/10/23 and 3/24/23. Progress note dated 3/03/23 at 3:45 PM indicated R13's right heel pressure ulcer was 1.7 cm by 2.5 cm with no depth. Peri-wound is less. Wound bed was starting to scab over. R13's foot/ankle was slightly swollen. R13 continued with green heel lift boots when in chair, wheel and recliner for protection. The next progress note related to R13's pressure ulcer was not until 18 days later, on 3/16/23 at 4:00 PM. R13's Progress Note dated 3/26/23 at 6:14 PM indicated pressure ulcer had a black color around the wound that looked like necrotic tissue. The same note indicated R13 stated that her daughter had been attending to her foot and putting an ointment on the area that was black in color and R13 was advised to not treat pressure ulcer without permission from her physician. On 3/29/23 at 2:09 PM R13 was observed sitting in her recliner chair waiting for treatment to her pressure ulcer on her right heel. R13 stated her foot hurt when she walked or if someone touched her heel, edema was noted on top of the right foot with a pinpoint area of bleeding on top of her foot near her second toe. R13 stated she was concerned that there was blood on top of her foot. Licensed Practical Nurse (LPN) X placed paper towel on floor and placed clean dressing supplies on top of the paper towel. LPN X placed gloves on the paper towel. Fingers of the gloves had touched the carpet. R13's pressure ulcer was observed with a pink wound bed surrounded by tissue that was black in color and firmly attached. Director of Nursing (DON) B was interviewed on 3/29/23 at 4:40 PM and stated R13's pressure ulcer was first noted on 1/22/23 and was a stage 2 at that time. DON B stated she wasn't aware R13 did not have an impaired skin integrity care plan. DON B stated in the same interview it was not acceptable to set up dressing change supplies on the floor. DON B stated she did not have an answer as to why wound documentation in the progress notes did not include stage of the pressure ulcer. On 4/04/23 at 10:00 AM, R13 was observed sitting in recliner wearing socks. R13 was not observed wearing a green boot on her right foot. Resident #28 (R28) R28's MDS assessment dated [DATE] revealed a BIMS score of 14 (13-15 Cognitively intact); and she had 3 unstageable (wound bed covered with slough and/eschar [Dead or devitalized tissue that was hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound] pressure ulcers that were facility acquired. R28 did not have a turning/repositioning program in place. R28's previous MDS assessment dated [DATE] indicated she was at risk for pressure ulcers. In review of R28's care plan, there were no care plans that indicated she had pressure ulcers. R28's potential for impaired skin integrity care plan dated 06/23/17 indicated risk was due to impaired mobility, history of stroke with left-sided weakness, and use of brace on her left leg. R28's same care plan revealed her goal was for skin to remain intact through 4/09/23. The same care plan indicated an intervention initiated on 6/23/17, to encourage R28 to wear proper footwear/ordered brace, to observe skin under brace, and to report changes to the nurse. Progress Note dated 12/01/22 at 1:53 PM indicated on 11/29/22 R28's left foot was noted to have an area of black eschar to the top of the 5th toe on her left foot that measured 1.0 centimeter (cm) by 1.3 cm, was also noted to have an area on the bottom left side of her left foot to be a suspected deep tissue injury (Purple or maroon area of discolored intact skin due to damage of underlying soft tissue, may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue) that was deep red in color measuring 5.0 cm by 4 cm; within that area there was an area of black/brown eschar tissue that measured 2.5 cm by 1.8 cm. R28 was also noted with raised area pink and blanchable in color to the top of her left big toe measuring 0.8 cm by 0.5 cm. Plan was R28 would be a Hoyer lift (total lift) for all of her transfers, not wear her tennis shoes as the areas of pressure are where her shoes and foot/leg brace made contact with her foot. In review of R28's care plans, there were no updates indicating not to not wear the brace until pressure ulcers were resolved. Occupational Therapy (OT) Discharge Summary, date of service 11/21/22 to 12/05/22, indicated on 12/04/22 R28 was not wearing knee ankle foot orthosis (used to compensate for lower limb instability) due to wound on left great toe and foot. R28 was discharged from therapy on 12/05/22 and a new orthosis was ordered. In review of progress notes, R28's pressure ulcers were not documented on between 11/30/22 and 1/16/23. R28's Braden Scale- Predication of Pressure Sore Risk assessment dated [DATE] at 1:50 PM indicated her risk score was 14 (total score of 13 to 14 indicated mild risk for pressure ulcer development). R28's progress note dated 1/17/23 at 3:30 PM revealed left foot and toes had area of black eschar to the top of the 5th toe on left foot measured 1.0 cm by 0.8 cm, the area to the bottom left side of the left foot had an area of eschar that measured 2.8 cm by 1.5 cm the suspected deep tissue injury that previously surrounded the area of eschar had resolved. The area to the top of the left big toe continued to be reddened and blanchable measuring 0.7 cm by 0.5 cm. R28 denied pain or discomfort to areas, continued to utilize a total lift for all of her transfers. The same note indicated R28 was not wearing shoes or her brace at that time to prevent any additional pressure to areas. In review of R28's progress notes, it was not clear the blanchable reddened area to the top of the left big toe was coded on the 1/11/23 MDS assessment as Unstageable due to slough/eschar. In review of R28's November 2022 Treatment Administration Record, physician orders dated 11/29/22 at 1:34 PM instructed to apply skin prep to eschar area on left fifth toe and to areas of eschar and redness to bottom of left foot and top of left big toe; and to wrap with gauze for protection. Progress Note dated 3/15/23 at 10:04 AM revealed pressure ulcer areas have continued to show improvement and current interventions of not wearing her brace or shoes had been effective. R28 used heels up cushion when in bed to assist with keeping pressure off of feet and heels. R28 had a new brace and shoes ordered when the areas have resolved. There was no mention of the measurements of the pressure ulcers, drainage or stage of pressure ulcers (Pressure ulcer staging was an assessment system that provided a description classification based on visual appearance and/or anatomic depth of soft tissue damage). R28's care plan did not indicate she was not to wear brace/shoes until pressure ulcers were healed or that a heels up cushion was to be used when in bed. Progress noted dated 3/24/23 at 11:15 AM indicated pressure areas to her left foot were assessed, area of black eschar on the side of left foot was a pale brown in color and measured 0.7cm by 0.5cm. There was no mention of the third unstageable pressure ulcer in the 3/24/23 progress note. Pressure Injury Prevention Guidelines policy, reviewed 11/08/22, indicated interventions would be documented in the care plan and communicated to all relevant staff. The same policy indicated for residents that had a pressure ulcer/injury, documentation would include a weekly wound summary. Resident #43 (R43) On 3/28/23 at 1:49 PM R43 was observed lying in bed positioned slightly on his left side. Soft green boots were observed on the floor next to bed. R43's MDS dated [DATE] revealed he admitted to the facility on [DATE], had a BIMS score of 03 (00-07 severe cognitive impairment), was completely dependent of 2 plus persons for bed mobility and transfers. The same MDS indicated functional ROM was limited on one side of both the upper (shoulder, elbow, wrist, hand) and lower (hip, knee, ankle, foot) extremities. The same MDS revealed R43 had a stage 2 pressure ulcer that was facility acquired and a state 3 pressure ulcer that was also facility acquired. The same MDS revealed R43 was not on a turning/repositioning program. DON B was interviewed on 3/29/23 at 4:15PM and stated R43 had 2 facility acquired pressure ulcers, on his coccyx and knee. DON B stated on 11/30/22 he was sitting in a plastic shower chair that reclined, the coccyx may have been pinched during the shower, at that time the area was not open. DON B stated R43 was only in the shower chair for approxi [TRUNCATED]

Based on observation, interview and record review, the facility failed to prevent the further development of 2 pressure ulcers for 1 (Resident #28) of 4 residents reviewed for pressure ulcers resulting in the development of 2 facility acquired pressure ulcers, [CONDITION(S)] related to pressure ulcer, [CONDITION(S)] (infection in the bone) and subsequent hospitalization . Findings include: Positioning interventions redistribute pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces (WOCN, 2010). Change the immobilized patient's position according to tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort (NPUPA, EUPAP, PPPIA, 2014). A standard turning interval of to 2 hours does not always prevent pressure ulcer development. Consider repositioning the patient at least every 2 hours if allowed by his or her overall condition. When repositioning, use positioning devices to protect bony prominences (WOCN, 2010). The WOCN guidelines (2010) recommend a 30-degree lateral position (Figure 48-15), which should prevent positioning directly over the bony prominence. To prevent shear and friction injuries, use a transfer device to lift rather than drag the patient when changing positions (see Chapter 39). Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition. Category/Stage 4: Full thickness tissue loss: Full thickness tissue loss with exposed bone, a tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput (back of head) and malleolus (ankle) do not have (adipose/fat) subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making [CONDITION(S)] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ According to the National Pressure Injury Advisory Panel, Pressure Injury Prevention Points revealed, 8. Avoid positioning an individual on an area of [CONDITION(S)] or pressure injury .Repositioning and Mobilization: 8. Continue to reposition an individual when placed on any support surface. (accessed: https://npiap.com/page/PreventionPoints) Review of an Admission Record revealed Resident #28 was a female, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #28, with a reference date of 1/18/22, revealed, a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which resident was cognitively intact. Review of current Care Plan for Resident #28, revised on 7/14/2021, revealed the focus, .ADLS: I, (Resident #28), require assistance with ADLS (Activities of Daily Living) and mobility R/T (related to) Generalized muscle weakness and [CONDITION(S)] ([CONDITION(S)]) . with the intervention .BED MOBILITY: EXT (extensive) 1-2 A (assist) . Review of Kardex for Resident #28 dated 4/27/22 revealed, .Turning/Positioning: Assist with repositioning for comfort .Bed Mobility: 1-2 A (assist) . Review of Progress Notes dated 11/10/2021 at 04:41 AM, revealed, Pt (patient) requires assistance with most all ADLs. Mechanical lift used for transfers. Review of Health Status Note dated 11/28/2021 at 1:07 PM, revealed, .Resident (Resident #28) continues on Covid isolation . Review of eMar note dated 12/3/21 at 11:14 AM, revealed, .Cleanse wounds to right buttock with normal saline .A no sting skin prep and cover with Proximel. Change dressing every 3 days or for loose or soiled dressing. Every day shift every 3 day(s) .Was completed on night shift . Review of Timeline for Wound Development and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The larger area appears to have been either a blister or area where skin is peeling off. It appears to be blue/purple in color no odor noted. Small amount of drainage noted to old dressing. Orders changed as it appears the current dressing is pulling off skin when it is removed and it needs additional protection. Resident is noted to be recovering from COVID 19. Has had recent decrease in mobility, appetite and general wellbeing . Review of Timeline for Wound Development and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Peri-wound pink and blanchable at this assessment. R buttock measuring 10.5cm long 6.0cm wide black/purple in color. Possible DTI (deep tissue injury) Small amount of bloody drainage noted in scattered areas. Slight odor with removal of dressing. Decreased when cleaned up and changed. Peri-wound area is pink and blanchable. Treatment orders are being changed to use calcium alginate to entire area and cover with sacral dressing. Dressing to be changed daily for close monitoring . Review of Health Status Note dated 12/28/2021, revealed, .Resident (Resident #28) continues on abx (antibiotic) for wound infection Wound assessed by DON and santyl on hold . Review of Skin/Wound Note for Resident #28 dated 12/28/2021, revealed, .Wound assessment complete. New measurements today are: left buttock 9.2 cm L x 3.8 cm .Wound bed is varied with pink, brown, white and yellow areas scattered throughout the wound bed. Slight odor with dressing change - none noted after cleaning. some drainage to old dressing - slight amount at this time . Right buttock: 9.2 cm L x 3.8 cm W with hard eschar to the wound base. Peri-wound is pink and blanchable. No pain noted to the area with assessment - no odor noted. Black area extends into the gluteal cleft area . Resident is shifting between bed and chair - she prefers to be up for her meals and then will shift back into her bed. She is receptive to shifting position-moving side to side in her bed with staff assist. APM in place. Pro-stat has been ordered and resident is currently taking as scheduled . Review of Health Status Note dated 12/29/2021, revealed, Pt was very weak and had to have pills spooned to her one at a time. Review of Timeline for Wound Development and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Top R 3.0cm long 4.0cm wide pink granulation present this area connects to the R side which measures 9.0cm long 5.5cm wide which present with 90% eschar and 10% slough next to the anal region unstageable at this time. L buttock wound bed showing improvement small area of slough some loosely attached. Other open area showing granulation tissue present in scattered areas. Wound to L buttock has area of granulation tissue at base of wound close to anal area that has pink granulation tissue present. Eschar is attached to wound bed securely at this time. Santyl to continue. Minimal to no odor after cleaning wound. No pain noted during care or assessment. Peri-wound surrounding eschar area has some pink border present assessments to continue . Review of Timeline for Wound Development and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Area measured across BIL buttock as area has merged together now. L buttock continues with pink and yellow tissue. The R buttock has eschar that is firmly attached in some areas and loosely attached in others. Beefy red tissue at the distal end of the open area. Eschar to the side and top. Slight odor when dressing being removed but after cleaning it decreases. No pain noted. Serosanguinous and bloody drainage noted to old dressing. Resident has APM in place and staff assist with shifting and repositioning frequently. Foley catheter remains in place. Current orders appear to be effective as wound bed continues to show progress. Will speak with NP about adding calcium alginate to beefy red areas on R side . Review of Health Status Note dated 1/12/22 at 4:30 AM, revealed, .Pt's condition has declined significantly since her COVID infection. She has deteriorated physically and mentally. She requires assistance with all ADLs and cueing with drinking and eating . Review of Timeline for Wound Development and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Moderate amount of serosanguinous drainage to old dressing. Scant odor noted . Review of Health Status Note dated 1/26/22 at 3:46 AM, revealed, .Pt's conditions has been declining. She has required increased assistance with all ADLs and she is being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of (Name of Wound Care Center) Wound Check Note for Resident #28 dated 1/27/22, revealed, .The condition began December with COVID and The condition is worsening. Xray ordered to rule out [CONDITION(S)], impression from x-ray soft tissue ulceration with suggestion of [CONDITION(S)] involving the distal sacral segments (triangular shaped bone, 5 segments fused together at the bottom of the spine) and coccygeal segments (tailbone). Depth of procedure: bone; Devitalized tissue debrided: skin, fat, muscle, tendons in connective tissue .serosanguineous - yellowish with small amounts of blood .odor: anaerobic----putrid odor foul smelling discharge. Exposed structure: bone .Concerns about infection: Chronic non-healing wounds or ulcers are serious and can lead to infection, loss of limb, or death. Your adherence to the treatment is crucial to the outcome .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Total area of wound in cm Sq: 78.4 CM2 (12.152 square inches) . Review of Skin/Wound Note for Resident #28 dated 1/28/2022 at 2:32 PM, revealed, .Removed dressing from residents buttocks after returning from (Hospital of preference) Xray department, drsg malodorous, wound cleansed with NS, most of wound bed beefy red except 11 o'clock which has dark grey slough, wound measures 11cm X 9.0cm X 5cm with a 4cm tunnel at center of wound bed heading towards 6 o'clock, applied NS [MEDICATION(S)] to tunnel and wound bed then calcium alginate to granulated edges covered with ABD pads, tolerated well .received call from (NP Wound Care Center) at wound care center stating that xray was probable for [CONDITION(S)] .he wants her to start [MEDICATION(S)] and have labs completed he will also order a bone scan since resident cant have an MRI . Review of Social Services Narrative dated 2/1/22, revealed, .Informed that resident became tearful this morning and expressed to staff that she doesn't have quality of life anymore .S'S (social services) spoke with resident and she expressed that she was having a rough morning with her shower r/t (related to) pain . Review of Health Status Note dated 2/1/22 at 6:00 AM, revealed, Resident (Resident #28) had a bed bath this shift. Staff was prepared to give her a shower per her request, but she was on the shower chair she felt like her buttocks was splitting in half and she was uncomfortable. Review of (Name of Wound Care Center) Wound Note for Resident #28 dated 2/3/22, revealed, .To the coccyx pressure ulcer .Wash with normal saline, Skin Prep, DuoDerm windowing the peri wound .White foam over the exposed and nearly exposed bone .Green foam to the remaining wound bed .Drape the wound and [NAME] to the hip (be sure to get drape under the [NAME]) .150-175 mm/hg continuous .Changed 3x a week .Measured at 91.4167 CM2 .Resident visited wound care center wound vac placed by wound care center . Review of Nutrition/Hydration Note dated 2/4/2022 at 2:05 PM, revealed, .Resident (Resident #28) is being followed r/t weight and wound concerns. CBW 173.2# indicates loss of 3.3% x90 days, loss of 5.9% x180 days. Non-significant weight loss trends. Resident has a wound to coccyx measuring 11cm X 9cm x 5cm which was infected and resident was started on ABX (1/28). ABX will be in place for 14 days . Review of Timeline for Wound Development and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . There is a tunnel present at 6:00 that is 3.6cm deep. There is undermining at 9:00 to 12:00 varying in depth from 2.5cm closer to 12:00 and 3.0cm toward 9:00. Wound vac dressing changed as ordered. Resident to see ID on 2/8 . Review of Timeline for Wound Development and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . 2/15/22 Pt returned to facility. Pt returned on oral [MEDICATION(S)] and IV [MEDICATION(S)] . Review of eMar noted dated 2/16/22 at 12:46 PM, revealed, [MEDICATION(S)] HCI in Dextrose Solution 1-5 GM/200ML-%. Use 1 gram intravenously one time a day for wound infection for 6 weeks. [MEDICATION(S)] was being held because of vanco trough level 21.1. Review of Timeline for Wound Development and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Timeline for Wound Development and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . AOx3 wound vac and foley in place. PICC line in place . Review of Provider Progress Note dated 2/25/22, revealed, .Plan: Septic shock: sec (secondary) to sacral ulcer, resumed same abx (antibiotic), review of records and inpt pharmacy notes, pt to be on 750mg vanco daily, level 2/24 was 10, d/w (discussed with) nursing clarification, check weekly labs starting Monday with vanco trough. Cont [MEDICATION(S)], [MEDICATION(S)], cont wound vac, f/u (follow up) with ID/wound clinic . Review of Timeline for Wound Development and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . She has a 2.5cm tunnel at the distal end of the wound 6:00. There is a small amount of gray yellow slough at 1:00 that is attached to the wound bed. Wound bed is beefy red in some areas and has made progress. Some areas at the distal end of the wound are close to the surface. Resident continues to follow up with the wound care center and ID. Resident has IV ABX Vaneo and [MEDICATION(S)] and oral [MEDICATION(S)] . Review of (Name of Wound Care Center) Wound Check Note for Resident #28 dated 3/8/22, revealed, .Returned to clinic having been hospitalized twice in the interval for [CONDITION(S)] and septic shock for 5 and 7 days respectively .IMPRESSION: 1. Deep decubitus ulcers in the central lower posterior pelvic soft tissues measuring 5.6 CM x 4.5 CM in transverse and cephalocaudal extent with a surrounding inflammation and thickening of the walls of the ulcer. 2. [CONDITION(S)] of the sacrum and coccyx with erosion of the S5 segment and coccyx with a few small residual bone fragments remaining . Review of Timeline for Wound Development and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident recent lab values indicate worsening infections. NP stated to send to (Hospital of preference). Resident returned to facility same day. treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Bone Scan for Resident #28 dated 3/15/22 revealed, .Additional History: Paralysis waist down due to MS ([CONDITION(S)]) .comparison: CT Pelvis dated 2/1/2022 .Impression: 1. Finding compatible with [CONDITION(S)] involving distal sacrum with adjacent soft tissue inflammation related to decubitus ulcer . Review of Health Status Note dated 3/16/22 at 12:50 PM, revealed, .Pt continues IV and PO ABX for [CONDITION(S)]. No s/sx of adverse reactions observed at this time. PICC line in right arm flushes without difficulty, dressing CDI. Wound vac to be changed today . Review of Skin/Wound Note dated 3/16/2022 at 3:43 PM, revealed, .Resident incontinent of large loose stool with mucous, placed resident in contact isolation .wound assessment to sacrum/buttock wound measures 7.5cm x 7.5cm x 2.5cm at deepest depth wound bed continues to be beefy red with granulation and tunnel at base of wound .5cm deep which is smaller than last week, undermine @ 11 - 2 o'clock 1.5-3.5cm with slough around 12 o'clock, no odor noted from wound, applied skin prep peri-wound allowed to dry applied wound vac opsite border applied then white foam to undermine and tunnel green foam to rest of wound secured with wound vac and changed wound vac cannister . Review of Timeline for Wound Development and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound bed is beefy red throughout with the exception of 12:00 there is an area of slough that is attached at the base but stringy and yellow white in color. IV ABX's d/c per provider instructions PICC line pulled . Review of Timeline for Wound Development and Treatmentfor Resident #28 revealed, .4/8/22 Measurements 8.0cm long 8.0 wide 1.7cm deep with 1.5cm undermining from 9-12:00 undermining and wound bed depth are improved from last assessment slough no longer present that was here prior to wound care visit. No odor, no pain continued bloody drainage to canister. Tunnel area has a small divot no longer a tunnel. Pt continues to be repositioned Q (every) 2 hours . Review of Order dated 4/22/22, revealed, .Order Summary: Sacral Wound Care/Vac: gently cleanse area with NS, apply skin prep to entire peri-wound allow to dry, apply white foam to tunnel leaving a tail for removal and to undermined area at top of wound then apply green foam to the rest of the wound cover with drape then wound vac at 150-175mm/hg continuous change every 3 days, every day shift every Mon, Wed, Fri for sacral ulcer . Review of Health Status Note dated 4/23/2022 at 1:15 AM, revealed, .Sacral wound vac changed this shift with the assistance of other staff nurses. Resident tolerated well. Scant amount of sanguineous drainage during dressing removal. No foul odor. Measurements: Length 6 cm, Width 7 cm, 2 cm deep and 1.5 cm around the tunneled area (9-3 o'clock) . During an observation on 4/28/22 at 9:55 AM, Resident #28 was observed lying on her back in her bed with the head of the bed elevated approximately 45 degrees. During an observation on 4/28/21 at 10:53 AM, Resident #28 was observed lying on her back in her bed with the head of the bed elevated to approximately 45 degrees. In an interview on 4/28/22 at 11:14 AM, Licensed Practical Nurse (LPN) H reported when he has worked with (Resident #28) she would never refuse care. In an interview on 4/18/22 at 11:03 AM, Certified Nursing Assistant (CNA) N reported when we do a check and change we would chart when we changed them and if they were continent or incontinent. In an interview on 4/27/22 at 12:21 PM, CNA N reported Resident #28's can move a little. During an observation on 4/28/22 at 11:33 AM, Resident #28 was observed laying in her bed in the supine position with the head of the bed elevated at approximately 45 degrees. During an observation on 4/28/22 at 12:02 PM, Resident #28 was observed laying in her bed in the supine position with the head of the bed elevated at approximately 45 degrees. In an interview on 4/28/22 at 12:46 PM. CNA M reported Resident #28 was positioned from right to back to left side when repositioned. In an interview on 4/27/22 at 2:43 PM, Assistant Director of Nursing (ADON) C and Unit Manager (UM) D reported the certified nursing assistants (CNAs) have probes in their view of the medical record where they should document if there were a change in assistance needed, range of motion, or any care changes the CNAs noticed when care was provided to the residents. UM D reported Resident #28 had begun to decline in her mobility and transfers in November 2021. In an interview on 4/27/22 at 12:22 PM, Resident #28's family member was visiting and reported the resident had COVID at the end of November/beginning of December 2021 and has been in the hospital at least 3 times since then. He reported he had a white board in the room with reposition/turn every two hours written on it for reminders to reposition/turn her. In an interview on 4/27/22 at 1:49 PM, Resident #28 stated she knew we (State Agency) were here as she .was getting more attention . from the staff. A white board which was located on the right side of the bed had a statement which indicated to reposition every two hours and Resident #28 stated .They do not reposition me every two hours . Resident #28 reported she was totally dependent on staff for her care as she was unable to reposition herself and she needed her table close and her items on the table close as her range of motion with her left arm was restricted. Note: staff did not enter the room while this writer was present. In an interview on 4/28/22 at 11:29 AM, CNA M reported when a resident has refused care it is reported to the nurse and documented in the medical record an alert the resident had refused cares. Review of Monitor - Behavior Symptoms for previous 30 days revealed, no recorded behaviors for refusals of care. Review of medical record showed no documentation Resident #28 was turned and repositioned every 2 hours. In an interview on 4/28/22 at 1:47 PM, Director of Nursing (DON) B reported she was responsible for completing the wound care for Resident #28, she would see the resident weekly and perform measurement and assessment on the wound. DON B reported the nursing team understood the importance of completed assessments and entered information for the treatment in the records as she monitored the medical record for documentation. The unit managers monitor to ensure the nursing staff were documenting in the record and implementing the care plan interventions. The MDS nurse was also involved as part of her assessments. DON B reported a wound note would be completed when she performed weekly wound rounds. DON B reported she had a wound prior and it healed, the nursing staff were keeping an eye on it and then the resident was diagnosed with COVID and this lessened her ability to do well. DON B reported the resident had developed a small open area and she hadn't seen her in a few days and a staff member came and got her to go down and see the resident. DON B reported she was removing the dressing and it was pulling off layers of skin and it was observed to be hard and purple. DON B reported she notified the nurse practitioner and team, her unit managers. DON B reported there was a point the resident was going out to the hospital a lot, and I believe she returned to quickly because she turned around and was sent back to the hospital. DON B reported the resident was referred to the wound care center in January, We didn't want to mess around with it too long, so we sent her to get evaluated. The wound care center diagnosed her with [CONDITION(S)] and the wound vac was started. DON B reported the resident had not been seen by the wound clinic much in the last few months due to her hospitalization s.

This citation pertains to intake number MI 713. Based on observation, interview, and record review the facility failed to ensure two out of two residents (Resident #2 & #3) received their medications from a licensed nursing professional, resulting in Immediate Jeopardy when two unlicensed staff, Certified Nursing Aids (CNAs), administered medications via oral, inhalation, and injection routes, resulting in the likelihood of serious harm, injury, and/or death. Findings Included: Resident #2 (R2): Review of the facility face sheet revealed R2 was admitted to the facility on [DATE], and resided on the North 2 Unit in room 52-2. Record review of a progress note, dated 10/11/2021, revealed R2 was moved to the South unit, which was identified to be the Covid Unit on 10/11/2021 Review a Minimum Data Set (MDS), dated [DATE], revealed R2 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. Review of a Medication Administration Record (MAR), for the month of October 2021, revealed that on 10/12 and 10/13/2021 R2 received [MEDICATION(S)] (a diuretic-water pill) 25 mg (milligrams) PO (by mouth), Aspirin 81 mg PO, [MEDICATION(S)] (stool softener) 100 mg two PO, [MEDICATION(S)] (diuretic) 20 mg PO, Klor-Con (potassium) 10 meq (milliequivelants) PO, [MEDICATION(S)] (acid reflux) 20 mg PO, and [MEDICATION(S)] 125 mcg (microgram) PO. In addition R2 received on 10/12/2021 received Tylenol 325 mg PO, and [MEDICATION(S)] (antidepressant also used for [CONDITION(S)]) 15 mg PO. Resident #3 (R3): Review of the facility face sheet revealed R3 had an admitted [DATE], and resided on the North 2 Unit in room 52-1. Record review a progress note, dated 10/11/2021, revealed R3 was moved to the Covid Unit on 10/11/2021 to room 62. Review of an MDS, dated [DATE], revealed R3 had a BIMS score of 13 out of 15, indicating intact cognition. Review of a MAR, for the month of October 2021, revealed that on 10/12 and 10/13/2021 R3 received [MEDICATION(S)] (for gout) 100 mg PO, [NAME] [CONDITION(S)] ([CONDITION(S)] medication) 15 mg and 90 mg for total of 105 mg PO, [MEDICATION(S)] (for cholesterol) 20 mg PO, [MEDICATION(S)] suspension (for congestion) 50 mcg two sprays in each nostril, [MEDICATION(S)] (anti-diabetic)100 mg PO, Novolog insulin 10 units subcutaneous (a under the skin injection) at bedtime, Singular (for asthma) 10 mg PO, [CONDITION(S)] tablet 90 mg PO, [MEDICATION(S)] (blood thinner) 5 mg PO twice a day, [MEDICATION(S)] (for high blood pressure ) 12.5 mg PO twice a day, [MEDICATION(S)] (for stomach acid reflex disease) 40 mg PO twice a day, [MEDICATION(S)] 25 mg PO twice a day, [MEDICATION(S)] inhaler (for asthma) two puffs twice a day, [MEDICATION(S)] extended release (Oxycodone abuse deterrent) 9 mg PO twice a day, Magnesium 400 mg PO three times a day, Novolog 10 units subcutaneous with each meal, [MEDICATION(S)] (muscle relaxant) 500 mg PO twice a day (received twice on 10/12 and one time on 10/13/2021), and Oxycodone 5 mg PO which was received once on 10/12/2021, at 9:29 AM. In an interview on 10/13/2021, at 11:40 AM, Certified Nurse Aid (CNA) C stated she worked in the Covid Unit by herself, and stated that when medications were administered to the two residents (R2 & R3) who resided in the Covid Unit then a nurse would administered them their medications. CNA C stated she had never been asked to give R2 or R3 their medications. In an interview on 10/13/2021, at 11:45 AM, R2, who resided in room 61 of the Covid Unit, stated that CNA C had given her medications that morning that were in pill form taken by mouth. In an interview on 10/13/2021, at 12:00 PM, R3, who resided in the identified Covid Unit, stated that a CNA (did not know the name of the CNA) had given her morning medications to her on 10/13/2021. In an interview on 10/13/2021, at 10:00 AM, Director of Nursing (DON) B stated that only a CNA was working in the Covid Unit and did not come out of the unit. DON B stated that she did not allow the nurses who worked on the North 2 Unit medication cart, which was where R2 and R3 previously resided, to go into the Covid Unit to administer R2 & R3 their medications, because she did not want the nurses going in and out of the Covid Unit then go into resident rooms that were not in the Covid Unit. DON B said that she herself, or a nurse manager, would go into the Covid Unit to administer R2 and R3 their medications, because she or a nurse manager did not go in and out of residents' rooms who did not reside on the Covid Unit, and would be less likely to transmit Covid-19 to other residents who did not reside on the Covid Unit. In an interview on 10/13/2021 at 2:07 PM, with DON B and Assistant Director of Nursing (ADON) G, ADON G stated that CNAs administering medications to residents who resided on the Covid Unit was not the long term plans. ADON G said she thought she understood CNAs could administered medications. In an interview on 10/13/2021 at 12:15 PM, Licensed Practical Nurse (LPN) D, who was the nurse on the North 2 medication cart, stated that she was directed by the nurse (Registered Nurse E), who she received report from on 10/13/2021, to put R2 and R3's resident's medications into a medication cup, put the residents name on the medication cup, leave the medications on the table inside the doors of the Covid Unit, then upon returning to the North 2 hall, call the CNA who was working in the Covid Unit to pick the medications up, and administer them to R2 & R3. LPN D stated that 10/13/2021 was the first time she had done that, and that she had no idea if R2 & R3 even took the medications, but stated she had signed the medications out as administered on R2 & R3's MAR. In an interview on 10/13/2021, at 12:30 PM, CNA C was interviewed again, and stated that she did pick up the two medication cups that were on the table inside the Covid Unit doors and take them to R2 & R3 where she left the medication cups in their rooms. CNA C said she could not state for sure if R2 & R3 actually took the medications when she left in their rooms. CNA C said the two medication cups were already on the table when she came in to work on 10/13/2021, and said she was called by LPN D to give the medication to R2 & R3. Record review of R2's Electronic Medical Record (EMR) revealed no assessment that R2 was assessed to be able to self-medicate, nor was a Physician's order was found in R2's EMR to self medicate. Record review of R3's Electronic Medical Record (EMR) revealed no assessment that R3 was assessed to be able to self-medicate, nor was a Physician's order was found in R3's EMR to self medicate. In an interview on 10/14/2021, at 8:40 AM, Registered Nurse (RN) E stated he worked on 10/12/2021 on third shift. RN E said he put R2 & R3's medications in a medication cup, then on a Styrofoam tray, wrote R2 & R3's names on the trays, but not on the medication cups, then placed the cups on the table inside the doors of the Covid Unit. RN E said he also pulled up 10 units of insulin into an insulin syringe for R3 and put that onto R3's Styrofoam tray with an alcohol wipe for the insulin to be administered. RN E said he then called CNA F, from outside of the Covid Unit, to pick up the medications to administer to R2 & R3. RN E said he directed CNA F to administer all the PO medications including R3's insulin and inhaler. RN E said CNA F was the only staff member working in the Covid Unit. RN E stated that placing the resident's medications on the table inside the Covid Unit, and then calling the CNA who was working in the Covid Unit had been the process used when the Covid Unit had residents residing in the unit at either the end of last year (2020), or beginning of the year (2021). RN F said he did not receive specific directions from anyone, but said that was the process used for medication administration when the Covid Unit was previously open, because he could not go in and out of the Covid Unit due to the unit being an isolation unit. RN E further stated that he did not perform respiratory assessments on R2 and R3 because he could not enter the Covid unit. In an interview on 10/14/2021, at 9:16 AM, CNA F stated that on 10/12/2021 she worked 6:00 PM to 6:00 AM on the Covid Unit by herself. CNA F said RN E was the nurse who worked the North 2 Unit. CNA F said RN E placed R2 and R3's medications on the table inside the Covid Unit doors on a Styrofoam tray and wrote R2 & R3's name on the tray so she would know which resident each tray of medications was for. CNA F said that both R2 & R3 received evening and morning medications. CNA F said she gave both R2 & R3 their medications, and stated she did administer R3 her insulin injection that was also on the tray. CNA F said she new R3 had a muscle relaxer and a pain medication also, but further stated that she did not know what the oral meds were that were in each cup, nor what each of the medications were for. CNA F said RN E did not physically come back into the Covid Unit. CNA F said she had to ask R3 where her insulin injection was usually given, and once instructed she administered the injection into R3's upper arm. CNA F said in the Covid Unit the CNAs administer the resident's their medications, but do not outside of the Covid Unit. CNA F said R3 also had an inhaler that she thought R3 took two puffs on and gave R3 the inhaler to take her two puffs. CNA F said R2 also had eye drops she administered to her, but stated that the only way she knew the correct dose to administer to R2 for her eye drops and to R3 for her inhaler was by asking each of the two residents what the correct doses where. CNA F said RN E told her the correct time to administer the eye drops and inhaler. CNA F stated that no nurse manager entered the Covid Unit during her shift, and said she was not comfortable administering the medications to R2 & R3, and was glad the process was going to be changed. CNA F also stated that she could not recall if she was directed by anyone else to administer R2 and R3's medications other than by RN E. Review of the Covid Unit schedule for the month of October 2021 revealed that on 10/12 and 10/13/2021 no nurse manager was scheduled to work in the Covid Unit on the night shift. Review of the facility's policy and procedure titled, Medication Administration General Guidelines, not dated, revealed on page #1, under Policy, Medications are administered as prescribed in accordance with good nursing principles and only be persons legally authorized to do so ., and under Procedures, Preparation 1. Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to prepare and administer medications. On page #3 the policy revealed, under Administration, #3 .Medications are not pre-poured either in advance of the med pass or for more than one resident at a time., and #5, The person who prepares the dose for administration is the person who administers the dose. On 10/14/2021, at 11:43 AM, the Administrator was notified of the Immediate Jeopardy that began on 10/12/2021 when it was identified that R2 and R3 received their medications via oral, injection, and inhaler routes by unlicensed nurses, CNA C and CNA F resulting in the likelihood of serious harm, injury, and/or death. On 10/18/2021 the survey confirmed the facility had implemented the following to remove the Immediate Jeopardy: 1). Beginning 10/14/2021, Assessments were completed by licensed nursing staff on Resident 2 and 3. No adverse effects are noted at this time. 2). A medication error report was completed for each of the residents on 10/14/21. The physician was notified on 10/14/21 and the error was reviewed. The following medications were identified as being administered by unlicensed personnel. Resident #2 on 10/12 was given the following: Acetaminophen 325 mg - 2 tabs, [MEDICATION(S)] 15 mg, artificial tears during the PM med pass. Resident #2 was given the following during the AM med pass on 10/13/21; [MEDICATION(S)] 25 mg, aspirin 81 mg, [MEDICATION(S)] sodium 100 mg x 2 caps, [MEDICATION(S)] 20 mg, Chlor-Con 10meq, [MEDICATION(S)] 20 mgm, [MEDICATION(S)] 125 mcg, artificial tears. Resident number 3 on 10/12 pm med pass was given the following: [MEDICATION(S)] 20 mg, Novolog 100 units /ml =10 units, Bio-freeze 4% to lower back, [MEDICATION(S)] 5 mg, [MEDICATION(S)] 25 mg, [MEDICATION(S)] 40 mg, [MEDICATION(S)] 25 mg, [MEDICATION(S)] aerosol-1600.45mcg/act. 2 puffs, Xtampzaer ER 9 mg, magnesium oxide 400 mg. On 10/13/21 during the AM med pass the following medications were given: Allupurinol 100 mg - 2 tabs, [NAME] [CONDITION(S)] 105 mg, [MEDICATION(S)] 100 mg, Singular 10 mg, Biofreeze gel to lower back, [MEDICATION(S)] 5 mg, [MEDICATION(S)] 12.5 mg, Protoxin 40 mg, [MEDICATION(S)] 25 mg, [MEDICATION(S)] aerosol 160-4.5mcg/act - 2 puffs, Xtampzaer 9 mg, Magnesium Oxide 400 mg. 3). On 10/14/2021, All 58 of the residents who resided in the facility were identified to have the potential to be affected. 4). Beginning on 10/14/21 all nursing staff currently working in the building - licensed nurses, C.N.A ' s and hospitality aides began to receive education including the policy and procedure for medication administration, the directions for med administration in the COVID unit, a schedule of the staff on the COVID unit so nurses are aware when they will need to go to that unit. C.N.A ' s and hospitality aides began to receive instruction on 10/14/21 that they are never to pass any type of medication and to report any such requests to a unit manager, ADON, DON or administrator immediately. 5). Beginning 10/14/21 audits will be conducted to ensure that appropriate, licensed personnel are the only staff passing medications to any resident. Although the Immediate Jeopardy was removed on 10/14/2021, the facility remained out of compliance at a scope of isolated that is no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance had not been verified by the State Agency.

Based on observation, interview, and record review the facility failed to ensure 2 out of 6 residents (Residents 229 and 274) were free of significant medication errors during a medication pass observation resulting in Immediate Jeopardy when R229 was observed to not receive her full dose of intravenous (IV) antibiotic medication for two doses, and when R274's IV antibiotic was observed to not infuse at the physician's orders [REDACTED]. Findings Included: Resident 229 (R229): Per the facility face sheet R229 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of R229's hospital discharge summary, dated 1/24/2020, revealed she had a discharge [DIAGNOSES REDACTED]. The summary revealed R229 had a left ankle, tibula, and fibula fracture with complications from infections. Record review of physician's orders [REDACTED]. On 1/29/2020, at 7:48 AM, Licensed Practical Nurse (LPN) U was observed during a medication administration for R229. During the observation it was observed that R229 had an IV bag of [MEDICATION NAME] 1.5 grams, that was infused on 1/28/2020 at 8:00 PM, still hanging on an IV pole and connected to an IV pump (machine that infuses the medication when set up with the specific physician's orders [REDACTED]. The bag of [MEDICATION NAME] was observed to have approximately 50 cc of [MEDICATION NAME] still remaining in the bag. LPN U was observed to throw the IV bag of [MEDICATION NAME] into the garbage can, and administer R229's 8:00 AM [MEDICATION NAME] dose. Further observation revealed R229's [MEDICATION NAME] 1.5 grams was a powder in a vial and was attached to a 500 cc bag of .9% normal saline (salt water). Review of the label on the IV bag revealed R229's [MEDICATION NAME] was to infuse at 167 cc per hour over 180 minutes. Continued observation with LPN U revealed she mixed the [MEDICATION NAME] powder into the 500 cc bag of .9% normal saline, attached IV tubing, and placed the tubing into the IV pump. LPN U was observed to set the IV pump at 166 cc per hour for 3 hours. In an interview with LPN U, immediately after she began R229's [MEDICATION NAME] infusion, she stated the IV pump would only allow a maximum rate of 166 cc per hour for [MEDICATION NAME]. LPN U was asked, based on the left over [MEDICATION NAME] in the IV bag that was in the garbage from R229's 8:00 PM dose on 1/28/2020, if she though R229 received all her order [MEDICATION NAME] from the infusion. LPN U stated that in order for R229 to have received the full ordered dose of her [MEDICATION NAME] the IV pump should have been set with more time to ensure complete infusion. In an observation on 1/29/2020, at 11:50 AM, Registered Nurse (RN) G, who was also a Unit Manager, was observed to disconnect R229's 8:00 AM dose of [MEDICATION NAME] from her peripheral inserted central catheter (PICC (IV line)) line and the IV pump. RN G was requested to measure the remaining [MEDICATION NAME] in the IV bag prior to throwing it in the garbage, in which it was observed to have 40 cc of [MEDICATION NAME] remaining. RN G was asked if she thought R229 received her full ordered dose of [MEDICATION NAME], in which she stated that due to the remaining 40 cc of [MEDICATION NAME] in the bag, R229 did not receive her full ordered dose of [MEDICATION NAME]. In an interview immediately following the observation with RN G she stated the IV pump would only allow the [MEDICATION NAME] to infuse at 166 cc maximum per hour. RN G was observed to attempt to set the pump rate at 167 cc per hour, but was not able to do so, and stated she did not know of any other way it could be set above 166 cc per hour. RN G stated the IV pump could have been set to infuse 540 cc instead of 500 cc to ensure the full dose of [MEDICATION NAME] was administered, but stated she had not ever been instructed to do that. In an interview on 1/29/2020, at 12:07 PM, Assistant Director of Nursing (ADON) C stated that based on the 40 cc of [MEDICATION NAME] left in the bag at the end of R229's infusion she would logically say R229 did not receive all of her ordered [MEDICATION NAME], and stated she would add another 40 cc extra to be infused to ensure R229 received all of her ordered [MEDICATION NAME]. Record review of R229's Medication Administration Record [REDACTED]. In an interview on 1/29/2020 at 2:55 PM, with Pump Coordinator (PC) P, who worked for the pharmacy where the facility received the IV pumps from, stated the maximum rate set on the IV pump for [MEDICATION NAME] is 166 cc hour which was the hard set rate, and stated the IV pump could be adjusted if needed under the basic settings, and then the rate could be set at 167 cc hour. In an interview on 1/29/2020, at 03:23 PM, Pharmacist (P) Z stated that if any volume of R229's [MEDICATION NAME] was left in the IV bag when it was thrown out then the R229 did not receive all of her ordered [MEDICATION NAME]. P Z stated that if there was 20-30 cc left in the 500 cc bag, and it was not infused, then R229 only received 1.4 grams of each dose of her [MEDICATION NAME] instead of the ordered 1.5 grams. P Z said that was significant and would affect the trough the levels (a blood test used to identify the amount of [MEDICATION NAME] in the blood which used to dose the right amount of [MEDICATION NAME] a person needs to be effective in treating an infection). P Z said the pharmacy used the trough levels to dose R229's [MEDICATION NAME], and stated the whole volume of 500 cc needed to be infused. In an interview on 1/29/2020, at 4:24 PM, Nurse Practitioner (NP) AA said she was sitting at the nurses' station and overheard the nursing staff discussing the issue with R229's [MEDICATION NAME] infusion, and stated the nurses' did not directly report the issue to her. With approximately 40 cc not infused per dose, review of the calculation of the 8 doses of [MEDICATION NAME] R229 received, from 1/25 through 1/29/2020, revealed R229 only received 1.38 grams of her 1.5 grams of [MEDICATION NAME] ordered per dose, meaning she did not receive 0.12 grams per dose for 8 doses. R229 did not receive 0.96 total grams of [MEDICATION NAME] over the 8 doses. This calculation is based on 1.5 times 460 divided by 500=1.38 grams received per dose, and 0.12 grams not received per dose. In another interview on 1/29/2020 at 3:57 PM, ADON C stated she just received the Policy and Procedure from the pharmacy on 1/29/20 , and stated no formal training for the nurses' on the use of the IV pump had been done, and stated that the manual that hung on the pump was the user guide the nurses' would use. ADON C stated she could not confirm the nurses' were competent on the use of the IV pump, and stated she did not have a competency check list for the nurses' use of the IV pump. ADON C stated the IV pump had hard limits set by the pharmacy for different antibiotics, and stated those could not be changed, and she was not sure if those limits could be changed in the basic settings. Review of the IV pump user guide, not dated, revealed on page #6 instructions to change the IV dose or flow rate, under Soft Keys, rate change or dose change-to change the dose or flow rate . Review of the facility's policy and procedure titled, Intermittent Infusion III Administration Procedures, dated (MONTH) 2009, on page #2, 20. Verify that the solution is infusing a the prescribed rate. Review of the facility's policy and procedure titled, Medication Errors, not dated, revealed on page one, under Definitions, Medication error means the observed or identified preparation or administration of medications or biological's which is not in accordance with the prescriber's order. Under, Policy Explanation and Compliance Guidelines, the policy revealed, 1. The facility will ensure medications will be administered as follows: a. According to physician's orders [REDACTED]. Review of the facility's, Medication Related Incident Report, not dated, revealed under, Incident Type F. Over/Under Infusion was listed as a medication error incident. In an interview on 1/30/2020, at 07:49 AM, RN Q stated she had been working at the facility for two months, and had not received training on the use of the IV pump. In an interview on 1/30/2020, 8:23 AM, LPN T stated he had been working at the facility for approximately three years, and said she had not ever received training on the use of IV pump. LPN T said the facility had not had the IV pumps for very long, and stated that he just figured it out as he went go along. In an interview on 1/30/2020, at 07:52 AM, Director of Nursing (DON) B stated the facility began using the IV pumps in (MONTH) of 2019, and said the pharmacy staff came to the facility and went around and trained the nursing staff, but said she had no documentation of that. DON B further stated not all nurses received the training because not all the nurses' were working at the time the pharmacy was at the facility. DON B was asked what her expectation was for her nursing staff related to left over medications in the IV bags at the end of the infusion, in which she replied, the pharmacy did not believe the bag were over filled, and stated there was an over ride function on the IV pump that herself, ADON C, and the nurses were not aware of. DON B said she would expect the nurses to call the physician and report that there was left over antibiotics in the IV bag and received direction from the physician, and also contact to make her aware of the issue. DON B stated that she did not think the nurses knew how to increase the total volume on the IV pump to ensure all the antibiotic solution was infused. On 1/30/2020, at 8:46 AM, the Administrator and DON were notified of the Immediate Jeopardy that was identified on 1/29/2020, and began on 1/29/2020 when it was observed R229 did not receive her full physician ordered dose of [MEDICATION NAME]. On 2/4/2020 this surveyor verified that the facility implemented the following to remove the Immediate Jeopardy: 1). On 1/30/2020 Resident #229 was assessed, and no adverse effects were noted at the time. 2). On 1/30/2020 R229's Physician was notified. 3). On 1/30/3020 a medication error report was completed. 4). On 1/30/2020 the Operations Manual was received for the Baxter IV pump from the company. 5). On 1/30/2020 education was received from pharmacy on how to use the override function. 6). On 1/30/2020 two residents were identified to receive IV antibiotics, and were assessed to have no adverse affects. 7). Beginning on 1/30/2020 the facility began education of all licensed nurses on the use of the Baxter IV pump, including the override function that will allow differing volumes other than the pre-programmed ones to be entered to assure that all of the medication will be infused. Return demonstration of use of pumps is included in the education. Staff will be educated to be sure the labeling on the medication and the programming on the pump match to be certain infusion is fully completed. 8). Beginning on 1/30/2020 licensed nurses were educated on the medication error policy and procedure and procedure for reporting medication errors. The policy defines what a medication error is, what the process is once identified, the forms to utilize when a medication error occurs, and who to report to upon discovery. 9). As of 1/30/2020 at 3:00 PM 10 out of 31 nurses have been in-serviced. The remaining nurses will be educated prior to the use of the Baxter IV pump. Resident 274 (R274): Per the facility face sheet R274 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of R274's MAR, for the month of (MONTH) 2020, revealed he was to receive [MEDICATION NAME] (antibiotic) 2 grams IV three times per day. In an observation on 1/31/2020, at 7:55 AM, LPN V was observed to administer R274's [MEDICATION NAME] via the IV pump. The IV bag was observed to contain 2 grams of [MEDICATION NAME] in a 100 cc bag of normal saline. The label on the IV bag was observed to contain the ordered rate to run the IV at 200 cc per hour. LPN V was observed to set the IV pump, under the [MEDICATION NAME] presetting's, at 100 cc per hour. LPN V was then observed to leave R274's room and walk down the hall. LPN V was then asked why she set the IV infusion rate on the IV pump at 100 cc per hour, and not at the ordered rate on the label of 200 cc per hour. LPN V stated that the preset rate on the IV pump for the [MEDICATION NAME] could not be overridden. LPN V said she knew she can go into the basic setting and do it, but said she do not know if she was supposed to do that. LPN V said she had attended the inservice training on 1/30/2020. In an interview on 1/31/2020, at 09:01 AM, ADON C stated she had trained LPN V on 1/30/2020 that they were not to use the preset setting for a specific medication, and to use the basic setting if the preset setting did not match the physician's orders [REDACTED]. ADON C stated the nurses were to use the basic settings to set the IV pump at the correct ordered dose. On 2/4/2010 this surveyor verified the facility implemented the following to remove the Immediate Jeopardy: 10). On 1/31/2020, LPN V made an error and was re-education at 9:45 AM on the IV pump and how to use basic mode when the programmed medication dose and rate are not an exact match to the current IV medication being infused. Employee stated understanding and was able to demonstrate proper procedure when hanging an IV medication. 11). On 1/31/2020 at 10:10 AM employee was able to verbalize that the medication [MEDICATION NAME] was not a medication that was in the pre-programmed medication library on the IV pump. Employee then programmed the IV pump using the basic mode to administer the medication at the correct rate of 100 ml/hr and the right volume of 100 ml. At approximately 1110 on 1/31/2020 upon completions of infusion the medication bag was visualized to ensure that all of the medication had been infused per physician's orders [REDACTED].>12). On 1/31/2020 the nurse on west unit was re-educated to ensure understanding of the IV pump and infusion rate as well as the importance of the entire bag of IV solution being infused. IV pump and medication were visualized as the resident was currently receiving the prescribed infusion and the pump was noted to be in the correct basic mode and the medication was also noted to be infusing at the correct rate of 167 ml/hr. Upon completion of the medication infusion on 1/31/2020 at approximately 1145 the medication bag was visualized to ensure that all of the medication had been infused per physician order. 13). Beginning 1/31/2020 all other nursing staff that have been educated will be re-educated on the use of the Baxter IV pump, including the over ride function that will allow differing volumes other than the pre-programmed ones to be entered to assure that all of the medication will be infused. Return demonstration of use of pumps is included in the education. Staff will be educated to be sure the labeling on the medication and the programming on the pump match to be certain infusion is fully completed. 14). Beginning 1/30/2020 a trained, licensed nurse who has been educated on the above will audit infusion completion on residents receiving IV infusions after each infusion to ensure that all medication has been delivered. 15). Beginning 1/31/2020 a nurse manager or designee will observe all infusions to verify that correct settings are in place on the pump and all medication is infused. Observations will continue for the next 48 hours. Although the Immediate Jeopardy was removed on 1/31/2010, the facility remained out of compliance at a scope of isolated and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency.

Based on observation, interview and record review, the facility failed to assess, monitor, and implement individualized interventions to prevent skin breakdown and worsening of pressure ulcers, in 2 of 2 residents reviewed with pressure ulcers (Resident #59 and #228), resulting in worsening of pressure ulcer, decreased quality of life, pain, and time-consuming treatments. Findings include: Resident #59 (R59) On 01/28/20 at 2:44 PM, R59 was observed sitting in a recliner chair with a gauze bandage wrapped around her right lower leg and an ankle foot orthosis (brace for foot drop) noted on the left lower extremity. R59's Minimum Data Set (MDS) 3.0 assessment dated [DATE] introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 10 (Scale 08-12 indicated Moderate Impairment). The same MDS assessment revealed R59 was admitted to the facility 6/21/2019 and had the [DIAGNOSES REDACTED]. The same MDS assessment revealed R59 did not reject evaluation or care and required extensive assistance (staff provided weight bearing support) in bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture) during the look-back period. The same MDS assessment identified a functional limitation in range of motion (limited ability to move a joint that interfered with daily functioning) on one side of her upper extremity (shoulder, elbow, wrist, hand). R59's MDS dated [DATE] indicated she was at risk for pressure ulcers and did not have a turning/repositioning program in her plan of care. R59's (MONTH) 2020 Medication Administration Record [REDACTED]. R59's Nurse Progress note dated 1/20/20 at 6:16 AM revealed .observed pea size blister on inner right buttocks towards coccyx (tailbone) that was fluid filled. purplish discoloration lines seen on each inner buttock towards coccyx . The same note indicated a dressing was placed protection. There were no revisions made to R59 care plan. There were no other assessments on this date describing R59's skin breakdown that included the size of the purple discoloration on both buttocks or the color of the fluid in the blister. Skin Observation Tool dated 1/23/2020 at 8:53 PM revealed R59's blister continued to the coccyx. The same assessment did not include whether the blister was intact, color of the fluid in the blister, a description of the surrounding area, or temperature of the skin. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility (LTCF) Resident Assessment Instrument (RAI) 3.0, Version 1.17.1, (MONTH) 2019, revealed evaluating the dimensions of the pressure ulcer was one aspect of the process of monitoring response to treatment and measurement findings were used to plan interventions that would best prepare the wound bed for healing. Skin Observation Tool dated 1/28/2020 at 3:28 PM and signed on 1/29/20 at 4:10 PM revealed at 6:00 PM R59 complained of her tailbone hurting, purple deep tissue injury (DTI) was observed to bilateral upper inner buttocks and open area to coccyx presented as a Stage 2 pressure ulcer with a mild odor and slough. CMS's LTCF RAI 3.0, Version 1.17.1, (MONTH) 2019, defined a Stage 2 pressure ulcer as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) or bruising or may also present as an intact or open/ ruptured blister. The same source defined suspected deep tissue injury as purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. The same source indicated suspected deep tissue injury required vigilant monitoring due to the potential for rapid deterioration and should be reflected in the care plan. CMS's (MONTH) 2019's LTCF RAI revealed pressure ulcers at more advanced stages typically require more aggressive interventions, including more frequent repositioning . and an existing pressure ulcer may put residents at risk for further complications or skin injury. In review of R59 care plans, current pressure ulcers or skin alterations were not noted. R59's risk for impaired skin integrity care plan, related to decreased mobility and incontinence, indicated 07/03/2019, target date of 03/26/2019, had a goal that her skin would remain intact and free of pressure ulcers/injuries, and other skin impairments. The same risk for impaired skin integrity care plan did not include any new interventions since 10/09/2019. R59's same care plan indicated to .Turn and reposition me frequently, initiated 07/03/2019, and did not include individualized instructions to reposition R59 in her bed, recliner or wheelchair. R59's Activities of Daily Living (ADL) care plan revealed BED MOBILITY: I choose to sleep in my recliner at times, and at times choose to sleep in my bed Date Initiated: 07/03/2019. The same care plan did not include instructions on turning and repositioning needs for R59. The National Pressure Ulcer Advisory Panel's website at http://www.npuap.org/wp-content/uploads/2016/04/Pressure-Injury-Prevention-Points-2016.pdf, in a document titled Pressure Injury Prevention Points, it was recommended to reposition weak individuals in chairs hourly and to avoid positioning the individual on body areas with pressure injury. During an interview on 01/30/20 at 4:08 PM, Registered Nurse (RN) Unit Manager (UM) [NAME] confirmed, at the time of her assessment on 01/28/2019, R59's coccyx wound consisted of 10 percent slough and the rest of the wound bed was visible and red. RN UM [NAME] stated in the same interview, she would stage R59's coccyx pressure ulcer as a stage 2. RN UM [NAME] stated in the same interview that she had last received pressure ulcer and wound assessment education in (YEAR). On 01/30/2020 at 4:45 PM, R59's was observed sitting in her room in a recliner chair. RN BB transferred R59 from the recliner to her bed. R59 chair was observed without a pressure reducing cushion in place. R59 had been sitting directly on a senor alarm pad, under the alarm was a cloth incontinence pad, and under the incontinence pad a deflated waffle cushion (plastic air-filled cushion) was observed. On 01/31/2020 at approximately 12:15 PM, Director of Nursing (DON) B and Assistant Director of Nursing (ADON) C was interviewed regarding R59's flattened waffle cushion and if it was checked for need of air to be pumped into it; DON B stated she was not aware R59 had that type of cushion in her recliner chair. During an interview on 01/31/2020 at approximately 1:00 PM, DON B stated she had observed R59 sitting on both the waffle cushion and the gel cushion in her recliner chair that afternoon. DON B stated in the same interview R59's waffle cushion was not approved by the facility, that brought in by her son and was replaced with just a gel cushion. Resident #228 (R228) On 01/29/2020 at 09:51 AM the Electronic Medical Record (EMR) reflected R228 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS: resident assessment tool) dated 01/13/2020 reflected R228 was cognitively intact, and had 1 stage 2 pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured blister) and 1 Unstageble (-Slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar). The Nursing Admission/Readmission Assessment -VS, Section C for skin integrity dated 01/03/2020 reflected- 49) right heel pressure 50) left heel pressure. Size nor staging were not indicated. The progress note by Nurse Practitioner (NP AA) dated 01/06/2020 reflected R228 seen today to evaluate on right heel ulcer. Right heel with purplish color to wound and open area with minimal drainage. The plan included to start topical treatment to right heel ulcer, pressure relieving devices, and monitor periodically. The Skin observation tool dated 01/06/2020 at 15:14 reflected: 50) left heel pressure 1.5 x 1 x 0 centimeters (cm) and 49) right heel pressure 3 x 2.5 x 0 cm Stage 2. Progress notes by LPN G reflected: 1/6/2020 15:23 Skin/Wound Note Note Text: This nurse observed residents heels, observed that right heel measures 3 cm x 2.5 cm x 0 cm, non blanchable, peri wound dry and flaky, appears that top dry blister layer has been cut off, wound bed is dark black blood, hard no blister present. Treatment to clean heel with NS (normal saline), pat dry, apply double layer of [MEDICATION NAME], and cover with allevyn, change QOD (every other day), and PRN (as needed). No drainage present. Left heel measures 1.5 cm x 1 cm x 0 cm, blanchable, hard dark yellow area on heel. Treatment order to be cleaned with NS, pat dry, and apply skin prep BID (two times a day), and keep open to air. This resident has apt (appointment) sch (scheduled) with wound clinic, and we will follow their orders after their assessment. Resident educated and resident family present upon assessment. The Nursing Admission/Readmission Assessment -VS, Section C for skin integrity dated 1/16/2020 section 11 reflected: Bottom of both feet dark purple in color. Right heel has dressing. Progress noted by LPN G reflected: 1/21/2020 12:38 Skin/Wound Note Note Text: Resident heels assessed this shift. Measurements obtained. 6 x 3 dry scaly area right heel, 2.8 x 2 deep tissue injury right heel. 2.4 x 1 dry area on left heel. Tx (treatment) to apply skin prep BID to left heel, and right heel clean with ns, pat dry, apply xeroform, ABD (abdominal dressing), wrap with conforming gauze, and secure with tape change QOD. Skin observation tool dated 01/21/2020 at 12:40 PM reflected: 49) right heel deep tissue injury 2.8 x 2 x 0 cm 49) right heel dry skin 6 x 3 x 0 cm 50) left heel dry skin 2.4 x 1 x 0 cm. On 01/28/20 at 04:42 PM R228 revealed he had a sore on the back of his right heal, and that's why he had to wear the black foam padded shoe like boot. R228 was observed on 01/29/2020 at 12:18 PM with a black colored shoe boot on his right foot. On 01/29/2020 at 03:16 PM R228's dressing change to his right heel was observed. R228's right heel had a circular concave area filled with black eschar (Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound). The left heel was closed with no opened areas noted. The License Practical Nurse (LPN G) was observed to measure the right heel, with measurements she verbalized as 2.2- 2.0 x 3.7-3.0 cm. However, the skin observation tool dated a 01/29/2020 at 05:56 PM reflected: 49) right heel 2.7 x 2 x 0 eschar 50) left scab 49) right heel dry peri 3.7 x 3 x 0. The measurements from the 01/29/2020 at 05:56 PM conflicted with the measurement taken by LPN G at 03:16 PM. Review of the (MONTH) 2020 Treatment Administration Record (TAR) reflected treatment to R228's right heel did not start until 01/07/2020 and treatment to his left heel started on 01/06/2020, and that R228 did not receive treatment to his right heel on (MONTH) 12, 13 and 27.

This citation has 2 Deficient Practice Statements, DPS A and DPS B. DPS A: Based on observation, interview and record review, the facility failed to assess, monitor, and implement individualized interventions to prevent a leg ulcer, in 2 of 3 residents reviewed with skin alterations (Resident #54, and #59), resulting in infection (R59) decreased quality of life (R#59 & R#54), pain (R#59), and time-consuming treatments(R#59). Findings include: Resident #59 (R59) On 01/28/20 at 2:44 PM, R59 was observed sitting in a recliner chair with a gauze bandage wrapped around her right lower leg and an ankle foot orthosis (brace for foot drop) over top of a compression stocking was noted on the left lower extremity. R59 was not wearing a compression stocking on her right leg. R59's Minimum Data Set (MDS) 3.0 assessment dated [DATE] introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 10 (Scale 08-12 indicated Moderate Impairment). The same MDS assessment revealed R59 was admitted to the facility 6/21/2019 and had the [DIAGNOSES REDACTED]. The same MDS assessment revealed R59 did not reject evaluation or care and required extensive assistance (staff provided weight bearing support) in bed mobility (how resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture) during the look-back period. The same MDS assessment identified a functional limitation in range of motion (limited ability to move a joint that interfered with daily functioning) on one side of her upper extremity (shoulder, elbow, wrist, hand). physician progress notes [REDACTED]. Skin Observation Tool dated 12/12/2019 indicated R59 had no skin issues noted. physician progress notes [REDACTED]. The same progress note indicated R59 had [MEDICAL CONDITION] (swelling) in her legs. Nurse Progress Note dated 1/6/2020 at 6:56 AM indicated R59's right shin ulcer had drainage with a foul odor and slough was present. The same note indicated the treatment dressing order was changed. There were no potential for wound infection or alterations in skin integrity problem statements, revised goals, or interventions to R59's care plan. Skin Observation Tool dated 01/09/2020 revealed R59 had a vascular ulcer that was healing on her left lower extremity. There were no measurements or description of the ulcer included in the assessment. Podiatrist Visit Summary dated 01/13/2020 noted venous stasis ulcerations to R59's right lower extremity. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility (LTCF) Resident Assessment Instrument (RAI) 3.0, Version 1.17.1, (MONTH) 2019, defined venous ulcers as ulcers caused by peripheral venous disease, which most commonly occur above the inner and outer ankle area, or on the lower calf area of the leg. The same source indicated venous ulcers should be accounted for in the interdisciplinary care plan. R59's (MONTH) 2020 Medication Administration Record [REDACTED]. Skin Observation Tool dated 1/23/2020 at 8:53 PM revealed R59's right lower leg presented with a vascular ulcer wound. There were no measurements, description of wound boarders or surrounding skin, color or amount of drainage. Nurses Progress Note dated 01/28/2020 at 2:26 PM revealed R59 had two open areas to her right lower extremity that were red and tender with tan drainage. The same note did not include the amount of drainage. There were no alterations in skin integrity problem statements, revised goals, or interventions to R59's care plan. Nurses Progress Note dated 02/03/2020 at 11:02 AM revealed R59 received [MEDICATION NAME] (antibiotic) for a wound infection on her right leg. In review of R59 care plans, current venous stasis ulcers or skin alterations were not noted. R59's risk for impaired skin integrity care plan, related to decreased mobility and incontinence, initiated 07/03/2019, target date of 03/26/2019, had a goal that her skin would remain intact and free of pressure ulcers/injuries, and other skin impairments. The same risk for impaired skin integrity care plan did not include any new interventions since 10/09/2019. R59's same care plan did not include individualized interventions to elevate her legs. R59's Activities of Daily Living (ADL) care plan dated 07/03/2019 and (MONTH) 2019 Treatment Administration Record (TAR) revealed she wore [MEDICAL CONDITION]-Embolic-Deterrent (TED, prevent blood clots) stockings on both legs, on in the AM and off in the PM was implemented on 07/25/2019. The same care plan/TAR did not include instructions on elevating R59's legs. According to a (MONTH) 2019 article titled Chronic [MEDICAL CONDITION], A Review for Nurses retrieved from the Nursing 2020 website at https://journals.lww.com/nursing/Fulltext/2019/ /Chronic_venous_insufficiency__A_review_for_nurses.8.aspx, patient teaching for prevention of venous stasis ulcers included to recommend leg elevation above the level of the heart for 30 minutes three to four times a day. The same source recommended to wash skin daily with mild soap and tepid water and to use a skin moisturizer at least daily. Resident #54 (R54): Per the facility face sheet R54 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. In an interview on 1/28/2020, at 01:57 PM, R54 stated she has a sore on her bottom from sitting too long, and the staff put cream on it. Observation on 1/28/2020, at 2:04 PM, of R54's buttocks revealed her right and left upper buttocks, middle, and lower buttock area was very excoriated (abrading or wearing off the skin, chafing). R54's left buttocks was observed to have scar tissue approximately 4 centimeters (cm) in diameter. Record review of progress notes, dated 10/24/2019, revealed R54 had open skin developed over previously healed pressure injuries. Review of R54's Skin Observation Tool revealed the following was documented on 12/27/2019, R54, Continues with open areas to buttocks. Review of R54's Skin Observation Tool revealed the following was documented on 1/17/2020, R54's, Skin is clean, dry, and intact. Review of R54's Skin Observation Tool revealed the following was documented on 1/24/2020, at 7:12 AM, R54, no skin issues to report. Review of R54's Skin Observation Tool revealed the following was documented on 1/24/2020, at 9:00 PM, R54, Continues with open areas to buttocks. Review of a, Pressure Ulcer Log revealed R54 was documented to have a stage 1 pressure ulcer to her left buttocks which measured 3 x 3.5 cm, and was first observed on 10/14/2019, and a stage 2 pressure ulcer to her right buttocks, that was first observed on 10/14/2019. The log revealed the log for R54's pressure ulcers was last updated on 1/13/2020. In an interview on 1/30/2020, at 12:26 PM, Registered Nurse [NAME] (RN), who was a Unit Manager (UM) for the north and south halls, stated when R54 was first admitted she had stage 3 and stage 4 pressure ulcer on her bottom and those were healed, but had scar tissue. RN [NAME] stated R54's previous pressure wounds had managed to stay closed, but had started to breakdown again. RN [NAME] said she usually would document R54's wound measurements on a wound care note under assessments in R54's Electronic Medical Record (EMR), but stated that she had not documented R54's wound's yet in her EMR. Record Review of R54's EMR with RN [NAME] during the interview revealed, R54 had no documented wound care notes in her EMR. RN [NAME] stated that she has not had time to measure R54's wounds as she had been working on the floor, and she could not assess resident wounds while she was assigned to work on the floor. RN [NAME] further stated that she would work third shift often and therefore was not onsite at the facility during the day to assess resident's wounds/skin issues. RN [NAME] said she did wound measurements weekly on Thursdays. RN [NAME] said she would try to keep tract of resident wounds to ensure the treatments are effective and if a treatment needed to be change. RN [NAME] said the nurses who work on the floor were responsible for resident skin assessments and were to check resident's skin with every shower, which was routinely done two times per week. RN [NAME] was asked how she would know if a resident's skin or wound was getting worse, and she stated that she assessed resident's skin weekly, and stated that the nurses documenting on a resident's skin assessment no new issues was not acceptable. DPS B Based on observation, interview and record review the facility failed to observe and ensure the administration of ingested medications as ordered by physician for Resident #33, resulting in medications documented as given that were not given, medications including a narcotic left unattended in residents room until survey discovery, and the potential for adverse side effects; and failed to assess [MEDICAL TREATMENT] Resident #228 access site resulting in the potential for residents AV Fistula not being cared for properly. Findings Include: Resident #33 (R33) While touring the south unit of the facility on 01/28/2020 at 11:06 AM R33 was observed in her room sitting up in her recliner watching TV. A medication cup was observed within reach on her bedside dresser with medications in it. R33 revealed the nurse had left them there for her to take. A total of 14 tablets were observed in the medicine cup with R33's last name written on it. At 11:09 AM the Assistant Director of Nursing (ADON C) revealed she had just picked up working as the floor nurse for the south unit at 10:00 AM. ADON C was asked if R33 had been assessed to self-administer her medications. ADON C looked in the Electronic Medical Record (EMR) for R33, could not locate one and revealed she did not think R33 had been assessed for self-administration of medications. ADON C was requested to pull up R33's medications on her Medication Administration Record [REDACTED] 1. [MEDICATION NAME] (anti-hypertensive) 1/2t (tablet) 15 milligrams (mg) 2. [MEDICATION NAME] (anti-depressant) 1t 10 mg 3. [MEDICATION NAME] (diuretic) 1t 40 mg 4. [MEDICATION NAME] ([MEDICAL CONDITION] medication) 1t 75 micrograms (mcg) 5. Aspirin (blood thinner) 1t 81 mg 6. Fish Oil (supplement) 1t 100 mg 7. Oyst-Cal with D (Vitamin D) 1t 500 mg - 200 IU (International Unit) 8. Magnesium Oxide (treats hypo-magnesium) 2t 250 mg 9. Multivitamin 1t 10. Tylenol ([MEDICATION NAME]) 2t 325 mg 11. Vitamin B12 TR 1t 1000 mcg 12. [MEDICATION NAME] (narcotic [MEDICATION NAME]) 1t 50 mg was signed out at 07:30 AM on the narcotic sheet by Registered Nurse (RN Q) witnessed by writer and ADON C. The above medications were signed out as given between 07:00 AM and 08:00 AM by RN Q. ADON C was asked if medications were to be signed out as given, if they had not been administered? ADON C replied, No. The above medications were then wasted by ADON C, witnessed by Licensed Practical Nurse (LPN R) into a drug buster container at 11:27 AM. The Ausmed 2020 online educational reference reflected the following about the 8 Rights of Medication Administration: Avoid Medication Errors: Most nurses have been taught the 8 Rights of Medication Administration, but here is a refresher: 1. Right Patient - use the three national patient identifiers to ensure that you are giving the medication to the patient it is intended for. Ask the patient to tell you their name while you check their unit record number (URN) and verify their date of birth. Then check the patient history you have matches the URN on their wrist. 2. Right Medication - check that the medication you are giving is the one that was actually ordered. 3. Right Dose - check that the order is appropriate for the patient. Too much or too little of a properly ordered medication can still cause issues for the patient. 4. Right Route - when checking the medication, it is important to determine whether you are giving the medication by the correct route. It is important to check that the order meets these requirements as well, and that the route is appropriate. 5. Right Time - ensure that you are giving the medication at the right time and that two dosages are not stacking up on one another. 6. Right Documentation - you should also check that you are properly documenting the medication, including the time, dosage, and route, so that you have proof of what you gave to the patient should there be a bad reaction. 7. Right Reason - you should also make sure that the medication is being given for the right reason. Does it make sense that you are giving this medication at this dosage? 8. Right Response - finally, check that the patient has had the correct and intended response to the medicine. For example, if you gave a beta-blocker to your patient with hypertension, check the patient later to determine if the blood pressure did, indeed, decrease. The facility's Resident Self Administration Of Medications policy revised (MONTH) (YEAR) reflected: Residents who are physically and cognitively able and so desire shall be allowed to self administer their own medications to allow maintenance of as much self-control, self-determination and independence as possible while at the same time maintaining the resident's safety. 1. Resident may self-administer their medications only after the assessment for self-administration of medication is complete and resident is competent and a physician order [REDACTED]. At the time of discovery a self-administration assessment had not been performed and/or completed for R33. Resident #228 (R228) On 01/29/20 at 09:51 AM the Electronic Medical Record (EMR) reflected Resident R228 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. R228's admission/5-day Minimum Data Set (MDS: resident assessment tool) dated 01/13/2020 reflected: cognitively intact, required extensive assistance of 1 to 2 persons for transfers, toilet use, dressing, hygiene and bathing. On 01/29/2020 at 12:18 PM R228 revealed he had just returned from [MEDICAL TREATMENT]. R228 was cleanly dressed/groomed and was observed to have a dry pressure dressing to his left lower forearm where he had a fistula. On 01/29/2020 at 05:10 PM R228's (MONTH) 2020 Medication Administration Record [REDACTED]. On 01/30/20 at 12:02 PM the Director of Nurses (DON B) was interviewed. DON B was asked if bruit and thrill checks should be done on [MEDICAL TREATMENT] patients who have fistulas. DON B revealed that bruit and thrill should be checked daily and documented on the patients Medication Administration Record [REDACTED]. The facility's Care of [MEDICAL TREATMENT] Resident policy dated (MONTH) (YEAR) reflected the following under PR[NAME]EDURE: [NAME] Assessment of a mature arterial/venous graft or fistula. 1. Observe the patient for signs and symptoms of adequate vascular circulation of access limb, every shift (and prn) and report any changes or abnormalities to the physician. Assess for color, warmth, feeling and pain. Changes may indicative of steal syndrome (decreased/absent pulses, cold painful extremity). The Aura vascular care online educational reference dated 2020 reflected: A [MEDICAL TREATMENT] fistula bruit, also called a vascular murmur, is an important sound and indicator of how well your [MEDICAL TREATMENT] access is functioning. [MEDICAL TREATMENT] requires access to your blood vessels. An arteriovenous fistula or AV fistula is one access type that is created by connecting an artery to a vein under the skin, usually in the upper or lower arm. The high blood flow from the artery through the vein allows the fistula to grow larger and stronger. A healthy AV fistula has: -A bruit (a rumbling sound that you can hear) -A thrill (a rumbling sensation that you can feel) -Good blood flow rate Small vessels or other medial conditions may make it difficult for some people to have a successful fistula, so it's important to check your progress. One of the most common issues patients with a [MEDICAL TREATMENT] fistula develop is stenosis or narrowing of the veins and/or artery. (ii) Changes in the bruit or thrill at the fistula site may indicate stenosis. If you do not feel thrill or hear the bruit on your access, call your doctor or the [MEDICAL TREATMENT] center immediately. Changes in fistula bruit may signal a serious issue with your [MEDICAL TREATMENT] fistula, so be sure to monitor it daily and report and changes to your doctor as soon as you notice them. Over time, blockages in the vein may reduce blood drainage of the flow of blood form your artery into the fistula, or your fistula may become fully blocked with blood clots.

This citation pertains to MI 748. Based on interview and record review the facility failed to provide one to one supervision of a resident with suicidal ideation during transport to the hospital for 1 of 2 (#201) sampled residents resulting in the potential for injury. Findings include: A review of the facility's admission record reflected that Resident 201 (R201) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. rhythm; psychotic symptoms; [MEDICAL CONDITION]; symbolic dysfunction (communication disorder related to dysfunctional speech, language and hearing processing); restless leg syndrome; muscle weakness; history of blood clots in the leg; history of urinary tract infections and [MEDICAL CONDITION]; prosthetic heart valve replacement 2 times; [DIAGNOSES REDACTED]; metabolic [MEDICAL CONDITION] (brain damage caused by disrupted body chemistry); anticoagulant use; gastric reflux (heart burn); history of [MEDICAL CONDITION] and stroke; [MEDICAL CONDITION]; hypertension and low blood pressure with syncopal [MEDICAL CONDITION] ([MEDICAL CONDITION] caused by low blood pressure). On 4/24/19 at 1:45 p.m., Director of Social Services Staff (SS) [NAME] was interviewed about transport of R201 to a Detroit hospital on [DATE]. R201 had been observed scratching at her wrists with the end of a paper clip on two occasions, and was saying things like, I don't want to be here, I want to die. R201 had also screamed and called out over the past several days, and was pointing at things on her wall that weren't there. R201 threatened to stop eating and taking medications because she was so upset. SS [NAME] said Psychologist M met with R201 and believed she was actively in danger to herself and should be sent out now. I spent all afternoon trying to arrange this admission to the Detroit hospital psych unit, SS [NAME] said. When asked about the decision to send R201 in the facility van with only a driver and not nursing staff to supervise her in case she became upset again, SSE said that R201 had settled down and was no longer making threats. A friend had been with her during the day, but was unable to go with her in the van. Ambulance service would only take a resident to the nearest hospital, not all the way to Detroit. R201 had also agreed to go to the hospital for treatment, said SS E. After this interview, SS [NAME] said that it was probably not a good idea to send her alone with only a driver. On 4/24/19 at 2:30 p.m., Director of Nurses (DON) B was interviewed, accompanied by Assistant Director of Nurses D. When asked why R201 was sent to Detroit hospital, DON B said it was because Psychologist M wanted the resident admitted after seeing her. Psychologist M suggested that her group admits at the Detroit hospital. R201 had already been to a local hospital for similar issues the day before, and was sent back with treatment for [REDACTED]. On 4/30/19 at 8:00 a.m., Transport Driver K was interviewed as follows; We left about 3:00 p.m., and it was a two hour drive (to the Detroit hospital), he said. When asked if he had ever received training about what to do if a resident became upset or unmanageable during a trip, Driver K said. I'm to pull over and dial 911. On 4/24/19 at 3:00 p.m., Psychologist M was interviewed discussed the evaluation of R201 after she had listened to what the nurses and social worker described. We should respond to a cry for help, she added. The facility had no policy/procedure about supervision while transporting a suicidal resident in the facility vehicle.

This citation pertains to MI 451 and MI 592 Based on observation, interview, and record review, the facility failed to implement care planned interventions for 2 (Resident #1 and #5) of 3 residents reviewed for falls, from a total sample of 6, resulting in immediate jeopardy when Resident #1 who was care planned to transfer and ambulate with 1 person contact guard assist while wearing shoes, fell on [DATE] at 9:50 pm, when Certified Nursing Assistant (CNA) D let go of Resident #1's gait belt resulting in Resident #1 sustaining a fall with right [MEDICAL CONDITION], hospitalization , and death and the potential for falls and/or injury for Resident #5. This deficient practice places 83 residents, who have been identified by the facility as being dependent on staff member assistance for transferring at risk for falls, injury, and/or death. Findings include: Resident #1 Review of the Admission Record and Minimum Data Set ((MDS) dated [DATE], revealed Resident #1 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #1 scored 3 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of Resident #1's Nursing Aide Care Card revised 7/17/17, revealed Resident #1 was a fall risk and required 1 person CGA (contact guard assist) for ambulation with a walker in her room. The Nursing Aide Care Card also revealed Resident #1 was to wear shoes. In an interview on 11/30/17 at 11:03 am, Director of Nursing (DON) B reported that CGA was holding onto gait belt while walking or transferring. Review of the Occurrence Statement Form, undated, revealed Resident (#1) walking with gait belt with CNA and CNA pulled covers back on bed to put resident to bed and resident fell backwards. The Occurrence Report revealed Resident #1's shoes were just removed for bed. In an interview on 11/29/17 at 3:53 pm, CNA D stated that was my 5th day of work (11/17/17, the day of Resident #1's fall) and CNA E was training her. CNA D reported it was her last day of orientation. CNA D stated we were kind of short staffed so (CNA E) thought I could walk (Resident #1) to the bathroom myself. CNA D reported Resident #1 was wearing regular socks because she forgot to put shoes on Resident #1. CNA D reported while walking Resident #1 back to bed, with a gait belt and walker, CNA D let go of Resident #1's gait belt so that CNA D could pull the blankets back on Resident #1's bed. CNA D reported Resident #1 then fell backwards and complained of right leg pain so CNA D rolled Resident #1 onto her left side and then notified Licensed Practical Nurse (LPN) C. In an interview on 11/30/17 at 11:55 am, Registered Nurse (RN) K reported she was the facility's educator. RN K reported she signed off on CNA D's competency check list on 11/17/17 at 1:30 pm. When asked how she knew CNA D was competent in following care plans, RN K stated I go based on what her trainers have documented and I discuss that with her (CNA D). RN K reported the verification of skills competency was going through a check list packet (packet that is checked off by the staff orienting a new staff member) and not physically going onto the floor to observe staff. In a telephone interview on 11/30/17 at 9:22 am, LPN C reported after Resident #1 fell , she quickly assessed Resident #1 and stated just looking at her I could tell her hip didn't look right .tried to see if she could straighten her leg and she wouldn't . LPN C reported Resident #1 was wearing regular socks. The surveyor attempted to contact CNA E via telephone on 11/29/17 at 4:07 pm and 12/4/17 at 12:13 pm. A return call was not received prior to the survey exit. DON B reported CNA E resigned after Resident #1's fall. Review of the facility's investigation, revealed .After completing HS (bedtime) care, the aide on duty was ambulating (Resident #1) using her walker and a gait belt was in place. At this point the aide began to turn down the blankets of the bed for (Resident #1). (Resident #1) was standing with her walker, supporting herself. The aide turned to turn down blankets when (Resident #1) lost her balance and fell on to her right side .The CNA did not follow the plan of care for someone with CGA, resulting in a fall .After being admitted to the hospital it was noted that (Resident #1) had fractured her right hip and right humerus. Surgery was performed to right hip . Review of the Certificate of Death dated 11/22/17, revealed Resident #1's manner of death was an accident due to right [MEDICAL CONDITION] & complications therof. Resident #5 Review of the Admission Record dated 11/16/17, revealed Resident #5 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Care Plan dated 11/15/17, revealed Resident #5 transferred and ambulated with the assistance of 2 staff members. Review of Resident #5's Fall Risk Evaluation dated 11/15/17, revealed a score of 11 (10 or above represents high risk). Review of Resident #5's Nursing Aide Care Card revised 11/27/17, revealed Resident #5 transferred with CGA (contact guard) assist of 2 staff and ambulated with CGA of 2 staff with a walker. An observation on 11/30/17 at 10:07 am, revealed LPN P ambulating Resident #5 from the bathroom to her recliner. Resident #5 was not wearing a gait belt, was not using a walker, and there was no assistance from a second staff member. In an interview on 11/30/17 at 10:10 am, when asked what Resident #5's transfer and ambulation status was, LPN P was unable to answer the question. LPN Q identified herself as training LPN P on 11/30/17 and reported Resident #5 was a stand by assist. When asked where that information was located, LPN P stated on her kardex (Nursing Aide Care Card). LPN P showed the surveyor Resident #5's care card on the back of her bedroom door and agreed the care card reflected Resident #5's transfer and ambulation status was 2 person contact guard assist. LPN P then stated I didn't even know that (care card) was there. I didn't want to say I didn't know, but I really didn't know. Today is my first day. NHA A was presented with Immediate Jeopardy Notification on 11/30/17 at 1:42 pm due to the facility's failure to to implement care planned interventions for 1 (Resident #1) who was care planned to transfer and ambulate with 1 person contact guard assist while wearing shoes. On 11/17/17 at 9:50 pm, while ambulating Resident #1 from the bathroom to bed, Certified Nursing Assistant (CNA) D let go of Resident #1's gait belt. Resident #1 sustained a fall with a right [MEDICAL CONDITION] resulting in hospitalization and death. A corrective action plan was requested from the facility to remove the immediate jeopardy. Immediate Jeopardy was removed on 11/30/17 when the facility had the following in place: 1) Effective 11/30/17, The Rehab Services Director and/or designee conducted therapy screens on all current residents to ensure the support required and ADL performance status is appropriate. 2) Effective 11/30/17, The Director of Nursing Services and/or designee have initiated educating all direct care staff on ADL performance as defined: Independent- no help or staff oversight Supervision-oversight, encouragement or cueing Limited assistance-resident highly involved in activity; staff provides guided maneuvering of limbs or other non-weight bearing assistance Extensive assistance-resident involved in activity; staff provides weight-bearing support Dependent-full staff performance 3) Effective 11/30/17, The Director of Nursing Services and/or designee transitioned all care cards to reflect the above terminology to assist all direct care staff with implementing appropriate care planned interventions. 4) Effective 11/30/17, The Director of Nursing Services and/or designee updated care plans and care cards to reflect any changes made during the therapy screen. 5) Effective 11/30/17, The Director of Nursing Services and/or designee has initiated competency evaluations in relation to care plans, care cards, and fall prevention. 6) Effective 11/30/17, Falls Prevention Policy and Procedure reviewed, no changes were made at this time. Resident Care Plan Policy and Procedure reviewed, no changes were made at this time. Resident Transfers Policy and Procedure reviewed, no changes were made at this time. 7) Effective 11/30/17, The Director of Nursing Services and/or designee have initiated education to all direct care staff on the above Policy and Procedures. Education was initiated to nursing staff regarding the importance of implementing care planned interventions with special focus on safe transfer/ambulation technique and prevention of falls. 8) 100% of direct care staff to be educated was initiated 11/30/17. All direct care staff will sign off before working the floor. Although the Immediate Jeopardy was removed on 11/30/17, the facility remained out of compliance at the scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy, due to the fact that sustained compliance could not be verified by the State Agency.

This citation pertains to MI 053 Based on observation, interview, and record review the facility failed to ensure medication orders were in place upon admission for 2 (Resident #2, #3) of 3 residents reviewed for admission orders [REDACTED]. Findings include: Review of the facility's Admissions Policy dated 12/2008, revealed Purpose: A licensed nurse, with or without the assistance of a nursing assistant, will complete the admission process for all guests in a timely manner following entrance to the facility. This process is completed in an effort to adapt guest to the facility, promote the guest's highest level of independence and quality of life, and create a comfortable living environment for the guest .9. The licensed nurse should verify the admission orders [REDACTED]. 10. Fax admissions orders to the pharmacy . Resident #2 Review of the Face Sheet revealed Resident #2 was a [AGE] year old female, admitted to the facility on [DATE], after a total knee replacement and with [DIAGNOSES REDACTED]. Resident #2 did not have an admission Minimum Data Set (MDS) completed. Resident #2 discharged from the facility on 9/16/17. In a telephone interview on 9/20/17 at 10:06 am, Resident #2 stated when I got there (the facility) they said no one sent my medicine with me. So I sat in my chair all day that day and all night and then the next day they came in and gave me a pill out of their box (narcotic pain medication out of the back up supply) .didn't get any medications until really late the next night .I was on heart medications and pain medications. When asked if she was in pain the night of admission, Resident #2 stated well yeah, I had 42 staples in my knee. I was supposed to be getting [MEDICATION NAME] (narcotic pain medication) every 4 hours and I wasn't getting any . Resident #2 reported she requested Tylenol, but was told it wasn't on her orders. Review of the Medical Record Pain assessment dated [DATE] (untimed), revealed Resident #2 had a current pain level of 6 out of 10 and her acceptable level of pain was 4 out of 10. In an interview on 9/20/17 at 3:03 pm, Licensed Practical Nurse (LPN) C reported he assisted Registered Nurse (RN) D by completing Resident #2's Pain assessment dated [DATE] between midnight and 1:00 am. LPN C reported he was unaware that orders were not in place. LPN C reported he informed RN D that Resident #2 was having knee pain and stated we offered to do ice. Review of Resident #2's medical record, revealed Physician Standing Orders which included Tylenol 650 mg (milligrams) by mouth every 6 hours as needed for pain. Review of Resident #2's Medication Administration Record [REDACTED]. Review of the physician's orders [REDACTED]. These orders included [MEDICATION NAME] 10/325 every 4 hours as needed for pain. Review of the Nursing Note dated the day after admission, 9/9/17 at 5:00 am and written by Registered Nurse (RN) D, revealed Res. (resident) upset (and) in pain r/t (related to) R TKR (right total knee replacement). (No) scripts were sent (with) res upon admission. (Name of hospital) notified who sent a copy of [MEDICATION NAME] (narcotic pain medication) script which was then forwarded to pharmacy. Res unhappy about this, but explained the circumstance. Res has since received one [MEDICATION NAME] 10/325 from back up. Received the ok @ 0700 (7:00 am/2 hours after Nursing Note was documented) (and) first shift nurse was able to properly medicate res. Review of the PRN (as needed) Pain Management Flow Sheet, revealed on 9/9/17 at 7:00 am, Resident #2 complained of 10 out of 10 knee pain and [MEDICATION NAME] was administered. Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. In an interview on 9/20/17 at 1:30 pm, RN H reported she was working on 9/8/17 when Resident #2 arrived to the facility around 5:30 pm without any orders. RN H stated I had nothing .I had to call over there (the hospital) and tell them I still needed orders to be faxed over. Those orders didn't come while I was here. When I gave report to RN D, I still didn't have orders for (Resident #2). RN H reported she did not complete Resident #2's admission assessment because there were 3 admissions that day after 3:00 pm and 3 discharges that same day. RN H reported she informed RN D, during shift change report, that nothing had been completed with Resident #2's admission. RN H stated, I couldn't verify orders that I didn't even have. In an interview on 9/20/17 at 12:00 pm, RN D reported she started work at 7:00 pm on 9/8/17 and there had been 3 admissions that day. RN D reported Resident #2's pain scripts were not sent with her from the hospital. RN D stated I know they (the scripts) were for pain because her primary complaint was pain. I had no order .I tried to explain it to the resident. I told her I knew she was in pain .We didn't even have a med (medication) list for her RN D reported she was finally able to get a hospital employee to fax copies of the script to the facility. When asked what was being done for Resident #2's pain, RN D stated I called the on call physician 3 or 4 times and never received a call back. When asked if she attempted to contact the medical director, RN D stated I never have. RN D reported she was aware there was a standing order for Tylenol and stated I didn't give it to her .I could have easily given her Tylenol and I should have . RN D stated she did not call the physician to verify admission orders [REDACTED]. In an interview on 9/21/17 at 8:10 am, LPN E reported Resident #2 was admitted on a Friday evening, and she worked Saturday morning. LPN E stated I got here and the resident was upset and wanted to go home because she didn't have any meds. (RN D) reported off to me and told me the resident didn't have anything for pain. We had a copy of the scripts by this time .This lady (Resident #2) hadn't had anything for pain and she was very painful, almost in tears, had a knee replacement. Pain level was 8, 9, or 10 . LPN E reported she called the hospital who informed her that the medications marked as admission on the Medication Reconciliation were to be continued at the facility. LPN E reported she then wrote out the medication orders and verified them with the physician. LPN E confirmed that Resident #2 had not received any pain medication prior to 7:00 am on 9/9/17. In an interview on 9/20/17 at 2:23 pm, Director of Nursing (DON) B reported she was unaware that Resident #2 did not have orders in place until the day after admission. DON B stated they didn't call the doctor? In a second interview on 9/21/17 at 10:11 am, DON B reported there was referral paperwork faxed to the facility on [DATE] for Resident #2, but reported those medications would not be used as orders because medications could change between then and the admission time. DON B reported standing orders are in every resident's chart and are included in every admission packet. DON B agreed that Tylenol was a standing order for pain. Resident #3 Review of the Face Sheet revealed Resident #3 was an [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 did not have an admission MDS completed. Observations on 9/19/17 at 3:13 pm and 9/20/17 at 8:26 and 3:57 pm, revealed Resident #3 was asleep in her recliner chair in her room. Review of the Nursing Note dated 9/9/17, revealed Resident #3 was admitted to the facility on [DATE] at approximately 5:00 pm. Review of the physician's orders [REDACTED]. Review of the Long-Term Care Admission/Readmission Nursing Evaluation dated 9/9/17, revealed Resident #3 had a history of [REDACTED]. The next section revealed Resident #3 had current 4 out of 10 pain in her legs. Review of Resident #3's medical record, revealed Physician Standing Orders which included Tylenol 650 mg (milligrams) by mouth every 6 hours as needed for pain. Review of Resident #3's Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the Pain Assessment (undated) revealed Resident #3 had constant severe pain. In an interview on 9/21/17 at 8:10 am, LPN E reported Resident #3 arrived to the facility towards the end of her shift on 9/9/17. LPN E reported she wrote out all the admission orders [REDACTED]. LPN E reported she passed it onto the next shift (LPN K) to be completed. LPN E reported she worked the next day (9/10) and Resident #3 was in pain and stated I do remember she was quite anxious and needed her [MEDICATION NAME]. LPN E reported she conducted the above mentioned Pain Assessment on 9/10/17. LPN E reported she found Resident #3's narcotic medication scripts in the facility's recycle box and was not sure why the scripts were in the recycle box, but she then retrieved a [MEDICATION NAME] from the facility's back up supply of medication. LPN E reported the facility still did not have any medications for Resident #3 so she called the pharmacy. The surveyor attempted to contact LPN K via telephone on 9/20/17 at 3:47 pm and on 9/21/17 at 8:03 am. In an interview on 9/20/17 at 11:20 am, DON B reported pharmacy delivered medications twice daily to the facility between 11:00 am and 12:00 pm and between 8:00 pm and 9:00 pm. DON B reported if medications were verified and faxed to pharmacy by 6:00 pm, the medications should arrive in that night's delivery. DON B reported after 6:00 pm and on the weekends, the facility could contact the hospital who would drop ship medications.

This citation pertains to MI 053 Based on observation, interview, and record review the facility failed to ensure timely assessment and treatment for [REDACTED].#2, #3) of 3 residents reviewed for pain, from a total sample of 4, resulting in pain and a delay in pain management. Findings include: Review of the facility's Admissions Policy dated 12/2008, revealed Purpose: A licensed nurse, with or without the assistance of a nursing assistant, will complete the admission process for all guests in a timely manner following entrance to the facility. This process is completed in an effort to adapt guest to the facility, promote the guest's highest level of independence and quality of life, and create a comfortable living environment for the guest .9. The licensed nurse should verify the admission orders [REDACTED]. 10. Fax admissions orders to the pharmacy . Resident #2 Review of the Face Sheet revealed Resident #2 was a [AGE] year old female, admitted to the facility on [DATE], after a total knee replacement and with [DIAGNOSES REDACTED]. Resident #2 did not have an admission Minimum Data Set (MDS) completed. Resident #2 discharged from the facility on 9/16/17. In a telephone interview on 9/20/17 at 10:06 am, Resident #2 stated when I got there (the facility) they said no one sent my medicine with me. So I sat in my chair all day that day and all night and then the next day they came in and gave me a pill out of their box (narcotic pain medication out of the back up supply) .didn't get any medications until really late the next night .I was on heart medications and pain medications. When asked if she was in pain the night of admission, Resident #2 stated well yeah, I had 42 staples in my knee. I was supposed to be getting [MEDICATION NAME] (narcotic pain medication) every 4 hours and I wasn't getting any . Resident #2 reported she requested Tylenol, but was told it wasn't on her orders. Review of Resident #2's entire medical record, revealed the first pain assessment was completed on 9/9/17. Review of the Pain assessment dated [DATE] (untimed), revealed Resident #2 had a current pain level of 6 out of 10 and her acceptable level of pain was 4 out of 10. In an interview on 9/20/17 at 3:03 pm, Licensed Practical Nurse (LPN) C reported he assisted Registered Nurse (RN) D by completing Resident #2's Pain assessment dated [DATE] between midnight and 1:00 am. LPN C reported he was unaware that orders were not in place. LPN C reported he informed RN D that Resident #2 was having knee pain and stated we offered to do ice. Review of Resident #2's medical record, revealed Physician Standing Orders which included Tylenol 650 mg (milligrams) by mouth every 6 hours as needed for pain. Review of Resident #2's Medication Administration Record [REDACTED]. Review of the physician's orders [REDACTED]. These orders included [MEDICATION NAME] 10/325 every 4 hours as needed for pain. Review of the Nursing Note, the day after admission, dated 9/9/17 at 5:00 am and written by Registered Nurse (RN) D, revealed Res. (resident) upset (and) in pain r/t (related to) R TKR (right total knee replacement). (No) scripts were sent (with) res upon admission. (Name of hospital) notified who sent a copy of [MEDICATION NAME] (narcotic pain medication) script which was then forwarded to pharmacy. Res unhappy about this, but explained the circumstance. Res has since received one [MEDICATION NAME] 10/325 from back up. Received the ok @ 0700 (7:00 am/2 hours after Nursing Note was documented) (and) first shift nurse was able to properly medicate res. Review of the PRN (as needed) Pain Management Flow Sheet, revealed on 9/9/17 at 7:00 am, Resident #2 complained of 10 out of 10 knee pain and [MEDICATION NAME] was administered. Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED] In an interview on 9/20/17 at 1:30 pm, RN H reported she was working on 9/8/17 when Resident #2 arrived to the facility around 5:30 pm without any orders. RN H stated I had nothing .I had to call over there (the hospital) and tell them I still needed orders to be faxed over. Those orders didn't come while I was here. When I gave report to RN D, I still didn't have orders for (Resident #2). RN H reported she did not complete Resident #2's admission assessment because there were 3 admissions that day after 3:00 pm and 3 discharges that same day. RN H reported she informed RN D, during shift change report, that nothing had been completed with Resident #2's admission. RN H stated I couldn't verify orders that I didn't even have. In an interview on 9/20/17 at 12:00 pm, RN D reported she started work at 7:00 pm on 9/8/17 and there had been 3 admissions that day. RN D reported Resident #2's pain scripts were not sent with her from the hospital. RN D stated I know they (the scripts) were for pain because her primary complaint was pain. I had no order .I tried to explain it to the resident. I told her I knew she was in pain .We didn't even have a med (medication) list for her RN D reported she was finally able to get a hospital employee to fax copies of the script to the facility. When asked what was being done for Resident #2's pain, RN D stated I called the on call physician 3 or 4 times and never received a call back. When asked if she attempted to contact the medical director, RN D stated I never have. RN D reported she was aware there was a standing order for Tylenol and stated I didn't give it to her .I could have easily given her Tylenol and I should have . RN D stated she did not call the physician to verify admission orders [REDACTED] In an interview on 9/21/17 at 8:10 am, LPN E reported Resident #2 was admitted on a Friday evening, and she worked Saturday morning. LPN E stated I got here and the resident was upset and wanted to go home because she didn't have any meds. (RN D) reported off to me and told me the resident didn't have anything for pain. We had a copy of the scripts by this time .This lady (Resident #2) hadn't had anything for pain and she was very painful, almost in tears, had a knee replacement. Pain level was 8, 9, or 10 . LPN E reported she called the hospital who informed her that the medications marked as admission on the Medication Reconciliation were to be continued at the facility. LPN E reported she then wrote out the medication orders and verified them with the physician. LPN E reported Resident #2 had not received any pain medication prior to 7:00 am on 9/9/17. In an interview on 9/20/17 at 2:23 pm, Director of Nursing (DON) B reported she was unaware that Resident #2 did not have orders in place until the day after admission. DON B stated they didn't call the doctor? In a second interview on 9/21/17 at 10:11 am, DON B reported there was referral paperwork faxed to the facility on [DATE] for Resident #2, but reported those medications would not be used as orders because medications could change between then and the admission time. DON B reported standing orders are in every resident's chart and are included in every admission packet. DON B agreed that Tylenol was a standing order for pain. Resident #3 Review of the Face Sheet revealed Resident #3 was an [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2 did not have an admission MDS completed. Observations on 9/19/17 at 3:13 pm and 9/20/17 at 8:26 and 3:57 pm, revealed Resident #3 was asleep in her recliner chair in her room. Review of the Nursing Note dated 9/9/17, revealed Resident #3 was admitted to the facility on [DATE] at approximately 5:00 pm. Review of the physician's orders [REDACTED]. Review of the Long-Term Care Admission/Readmission Nursing Evaluation dated 9/9/17, revealed Resident #3 had a history of [REDACTED]. The next section revealed Resident #3 had current 4 out of 10 pain in her legs. Review of Resident #3's medical record, revealed Physician Standing Orders which included Tylenol 650 mg (milligrams) by mouth every 6 hours as needed for pain. Review of Resident #3's Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the Pain Assessment (undated) revealed Resident #3 had constant severe pain. In an interview on 9/21/17 at 8:10 am, LPN E reported Resident #3 arrived to the facility towards the end of her shift on 9/9/17. LPN E reported she wrote out all the admission orders [REDACTED]. LPN E reported she passed it onto the next shift (LPN K) to be completed. LPN E reported she worked the next day (9/10) and Resident #3 was in pain and stated I do remember she was quite anxious and needed her [MEDICATION NAME]. LPN E reported she conducted the above mentioned Pain Assessment on 9/10/17. LPN E reported she found Resident #3's narcotic medication scripts in the facility's recycle box and was not sure why the scripts were in the recycle box, but she then retrieved a [MEDICATION NAME] from the facility's back up supply of medication. LPN E reported the facility still did not have any medications for Resident #3 so she called the pharmacy. The surveyor attempted to contact LPN K via telephone on 9/20/17 at 3:47 pm and on 9/21/17 at 8:03 am. In an interview on 9/20/17 at 11:20 am, DON B reported pharmacy delivered medications twice daily to the facility between 11:00 am and 12:00 pm and between 8:00 pm and 9:00 pm. DON B reported if medications were verified and faxed to pharmacy by 6:00 pm, the medications should arrive in that night's delivery. DON B reported after 6:00 pm and on the weekends, the facility could contact the hospital who would drop ship medications.

This citation pertains to intake MI 166 & MI 326. Based on observation, interview, and record review, the facility failed to provide adequate supervision and answer call bells timely for 3 of 5 residents reviewed with falls (Residents #51, #52, & #57), from a total sample of 8 residents, resulting in fractures (Residents #52 & #57) and increased risk for falls. Findings include: Resident #51 On 1/18/17 at 7:40 AM, Resident #51 was observed sitting in a wheelchair in the North 1 unit dining room with his eyes closed. Resident #51's Admission Record dated 9/3/0/16 revealed he was a [AGE] year old with the [DIAGNOSES REDACTED]. Resident #51's most recent Minimum Data Set (MDS: Residnet Assessment Tool) dated 12/6/16 revealed his cognition was severely impaired and required extensive assist of two people for bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #51's risk for impaired skin integrity care plan dated as revised on 6/21/16 revealed to encourage and assist with turning and repositioning approximately every 2 hours and as needed. The impaired mobility and activity of daily living care plan dated as revised on 6/12/15 with a goal to be clean, appropriately dressed and well groomed at all times revealed Resident #51 required the use of a mechanical lift with 2 person assist for transfers. Occupational Therapy noted dated 4/20/16 indicated Resident #51 required a high-back wheelchair due to leaning toward his right side and a bolster applied to his arm rest due to fall risk precautions. 1/17/17 at 2:20 PM, Resident #51's family member K was interviewed and stated the facility was in need of an additional nurse assistant on North 1 unit and she had waited approximately 50 minutes for his call bell to be answered the previous Sunday for care needs. During the same interview, Resident #51's family K stated in the same interview that call bell response times were an on-going issue as well as receiving appropriate activities of daily living (ADL) care. Resident #52 On 1/17/17 at 12:45 PM, Resident #52 was observed sitting in a wheelchair in her room with a cast on her lower left leg and whiskers on her chin. Resident #52 stated I don't know how long my call light (bell)was on last night, but it was a long time and also recalled that she recently waited 25 minutes for a nurse to come to assist her with a leaking colostomy bag. Resident #52's family member L stated she felt that the facility was understaffed and that her mother required a lot of care. Family member L stated during the same interview that she had voiced her care concerns to management on several occasions. On 1/18/17 at 2:20 p.m., the Tight VNC Viewer call bell tracking system manufactured by Compass revealed on 1/16/17 at 6:32 p.m., Resident #52's call light was on for over 74 minutes. Resident #52's Admission Record dated 1/4/17 revealed she was a [AGE] year old with the [DIAGNOSES REDACTED]. Resident #52's most recent MDS assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating her cognition was intact. The same MDS assessment indicated she required extensive assistance of two people for transfers, bed mobility, and toileting. Occurrence Statement Form dated 4/30/16 at 8:30 AM revealed Resident #52 was observed on the bathroom floor in front of the toilet on her left side complaining of left hip pain. The fall investigation summary titled Occurrence Incident dated 4/30/16 revealed Resident #52 had fractured her left hip. Occurrence Statement Form dated 9/26/16 at 11:50 PM revealed Resident #52 requested to use the commode, the Certified Nurse Assistant (CNA) assisted her to sit on the side of the bed, and while standing in the doorway asking for help, Resident #52 fell to the floor. The fall investigation summary titled Occurrence Incident dated 9/29/16 revealed Resident #52's ankle became swollen and bruised following the fall. Resident #52's ADL care plan dated as revised on 1/4/17, indicated to assist her with 2 person assistance for transfers. Occurrence Statement Form dated 12/25/16 at 8:35 AM, revealed Resident #52 was lowered to the floor next to her bed. Occurrence Incident Staff Statement dated 12/25/16 at 8:35 AM indicated the CNA attempted to transfer Resident #52 with a one person assist from the bed to her wheelchair and after standing Resident #52 stated she felt like her knee was going to give out, and was lowered to the floor. The same statement revealed Resident #52's care plan was not followed because a second assist person and a gait belt were not used. 1/18/17 at 2:50 PM, CNA D stated that if another CNA would have been available, she would not have attempted to transfer Resident #52 by herself on 12/25/16. Resident #57 Resident #57's Admission Record dated 1/18/17 revealed he was [AGE] years old with the [DIAGNOSES REDACTED]. Resident #57's most recent MDS assessment dated [DATE] revealed his Brief Interview for Mental Status (BIMS) score was a 13 out of 15, indicating he was cognitively intact. The same MDS assessment indicated Resident #57 required extensive assistance with bed mobility, transfers, locomotion on and off the unit, eating, personal hygiene and toilet use. Occurrence Statement Form dated 1/15/17 at 6:00 PM, revealed Resident #57 was propelling himself back from supper and leaned forward to .fold (the) foot pedal up and toppled face first to (the) floor . Director of Nursing (DON) B stated on 1/18/17 at 11:00 AM that Resident #57 was able to propel his wheelchair with his feet, and the detachable wheelchair foot rests were left on his wheelchair at all times in case he needed assistance. According to the witness statements, all 3 assigned CNA's were assisting other residents with eating at the time of the fall. According to an article titled Real Solutions dated September 1995, retrieved from http://www.wheelchairnet.org/WCN_ProdServ/Docs/TeamRehab/RR_95/9509art1.PDF, If the foot rests are not needed for support, remove them and position the resident's feet flat on the floor. In an institutionalized setting, removing foot rests can allow residents to use their feet to self-propel or to reposition their feet during the day. Removing foot rests can also reduce lower-extremity skin tears and reduce the risk of falls from tripping over the front riggings. Discharge Instructions dated 1/16/17 revealed Resident #57, following the fall, was diagnosed with [REDACTED]. The same instructions revealed Resident #57 was to follow up with orthopedics within the next one to two weeks. ( ) On 1/18/17 at 1:25 p.m., an interview was conducted with Nurse Manger I regarding the facility call bell tracking system. Nurse Manger I responded: The system is Tight VNC Viewer and Compass is the company. On 1/18/17 at 1:35 p.m., Administrator A was asked if the facility had a specific Policy/Procedure for the call bell system. Administrator A replied: Yes, I believe we do. On 1/18/17 at 2:00 p.m., record review of the Policy/Procedure entitled: Call Light System dated 12/2015 revealed under Policy: To provide efficient and quality care to residents through a pager call light system. Additionally the Policy/Procedure entitled: Call Light System dated 12/2015 revealed under Purpose: The purpose of this policy is to timely accommodate the needs of residents by answering their call lights. Prompt answering of call lights can help decrease the risk of falls, helps encourage dignity/respect and overall promotes quality care and good resident outcomes. On 1/18/17 at 2:20 p.m., record review of the Tight VNC Viewer call bell tracking system manufactured by Compass revealed the following information: Resident Room Date Time Call Bell Response Time (Minutes) 26-1 (Resident #51) 11/17/16 1:08 p.m. 99:59 12/08/16 4:15 p.m. 30:53 12/15/16 4:10 p.m. 44:34 20-2 (Resident #52) 10/25/16 6:07 p.m. 44:49 10/27/16 6:03 p.m. 41:46 10/28/16 4:58 p.m. 48:28 11/05/16 9:48 p.m. 48:19 11/21/16 5:45 p.m. 61:18 11/24/16 5:42 p.m. 67:11 11/27/16 4:28 a.m. 82:06 12/02/16 5:55 p.m. 76:37 12/05/16 5:22 p.m. 89:39 12/08/16 8:54 p.m. 88:41 01/04/17 9:48 a.m. 65:18 01/08/17 6:05 p.m. 78:06 01/16/17 6:32 p.m. 74:21 27-2 (Resident #57) 12/05/16 6:56 p.m. 54:23 12/23/16 10:01 p.m. 61:06 12/24/16 7:06 a.m. 82:27 01/03/17 6:59 a.m. 84:25 01/15/17 6:03 p.m. 40:09 Note: The aforementioned call bell response time in minutes ranged from a minimum of 30:53 to a maximum of 99:59. ( )

This citation pertains to MI 174, MI 444 & MI 260. Based on interview and record review the facility failed to ensure proper use of a gait belt for 1 sampled resident (#1) out of 7 assessed for falls and put interventions in place for 1 sampled resident (#11) with frequent falls from a total of 19 resulting in a fractured arm, pain and a significant decline in condition for Resident #1 and continued falls for resident #11. Findings include: A review of documents provided by the facility in lieu of a request for a policy, titled Gait/Transfer Belts, and dated 1994, reflected, Gait/Transfer Belts are to be USED AT ALL TIMES! Make sure your hand is always firmly holding the gait belt at all times during the transfer or ambulation. Do not turn away from the patient for any reason during a transfer or while patient standing/ambulating. Resident #1 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. curve in upper spine) with restrictive lung disease (curved spine won't allow full use of lungs), and constipation. According to the Minimum Data Set (MDS - resident assessment), dated 5/21/16, Resident #1 exhibited moderate memory problems, had impaired vision, required the assist of 1 staff person for bed mobility, transfers, ambulation, dressing, hygiene and bathing and toileting, and set-up only for eating. She was incontinent of bladder, had no complaints of, signs and symptoms of pain, and no falls in the past 3 months. According to the facility's physician order [REDACTED].#1 was prescribed Lyrica (for nerve pain), metoprolol (to lower blood pressure), Lasix (diuretic) and Ultram (for pain) that all have the potential to contribute to falls in the elderly. According to the care plan for mobility, dated 6/6/16, Resident #1 was to ambulate 2 to 3 times daily with a 4-wheeled walker, 1 staff person and gait belt for 50 to 100 feet. Resident #1 often forgot to use her call light before self-transferring. According to the fall risk assessment, dated 5/20/16, Resident #1 scored a 16 that indicated she was a high risk for falls. According to the facility's occurrence statement form, on 7/27/16 at 11:10 a.m., Resident #1 was ambulating past the north unit nurse's station and towards the dining room, using her 4-wheeled walker. Certified Nurse Assistant (CNA) N had a hold of Resident #1's gait belt in the back and was carrying Resident #1's mobility alarm in her other hand. CNA N turned away from Resident #1, let go of the gait belt to pull out a chair and Resident #1 fell and attempted to use her left arm to brace her fall. Resident #1 was assessed by Licensed Practical Nurse (LPN) M, returned to her bed, complained of left arm and right hip pain and sent to the hospital where she was diagnosed with [REDACTED]. On 9/13/16 at 9:15 a.m., LPN M was interviewed. When asked to recall what happened with Resident #1's fall on 8/27/16, LPN M said that she observed CNA N walking Resident #1 with the 4-wheeled walker and a gait belt, glasses and non-slip shoes. They proceeded and LPN M said that she felt something brush her leg, turned around and observed Resident #1 on the floor. When asked, LPN M said that you never let go of the gait belt, especially with Resident #1's tendency to push backwards with her feet, probably due to her poor balance. You could feel her do it when your hand was on the gait belt, said LPN M. On 9/13/16 at 12:50 p.m., CNA N was interviewed via phone. When asked what she could tell me about the use of gait belts, CNA N said, Never let go. I learned a terrible lesson. When asked if she was aware of this prior to Resident #1's fall, CNA N said that she was aware. When asked what happened that she took her hand off Resident #1's gait belt, CNA N said that she had an alarm in one hand, and needed to pull out the chair so Resident #1 could sit down. According to the MDS for significant change in condition, dated 8/3/16, Resident #1 had declined in several areas as follows: she now required the assist of 2 staff persons for bed mobility, transfers, ambulation in room and corridor, dressing, showers and toileting, and extensive assist of 1 staff person to eat. A review of 9/2016 physician's orders [REDACTED].#1 was prescribed Fentanyl patch (narcotic) after her fall and fracture. ( ) According to the Electronic Medical Record (EMR), Resided #11 was recently readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #11's significant change Minimum, Data Set (MDS) completed on 8/30/16 reflected he was moderately cognitively impaired, required extensive assistance to transfer and ambulate. Resident #11 was documented as having four falls since his admission on the following dates: 8/3/16, 8/16/16, 8/21/16 and 9/1/16. None of the four falls previously listed, had any new interventions developed and/or implemented to Resident #11's fall care plan to aide in the prevention of falls. Fall #2: 8/16/16 at 3:00 PM Resident found lying on his left side in front of his bathroom with walker on top of him. Bump of back of head, and thin abrasion top coccyx. Fall #3: 8/21/16 at 1:25 AM Resident found on the floor. No injury. Alarms in place. Fall #4: 9/1/16 at 5:00 AM Resident found on floor in front of recliner. No injury. Alarm in place. 9/15/16 at 10:38 AM Registered Nurse (RN Q) was interviewed related to Resident #11's multiple falls. RN Q stated, I didn't start here until 8/29/16. We don't do interventions on the care plan. For the falls nursing/nurse management are to do those and write them on the care plan. When I'm updating with a significant change, I will update if interventions are still relevant. Later the same day at around 11:15 AM RN (H) was interviewed related to Resident #11's multiple falls. RN H stated, The last one, I have not done. I have not updated the care plan for that one yet. He started radiation treatments and then he started to decline. He had frequent falls before he came in. I ran out of ideas and physical things to do. ( )

This citation pertains to intake number MI 382 and MI 385 Based on observation, interview, and record review, the facility failed to maintain beds at a safe distance from electric baseboard heaters to 1) prevent a blanket from being burned for 1 (Resident #3) and 2) prevent injury for 1 (Resident #1) of 3 reviewed for safe environment, from a total sample of 3, resulting in Resident #3's blanket being burned and Resident #1 sustaining 2nd and 3rd degree burns after his upper body was wedged between his bed and wall, onto the electric baseboard heating unit. Findings include: Resident #1 Review of the Face Sheet, revealed Resident #1 was a [AGE] year old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's fall risk evaluation dated 4/24/15, revealed a score of 18 (10 or above represents high risk for falls). Review of the Unusual Occurrence: Statement Form dated 4/25/15 at 9:55 am, revealed an incident in Resident #1's room that was unwitnessed and resulted in burn to right upper arm, right flank. In an interview on 4/29/15 at 9:14 am, Resident #1 reported that he fell between the bed and the floor heat register. Resident #1 reported his left leg dropped off the side of his bed and he recalled throwing his right leg over to try to catch his balance. Resident #1 stated I remember burning and it was painful. Resident #1 reported he yelled quite a bit for help and stated please don't let me burn. Resident #1 stated I knew I was in trouble. I kept waiting for my brief to catch on fire. When queried about his current pain level, Resident #1 stated probably about a 7 (using 0-10 pain scale). In a telephone interview on 4/30/15 at 10:00 am, Physical Therapist (PT) G reported that on 4/25/15, he went to Resident #1's room to perform a physical therapy evaluation. PT G reported that Resident #1's door was either partially or completely closed. PT G knocked on the door with no response and then knocked again while pushing the door open. PT G reported he then heard mumbling, opened the door more and heard louder mumbling. PT G reported he observed Resident #1's lower body on the bed, covered with blankets, and his upper body off the bed, between the bed and wall. PT G reported the bed was approximately 6-8 inches away from the wall, with the electric baseboard heater against that wall. PT G reported he called for help and everyone came running and it was a panic situation to save his (Resident #1) life. In an interview on 4/29/15 at 1:45 pm Registered Nurse (RN) E reported that she did not work Resident #1's unit that day, but was walking through the hall. RN E stated when I went in, I saw (Resident #1) with his head and the top of his body off the bed, between the bed and the wall. I got into the bed and tried to pull him up. I saw his arm was on the heater. I yelled he's being burned, move the bed. In an interview on 4/29/15 at 2:00 pm, Licensed Practical Nurse (LPN) F reported that she had last visualized Resident #1 lying in bed at approximately 9:30 am on 4/25/15. LPN F reported when she entered Resident #1's room during the incident, RN E was already present. LPN F reported herself and a Certified Nursing Assistant (CNA) grabbed the bed and threw the whole bottom portion of the bed over. Review of the emergency department's records dated 4/25/14, revealed (Resident #1) had an area on the right shoulder and right mid axillary region where there is mainly first and second degree burns. There is a small area on the left shoulder that's about 5 cm (centimeters) x 2 cm of third degree burn and also an area 2 cm x 2 cm in the right mid axillary region that is also third-degree burn. The primary [DIAGNOSES REDACTED]. Resident #1 was prescribed hydrocodone-acetaminophen 10-325 mg (milligrams)/15 mL (milliliters), give 15 mL via PEG tube (feeding tube) every 4-6 hours as needed for pain. An observation of wound care on 4/29/15 with RN E, revealed 6 burns on Resident #1's right upper arm and 1 burn right mid axillary. RN E confirmed there were 7 burn areas. The largest burn near Resident #1's right shoulder had a black eschar wound bed. Resident #1 held his brother's hand during most of the treatment, despite being administered pain medication prior to the wound treatment. Review of the facility's weekly wound assessment dated [DATE], revealed Resident #1 had 6 burns assessed and measured. There was no documentation of the 7th burn. The wound measurements were as follows: Right shoulder burn 10 cm x 2 cm Right shoulder burn 11 cm x 3 cm Right shoulder burn 16 cm x 6.5 cm Right shoulder burn 4 cm x 1.5 cm Right shoulder burn 8 cm x 2.5 cm Right axillary burn 6 cm x 5 cm During an interview on 4/29/15 at approximately 9:50 am, Maintenance Director C reported that the temperatures on the electric baseboard heat covers range from 160-190 degrees Fahrenheit when the heaters are on because the room is calling for heat. Maintenance Director C reported that the thermostats were across the room from the heaters and therefore, the heater would stay on until the thermostat recognized that the room had met the set temperature. An observation in room 58 (Resident #1's previous room) revealed that within 1 minute of the thermostat being turned on, the temperature of the electric baseboard heater was 165 degrees Fahrenheit based on the infrared gun. The coils between the top and front covers of the heater reached a temperature of 300 degrees Fahrenheit. Maintenance Director C stated the day it (Resident #1's burns) happened, we checked it (the heater) at 164 degrees. Maintenance Director C reported that all staff and residents have access to thermostats in the resident rooms. Resident #3 Review of the Face Sheet and MDS dated [DATE], revealed Resident #3 was a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#3 scored 12/15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). During an observation and interview on 4/29/15 at 9:35 am, Resident #3 reported that her bed was previously positioned under the window. An observation revealed an electric heating unit under the window. Resident #3 reported her bed was moved because approximately a month ago, her afghan was scorched by the heater and it was washed multiple times to get the smell out. An observation of Resident #3's afghan revealed 2 small yellowish discolorations near the center. There were 2 black linear discolorations, with the inside stuffing exposed, on the other bedspread covering Resident #3's bed. In an interview on 4/29/15 at 2:00 pm, LPN F reported that she was aware of the incident with Resident #3's afghan and reported it to maintenance. In an interview on 4/29/15 at 3:00 pm, Maintenance Staff D reported that nursing notified him of Resident #3's afghan. Maintenance Staff D could not recall the date, but reported it was before Resident #1 sustained burns from the heating unit. Maintenance Staff D reported he moved Resident #3's bed further away from the electric heating unit at that time. In an interview on 4/29/15 at 2:55 pm, Maintenance Director C reported he was not aware of the incident that involved Resident #3's afghan. In an interview on 4/30/15 at 11:00 am, Director of Nursing (DON) B reported she was not aware of the incident that involved Resident #3's afghan. When queried if Resident #1's burns could have been prevented, DON B stated If the bed would have been further away. In an interview on 4/30/15 at 12:00 pm, Nursing Home Administrator (NHA) A reported that he was not aware of Resident #3's afghan until 4/29/15. NHA A reported that had he been made aware, the interventions that the facility had implemented starting 4/25/15, would have been implemented at the time of the incident with Resident #3's afghan. Such interventions included: -ensure safety of like residents by moving beds 4 feet from the electric baseboard heater and the chairs/personal belongings 1 foot from the electric baseboard heaters -place markers in resident rooms to identify the 1 and 4 foot distances from the electric baseboard heaters -staff education regarding room configuration -monitoring room configuration compliance -implemented a policy and procedure regarding room configuration. Review of the Alert Burn Hazards Related to Heated Surfaces in Long Term Care Facilities dated 10/12/2004 and sent out by the State Agency Department of Community Health, revealed that a first degree burn will occur in approximately 3 seconds from a surface that is 140 degrees Fahrenheit. The document revealed Underwriter's Laboratory specifies that electrical baseboard heater surface temperatures not exceed 185 degrees F (Fahrenheit). The standard temperature for hot water boilers for fin tube radiation is 180 degrees F. However, these are the temperatures of the heating elements, not the covers of the radiators.Based on research by our Health Facilities Engineering Section, it has been determined that a temperature of 125 degrees Fahrenheit is normally acceptable on the surface of a heating unit in a nursing home or long term care facility. This temperature was determined from information found in ASTM International Standard C1055-03, titled Standard Guide for Heated System Surface Conditions that Produce Contact Burn Injuries.This maximum acceptable temperature is based on a maximum acceptable injury level of a first degree burn, which i reversible, and causes no permanent tissue damage, and a maximum contact time with the heats surface of 60 seconds, to reflect the slower reaction times of the elderly or the infirm. At this temperature, one must recognize that there is some risk.it is incumbent upon the facilities to identify those residents who may be unable to recognize the danger or pull away from the heat source and provide extra protective measures for those residents as needed. ( )

This citation pertains to MI 899 Based on observation, interview, and record review, the facility failed to ensure that fall alarms were out of reach, secure, and functional in 4 (Resident #101, #102, #103, and #104) of 6 sampled residents reviewed for falls, in a total sample of 6, resulting in: 1) Resident #101 sustaining a right hip fracture after a fall where the sensor (pressure) pad alarm box was not secure, in reach, and the switch was in the off position; 2) the potential for injury for Resident #102 after she was found with a sensor pad alarm box with the LED indicating a sensor was not installed; 3) the potential for injury for Resident #103 after she was found with an alarm box in reach; and 4) the potential for injury for Resident #104 after he was found with an alarm box that was not secure. Findings include: Review of the facility's Falls Prevention Policy and Procedure revised 4/2013, revealed "Fall prevention interventions used for all residents will be implemented" and "safety alarms are used in conjunction with other strategies...as an additional 'safety mechanism' to support the resident's increased care needs". Review of the Skil-Care Corporation MultiPro Wheelchair and Bed Alarm guidelines (undated), revealed "LED should flash when patient/resident is seated on the sensor pad. If LED fails to flash, check battery. Replace if necessary. If LED does not glow after battery is replaced, check sensor pad. Replace if necessary". The guidelines revealed there were three light sensor conditions. The first status of "on steady" was a condition of "no sensor installed, battery installed". The "slow flash" status was a condition of "sensor connected, battery installed" and the third "rapid flash" was a condition of "sensor connected, alarm activated". The guidelines revealed the alarms should be secured to a wheelchair with a cord loop or a Velcro tab and secured to the bed with a Velcro strip. Resident #101 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #101 was a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed that Resident #101 scored 3/15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of the Fall Risk assessment dated [DATE], revealed Resident #101 scored 22. A total score of 10 or above represents high risk. Review of the Impaired Mobility/ADL (Activities of Daily Living) Self Performance Care Plan dated 3/22/13, revealed Resident #101 transferred and ambulated with the assistance of 2 people. Review for the Risk for Injury/Falls Care Plan dated 3/22/13, revealed Resident #101 had a pressure alarm and tab alarm in place at all times. Review of the Nursing Notes dated 3/24/13, revealed "Res (Resident #101) was laying on floor with head against recliner, laying on right side. Res c/o (complained of) right leg/hip pain". Review of the Unusual Occurrence: Statement Form dated 3/24/13, revealed Resident #101 had an unwitnessed fall and had a pressure alarm that was "not turned on". Review of the Radiology Report dated 3/24/13, revealed Resident #101 had an "acute right hip fracture". During an interview on 7/17/13 at 1:50 PM, Registered Nurse (RN) #6 reported that she had been a Certified Nursing Assistant (CNA) and assigned to Resident #101 on 3/24/13 when Resident #101 fell . RN #6 stated that when she placed Resident #101 in bed, RN #6 secured the tab alarm box to Velcro on the head of the bed and placed the pressure alarm box on the night stand "right next to the bed, like within reaching". RN #6 reported that Resident #101's family visited and then notified RN #6 when they left. RN #6 reported that Resident #101 was observed on the floor approximately 10 to 15 minutes after her family left. RN #6 reported that she did not go into Resident #101's room between the time the family left and the fall occurred. RN #6 stated that when Resident #101 fell , "the alarms weren't sounding". When queried if she had ever witnessed Resident #101 manipulate the alarms, RN #6 stated "um yeah. I had seen her playing with them asking what they were". When queried how Resident #101 played with her alarms, RN #6 stated "she would unhook her tab alarm. I know that". When queried if the tab alarm was unhooked when Resident #101 fell , RN #6 stated "yeah" and reported that the magnet was attached to the alarm box, but the clip was unattached from Resident #101. During an interview on 7/17/13 at 11:41 AM, CNA #5 reported that on 3/24/13, she was walking down the hall and heard someone whimpering. CNA #5 reported that Resident #101's door was partly open and when CNA #5 opened the door, she observed Resident #101 lying on the floor a couple feet from her bed. CNA #5 reported that Resident #101 had both pressure and tab alarms, but no alarms were sounding. CNA #5 stated "neither were sounding, not sure why or how they would have not been sounding". CNA #5 reported that alarm boxes should be kept out of reach of residents. During a telephone interview on 7/17/13 at 1:40 PM, CNA #7 reported that he was making rounds with CNA #5 on 3/24/13. CNA #7 reported that when they "peeked in" on Resident #101, she was on the floor, quietly calling for help, and "no alarms sounding". CNA #7 stated "she (Resident #101) was supposed to have alarms. They should have been in place". During an interview on 7/17/13 at 3:20 PM, Licensed Practical Nurse (LPN) #10 stated "it was planned for her (Resident #101) to have an alarm in bed and that wasn't put on correctly. She got out of bed. Alarms weren't sounding". When queried what was incorrect about the alarm, LPN #10 stated "I don't think the alarm was switched on". LPN #10 stated "at that time, I'm not sure we had a policy in place to check alarms". LPN #10 reported that alarm boxes should be out of reach of the resident. LPN #10 stated "I think they do get put on the nightstand often". When queried if that was okay, LPN #10 stated "no". LPN #10 stated the "plan wasn't followed correctly". During an interview on 7/17/13 at 11:50 AM, when queried where alarm boxes should be placed, Director of Nursing (DON) #1 stated "they should be out of reach". During an observation on 7/17/13 at 2:20 PM, DON #1 showed this surveyor the type of sensor pad alarm box (Smart Economy Alarm) that was used for Resident #101 on 3/24/13. The alarm box was observed to have an attached strap with a buckle. When queried if she had the manufacturers guidelines for the alarm, DON #1 stated "no". Review of the Facility's Investigation revealed all staff witness statements regarding Resident #101's fall on 3/24/13, revealed the care plan was not followed because alarms were not sounding/turned on. An observation on 7/17/13 at 9:45 AM revealed Resident #101 sitting in a dining room chair, participating in an activity. Resident #101 had a pressure alarm in place with the alarm box sitting on the floor under her chair. Resident #102 Review of the Face Sheet and MDS dated [DATE], revealed Resident #102 was a [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #102 scored 1/15 (severe cognitive impairment) on the BIMS. Review of the At Risk for Injury/Falls Care Plan dated 1/15/13, revealed Resident #102 had a pressure alarm on at all times. An observation on 7/17/13 during initial tour, revealed Resident #102 was sitting in her wheelchair in the dining room during an activity. Resident #102 had a sensor pad alarm box on the back of her wheelchair. The LED light was a solid red (steady). The sensor pad cord appeared to be plugged in. This surveyor observed an alarm box that was not being used and did not have a sensor pad attached. That alarm box also had a solid red LED. During an interview on 7/17/13 at 10:15 AM, RN #2 was unable to correctly describe the meaning of the alarm box LED status per manufacturer's guidelines. During an interview on 7/17/13, CNA #4 was unable to correctly describe the meaning of the alarm box LED status per manufacturer's guidelines. During an interview on 7/17/13 at 1:50 PM, RN #6 was unable to correctly describe the meaning of the alarm box LED status per manufacturer's guidelines. Resident #103 Review of the Face Sheet and MDS dated [DATE], revealed Resident #103 was an [AGE] year old female, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS revealed Resident #103 scored 7/15 (severe cognitive impairment) on the BIMS. Review of the Fall Risk Evaluation dated 7/9/13, revealed Resident #103 scored 15. Review of the Risk for Injury/Falls Care Plan dated 7/16/13, revealed Resident #103 had a pressure alarm in place at all times. An observation on 7/17/13 at 9:10 AM, revealed Resident #103 was transferred with 2 staff assistance back into her electric recliner. The sensor pad alarm beeped when Resident #103 sat down. Staff placed the alarm box on the left arm rest of the recliner and left the room. The alarm box was observed to be in Resident #103's reach. An observation on 7/17/13 at 11:25 AM, revealed Resident #103 was sitting in her electric recliner in her room. The sensor alarm box was sitting on the left arm rest, within resident reach. Resident #104 Review of the Face Sheet and MDS dated [DATE], revealed Resident #104 was a [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS revealed Resident #104 scored 6/15 (severe cognitive impairment) on the BIMS. Review of the Fall Risk Evaluation dated 7/4/13, revealed Resident #104 scored 12. Review of the Risk for Injury/Falls Care Plan dated 6/25/13, revealed Resident #104 had a pressure alarm to chair at all times. An observation on 7/17/13 at 9:05 AM, revealed Resident #104 sitting in the electric recliner in his room. The pressure alarm was in place and the alarm box was sitting on the floor. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO PREVENT THE DEVELOPMENT OF PRESSURE SORES FOR 1 OUT OF 3 RESIDENTS REVIEWED (#5)FROM A TOTAL REVIEWED SAMPLE OF 21 RESIDENTS, RESULTING IN STAGE III AND UNSTAGEABLE PRESSURE SORES TO BILATERAL HEELS, INCREASE PAIN AND SIGNIFICANT DECLINE FROM AMBULATION TO HER INABILITY TO WALK FOR RESIDENT #5. FINDINGS INCLUDE: ACCORDING TO THE RECORD FACE SHEET DATED 07/16/2012, RESIDENT #5 WAS A [AGE] year OLD FEMALE WITH IMPAIRED COGNITION AND ACCUMULATIVE [DIAGNOSES REDACTED]. DURING OBSERVATION OF RESIDENT #5 ON 11/14/2012 IN THE AFTERNOON, RESIDENT #5 WAS LYING IN HER BED, BOTH FEET HAD HEEL PROTECTORS IN PLACE AND RESIDENT HAD HER EYES CLOSED. OBSERVATION OF RESIDENT #5 ON 11/15/2012 AT 8:15 AM IN THE NORTH DINING ROOM, RESIDENT #5 WAS SITTING IN A GERIATRIC RECLINING CHAIR AT THE BREAKFAST TABLE AND BEING FED BY UNIT STAFF. RESIDENT #5'S FEET HAD HEEL PROTECTORS IN PLACE AND SHE WAS SLIGHTLY RECLINED. OBSERVATION ON 11/15/2012 AT 9:40 AM IN RESIDENT #5'S ROOM, DRESSING CHANGE WAS OBSERVED TO LEFT HEEL. THE LEFT HEEL SHOWED GRANULATION TISSUE (PINK-RED MOIST TISSUE THAT FILLS AN OPEN WOUND WHEN IT STARTS TO HEAL). STAFF LPN (LICENSED PRACTICAL NURSE) "B" AFTER CLEANSING THE AREA APPLIED COOL MAGIC AND USED TEGAFOAM TO COVER THE LEFT HEEL. AN ORDER WAS WRITTEN TO CHANGE EVERY 3 DAYS. RIGHT HEEL SHOWED DRIED SKIN WITH NO OPEN AREAS. ACCORDING TO THE WOUND SHEET DATED 11/05/2012 AND 11/12/2012, RESIDENT #5'S LEFT HEEL WOUND WAS 1.8 CM (CENTIMETERS) WIDTH AND 2.0 CM LENGTH WITH A DEPTH OF 0.1 CM AND ON 11/12/2012 THE WIDTH WAS 1.4 CM AND THE LENGTH IS 2.8 CM WITH THE DEPTH REMAINING AT 0.1 CM. DURING THE INITIAL TOUR OF FACILITY NORTH TWO HALL ON 11/14/2012 AT APPROXIMATELY 10:30 AM, WHILE STANDING AT RESIDENT #5'S ROOM. STAFF LPN "B" STATED, " THIS IS MY ONLY CENTER ACQUIRED PRESSURE SORE IN THE BUILDING; SHE HAS A SORE ON HER LEFT HEEL". WHEN ASKED HOW RESIDENT #5 OBTAINED A PRESSURE SORE TO HER LEFT HEEL, STAFF "B" STATED, " SHE USED TO BE COMBATIVE WITH HER CARE". STAFF "B" WAS ASKED IF RESIDENT #5 WAS AMBULATORY AND STAFF "B" STATED, "YES, SHE USED TO WALK AROUND THE HALLS WITH ASSISTANCE". INTERVIEWING STAFF "B" ON 11/15/2012 AT 9:40 AM IN RESIDENT #5'S ROOM DURING THE ORDERED DRESSING CHANGE, STAFF "B" WAS ASKED IF THIS WAS THE ONLY PRESSURE SORE FOR RESIDENT #5 AND STAFF "B" STATED, "NO, SHE HAD ANOTHER SORE ON THE RIGHT HEEL BUT THAT IS HEALED; SHE ORIGINALLY HAD SORES ON BOTH HEELS". A RECORD REVIEW OF THE MDS (MINIMUM DATA SET) DATED 02/14/2012 AND 05/15/2012 ON SECTION M (SKIN CONDITION) HAD A CODE OF ZERO MEANING NO EVIDENCE OF PRESSURE ULCER. ON 08/15/2012 THE MDS SECTION M, CODED A STAGE 2 ON LEFT HEEL AND UNSTAGEABLE ON RIGHT HEEL. THE CARE PLAN FOR SKIN ULCERATION WAS NOT DEVELOPED UNTIL 08/17/2012. DURING AN INTERVIEW ON 11/15/2012 AT 10:10 AM IN THE DON'S (DIRECTOR OF NURSING) OFFICE, THE DON WAS ASKED, "DO YOU USE THE CLINICAL PROCESS GUIDELINES FOR WOUNDS"? THE DON STATED, "NO, WE USE WHAT THE WOUND CLINIC ADVISES". THE DON WAS ASKED WHEN RESIDENT #5'S HEEL WOUNDS WERE REPORTED. THE DON STATED, "PROBABLY ABOUT THE TIME SHE WAS SEEN BY THE WOUND DOCTOR". REVIEW OF THE CLINICAL RECORD ON 11/15/2012 HAD AN ORDER ON 07/04/2012 " ...HEEL PROTECTORS WHILE IN BED DUE TO BLISTER ON HEEL..., ANOTHER ORDER WAS WRITTEN ON 07/05/2012 ...1. L HEEL: CLEANSE WITH NORMAL SALINE SOLUTION (NS), GENTLY PAT DRY - APPLY [MEDICATION NAME] AG MESH TO BLISTER AREA, SKIN PREP TO WOUND -LET DRY THEN COVER WITH TAGADERM FOAM ADHESIVE DRSG. CHANGE EVERY 3 DAYS, PRN 2. R HEEL: CLEANSE WITH NS, PAT DRY APPLY SKIN PREP TO HEEL, LET DRY THEN APPLY [MEDICATION NAME] FOAM ADHESIVE, CHANGE DRSG (DRESSING) . EVERY 3 DAYS +PRN...". REVIEWING THE UNUSUAL OCCURRENCE STATEMENT FORM DATED 07/04/2012 AT 1:30 PM REVEALED "...CNA'S WERE PUTTING RESIDENT TO BED WHEN THEY NOTICED A BLISTER THAT HAD POPPED AND DESCRIPTION OF INJURIES: BLISTER TO LEFT HEEL AND REDNESS TO RIGHT HEEL...". FURTHER RECORD REVIEW REVEALED A WOUND CARE CONSULTATION ON 07/25/2012. CHIEF COMPLAINT : "...PRESSURE ULCERS OF BILATERAL HEELS...". WOUND LOCATION LEFT HEEL, MEASUREMENTS "...LENGTH 2.5 CM BY WIDTH 2.3 CM AND DEPTH 0.1 CM, TYPE/STAGE III..." (STAGE III FULL THICKNESS TISSUE LOSS). THE NOTE FURTHER READS ..." I AM UNABLE TO DEPTH THE WHOLE THING BECAUSE THERE IS NECROTIC AREA ALMOST IN THE CENTER OF IT" ..."RIGHT HEEL LENGTH 2.5 CM BY 1.6 CM WIDTH WITH NO DEPTH, TYPE/STAGE COVERED WITH ESCHAR..." (ESCHAR IS DESCRIBED AS THICK, LEATHERY BLACK OR BROWN COLOR, NECROTIC (DEAD) TISSUE). "...IT IS QUITE PAINFUL WHEN YOU MANIPULATE EITHER HEEL TO CLEAN THEM...". REVIEWING SHOWER SHEETS FOR RESIDENT #5 FROM THE DATES OF 07/20/2012 THROUGH 10/30/2012, SHOWED THAT NURSING STAFF ON 3 DATES ( 08/10/2012,10/16/2012, 10/19/2012) OBSERVED SKIN ISSUES WITH RESIDENT #5 HEELS DURING HER SHOWER TIMES OF TWICE A WEEK. THE THREE SHOWER SHEETS STATED, "...OLD OPEN AREAS ON THE LEFT HEEL FOR 07/20/2012 AND OLD AREAS ON LEFT AND RIGHT HEEL FOR 10/16/2012 AND 10/19/2012...". THE OTHER SHOWER SHEETS HAD NOTHING MARKED UNDER "NEW SKIN ISSUE" AND THE DIAGRAM OF THE BODY (FRONT AND BACK) WERE BLANK. NURSES NOTES REVIEWED ON 11/16/2012, REVEALED THE MONTHLY SUMMARY FOR MAY (WRITTEN ON 06/04/2012) AND JUNE (WRITTEN ON 06/30/2012) "...NO NEW SKIN ISSUES...". THE NURSES NOTES FOR 07/02/2012 "...RESIDENT #5 YELLING AND MOANING IN BED, YELLS AND CRIES WHEN LEGS ARE TOUCHED OR MOVED, CNA (CERTIFIED NURSING ASSISTANT) STATES IT HAS BEEN HARD TO TRANSFER RESIDENT SINCE FRIDAY. TYLENOL 1000 MG (MILLIGRAMS) PO GIVEN FOR PAIN...". NURSES NOTES FOR 07/04/2012 "...RESIDENT APPEARS PAINFUL THIS SHIFT, OBSERVED SLOUCHING TO THE SIDE AND SAYS OUCH WHEN YOU TRY TO LIFT HER UP...". NEW PHYSICIANS ORDER ON 07/05/2012 "[MEDICATION NAME] 5/325 MG 1/2 TAB PO BID (TWICE) FOR PAIN...". IT WAS UNCLEAR HOW THE FACILITY WAS PROACTIVE IN ADDRESSING THE BLISTER AND REDNESS ON BOTH HEELS AS EARLY AS 7/04/12. A CARE PLAN THAT WAS DEVELOPED TO ADDRESS THE PRESSURE ULCERS WAS STARTED ON 8/17/12. IT WAS UNCLEAR HOW FACILITY STAFF SYSTEMATICALLY MONITORED THE PROGRESSION OF THE PRESSURE ULCERS THROUGH SPECIFIC INTERVENTIONS, UPDATED CARE PLANS TO REFLECT A CONTINUOS EVALUATIONS OF THE EFFICACY OF THEIR INTERVENTIONS TO ADDRESS THE BILATERAL PRESSURE ULCERS. ACCORDING TO THE CARE PLAN REVIEWED ON 11/15/2012, RESIDENT #5 REQUIRED EXTENSIVE TO TOTAL ASSISTANCE FOR PHYSICAL LIMITATIONS. THIS CARE PLAN WAS INITIATED 08/17/2012. INTERVENTIONS WAS UP IN GERI-CHAIR WITH A HOYER LIFT AND 2 ASSIST. CARE PLAN INITIATED ON 03/14/2011 "...REMIND AT TIMES TO USE HER WALKER...". THE MDS (MINIMUM DATA SET) DATED 02/14/2012 QUARTERLY REVIEW,"... CODED RESIDENT #5'S BED MOBILITY AS INDEPENDENT AND WALK IN ROOM EXTENSIVE. THE MDS QUARTERLY REVIEW FOR 05/15/2012 CODED INDEPENDENT FOR BED MOBILITY AND EXTENSIVE ASSISTANCE FOR WALK IN ROOM. THE MDS dated [DATE] WAS A SIGNIFICANT CHANGE ASSESSMENT AND HAD RESIDENT #5 CODED AS EXTENSIVE ASSISTANCE FOR BED MOBILITY AND WALK IN ROOM CODED AS ACTIVITY DID NOT OCCUR. THE MDS QUARTERLY REVIEW DATED 11/13/2012 CODED RESIDENT #5'S BED MOBILITY AS TOTAL DEPENDENCE AND WALK IN ROOM DID NOT OCCUR...". THERE WAS A SIGNIFICANT DECLINE IN RESIDENT #5'S AMBULATION AND TRANSFER. THE MDS SHOWED A SIGNIFICANT DECLINE IN BED MOBILITY AND WALKING, REQUIRING INCREASED ASSISTANCE IN THE AREA OF TRANSFERRING. RESIDENT #5 WAS NO LONGER WALKING IN THE FACILITY. IN ADDITION RESIDENT #5 REQUIRED AN INCREASE IN PAIN MEDICATION. THESE DECLINE IN THE FUNCTIONAL LEVEL OCCURRED AFTER THE DEVELOPMENT OF THE 2 PREVENTABLE PRESSURE ULCERS IN BOTH HEELS; A STAGE 111 IN HER LEFT HEEL AND AN UNSTAGEABLE IN HER RIGHT HEEL FOR RESIDENT #5. ( )

This citation pertains to intake numbers MI 556 & MI 729. Based on interview and record review, the facility failed to provide supervision and/or assistive devices to prevent accidents for 3 of 4 sampled residents (#501, 503, & 504), who were at risk for falls in a total sample of 5, resulting in facial lacerations for Resident #501, a fractured nose for Resident #503, and a hematoma to the wrist for Resident #504. Findings include: Resident #501: Per the facility face sheet Resident #501 was an [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the Minimum Data Set ((MDS) dated [DATE] revealed that Resident #501 had unclear speech and sometimes could understand others. The MDS revealed that Resident #501 required two person assist with bed mobility, transfers, did not ambulate, was totally dependent on others for locomotion, dressing, eating, toilet use, hygiene, and bathing. The MDS also revealed that Resident #501 was incontinent of bowel and bladder. The MDS revealed that Resident #501 had partial loss of movement to an undisclosed side of her arm, hand, leg, foot, and other areas of her body. Record review of a care plan dated 2/18/2011 revealed that Resident #501 required total assistance with most activities of daily living related to her dementia and Parkinson's disease. Interventions that were listed on the care plan were to ensure that Resident #501's call light was within reach at all times because she was a fall risk and unable to comprehend the use of the call light. Another intervention was to reposition Resident #501 while in her wheelchair frequently. Another care plan dated 12/1/2010 revealed that Resident #501 was at risk for falls. Interventions were to anticipate Resident #501's needs because she did not always comprehend the use of her call light. The interventions also revealed that Resident #501 was to have a tab alarm and pressure alarm (alarms that sounds when a resident attempts to get up without assistance) in place. The alarm interventions dated 12/1/2010 were not crossed out or evident that they were discontinued. The care plan also revealed an intervention dated 5/1/2011 for a tab and pressure alarm to be in place. An intervention was added on 5/2/2011 to not leave Resident #501 alone in her room while she was up in her wheelchair. Record review of an "Unusual Occurrence Statement Form" dated 5/1/2011 revealed that Resident #501 was observed on the floor in her room lying on her left side by the door. Injuries included a laceration to the left eyebrow, bruise on the left cheek, an abrasion on the left shoulder, redness on the left shoulder and left hip. The incident report revealed that Resident #501 was non-ambulatory, was a two person or mechanical lift, and did not have any alarms prior to her fall. The incident report revealed that Resident #501 was not able to move on her own. The incident report revealed a statement from Staff Member #1, a Certified Nurse Aid (CNA), which stated that CNA #1 walked into the facility to pick up her paycheck when she noticed Resident #501 lying on the floor in her room. The incident report revealed a statement from Staff Member #2, a CNA, which stated that CNA #2 was off the unit at her lunch break. The statement revealed that CNA #2 observed Resident #501 sitting in her wheelchair with her call light on the wheelchair and the wheelchair in locked position. The incident report also revealed that Resident #501, when found on the floor, had been incontinent of urine and stool. Record review of a "Fall Risk Assessment" dated 12/1/2010 revealed that Resident #501 scored a 12 on her fall risk. A score of 10 or higher indicated a high risk for falls, per the "Fall Risk Assessment" form. CNA #2 was interviewed on 5/25/2011 at 1:10 PM. She said that Resident #501 did not have any alarms on at the time of her fall. She said that the alarms had been discontinued at sometime because Resident #501 did not attempt to get up on her own nor had any falls. She said that she saw Resident#501's call light on her lap while she was up in her wheelchair. CNA #1 was interviewed on 5/25/2011 at 1:30 PM. CNA #1 said that she had gone to the facility to pick up her pay check when she walked passed Resident #501's room and saw her lying on the floor in her room. She said that Resident #501 was lying on the floor on her left side facing her bed, as if she just slid out of her wheelchair. She said that she spoke to Resident #501 but Resident #501 did not respond. CNA #1 said that Resident #501 had a laceration to her left eye and her left shoulder was red. She said that no alarms were on Resident #501 when she found her. She said that the breaks on the wheelchair were on, but the foot pedals were not on the wheelchair. CNA #1 said that Resident #501 was to have her foot pedals on while she was up in her wheelchair. Staff Member #3, a Licensed Practical Nurse (LPN), was interviewed on 5/27/2011 at 9:24 AM. She said that she was Resident #501's primary nurse on the day of the fall. She said that CNA #1 came to her and told her that Resident #501 was lying on the floor in her room. She said that Resident #501 was lying on her left side facing the door. She said that Resident #501 had a laceration to her left eye, was bleeding, had a bruise around her left eye, a bruise on her cheek, and left shoulder. LPN #3 said that Resident #501 did not use her call light, did not move, nor had any prior falls. She said that Resident #501 generally was not up in her wheelchair for long periods of time. LPN #3 said that Resident #501 had alarms in place at one time because Resident #501 would lean forward in her wheelchair and pick at the air as if she was attempting to pick something up. She said that alarms had been discontinued but she was not sure when; she thought maybe December 2010. She said the basis for the alarms being discontinued was because Resident #501 had not leaned forward while in her wheelchair in a long time. She said that Resident #501 would lean to her left side while in her wheelchair. Staff Member #4, Resident #501's primary CNA, was interviewed on 5/27/2011 at 10:12 AM. She said that after breakfast on the day of the fall some other staff member took Resident #501 to her room, but she did not know who the staff member was. Staff Member #5, an Occupational Therapist, was interviewed on 5/27/2011 at 1:20 PM. He said that he had not noticed Resident #501 leaning forward while in her wheelchair. He said that the CNA's had been positioning Resident #501 incorrectly in her wheelchair. He said that he had instructed the staff back in June of 2010 on correct positioning of Resident #501 while up in her wheelchair. OT #5 said that he understood that Resident #501's care plan had included the intervention that Resident #501 was to be in the hall or a common area while she was up in her wheelchair, and for Resident #501 to be in her bed when she was in her room. Resident #501's roommate was interviewed on 5/27/2011 at 2:10 PM. She said that she had resided at the facility for 2 years. She said that she was not present in the room when Resident #501 fell , but that Resident #501 would occasionally lean forward while in her wheelchair. She said it looked like Resident #501 was trying to pick something up from the floor. The roommate said that she had told staff before that Resident #501 was going to fall out of her wheelchair because she kept leaning forward. She said that she even had mentioned it to staff around Easter time of this year (2011), but she could not remember who the specific staff was that she told. Resident #503: Resident #503 no longer resided at the facility at the time of the investigation. Per the facility face sheet Resident #503 was a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of an MDS dated [DATE] revealed that Resident #503 required extensive assistance with dressing, toilet use, and limited assistance with hygiene. Record review of a "Fall Risk Assessment" dated 4/27/2011 revealed that Resident #503 scored a 17 on her fall risk assessment. Record review of an "Unusual Occurrence Statement Form" dated 4/21/2011 revealed that Resident #503 was on the toilet during her morning care, with CNA #6. The report revealed that Resident #503 leaned forward to pull her pants up, while sitting on the toilet, and slipped forward onto the bathroom floor hitting her face. The incident report revealed that Resident #503 had a laceration to her nose, left eye, and a small cut to the inside of her lower lip. The report revealed that Resident #503 was transferred to the hospital. Record review of the CAT scan from the hospital records dated 4/21/2011 revealed that Resident #503 had fractured nasal bones. Record review of an "Occupational Therapy Note" dated 4/21/2011 revealed a notation that stated, "Discussed why she fell , "I reached too far forward while trying to get my panties from falling down and over I went, on my face." Talked about how she was trained with a "reacher" (an assistive device that reaches for items and allows the user to not have to lean or reach) for ADL's." Record review of Resident #503's care plans revealed the use of a "reacher" was not on any care plan as an intervention. CNA #6, who assisted Resident #503 to the bathroom, was interviewed on 5/27/2011 at 12:41 PM. CNA #6 said she assisted Resident #503 to the bathroom. She said that Resident #503 was to be discharged to home on the day of her fall. She said Resident #503 pulled her pants down to her thigh area and then sat down on the toilet. She said Resident #503 began to take her pants off and refused any type of help with doing so. She said that Resident #503 fell while she was attempting to take her pants off. CNA #6 said Resident #503 had her lower legs in an outward position and her feet slipped backwards, causing her to fall forward. She said Resident #503 hit her face on the door jam on the floor which cut and fractured her nose. She said that she was not aware that Resident #503 needed to use a "reacher" in order to assist her with ADL's, such as dressing and un-dressing. OT #5 was interviewed on 5/27/2011 at 1:20 PM. He said that Resident #503 was to use a "reacher" to assist her with her ADL's. He said that the staff knew and so did Resident #503. He said that Resident #503 required the use of assistive devices for performance of ADL's. He said that Resident #503 would be non-complaint with use of her "reacher". Staff Member # 7, the Unit Manager and LPN, was interviewed on 6/6/2011 at 11:52 AM. She said that Resident #503 was to use a "reacher" while performing her ADL's and that Resident #503 had a "reacher" in her room. LPN #7 said that the "reacher" was not part of Resident #503's care plan as an intervention prior to her fall, but was added after the fall. She said that if Resident #503 needed to use a "reacher" then the therapy department would have written a physician order. She said that Resident #503 only needed a "reacher" while she received therapy. Record review of physician orders for the months of March, April, and May 2011 revealed no order for Resident #503 to use a "reacher" while performing her ADL's. Record review of the CNA "Resident Care Guide" revealed no intervention for Resident #503 to use a "reacher" while performing her ADL's. Staff Member #8, a Registered Nurse (RN) and Resident #503's primary nurse, was interviewed on 6/6/2011 at 1:05 PM. She said that she heard CNA #6 yell out for her and when she entered the bathroom saw Resident #503 on the floor face down. She said that CNA #6 had used a gait belt to ambulate Resident #503 to the bathroom. She said that the therapy department would write a physician's order for an assistive device if one was needed and then nursing would write the order onto a care plan. She said that the therapy department staff would not tell them when an assistive device was needed. She said that she did not know if a "reacher" was in Resident #503's room for her use. Resident #504: Resident #504 no longer resided at the facility at the time of the investigation. Per the facility face sheet Resident #504 was a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the MDS dated [DATE] revealed that Resident #504 required extensive assistance with transfers, ambulation, dressing, toilet use, and hygiene. Record review of a "Fall Risk" assessment dated [DATE] revealed that Resident #504 scored a 20 on her fall risk assessment, with greater than 10 being at high risk for falls, per the "Fall Risk" assessment form. Record review of an "Unusual Occurrence Statement Form" dated 4/14/2011 revealed that Resident #504 was found on the floor in front of her toilet. The report revealed that no one had observed the fall. The report also revealed that Resident #504 did have a fall alarm in place and that CNA#9 was re-educated to remain in resident's room while resident was on the toilet. The conclusion documented on the report revealed that Resident #504 was left unattended. The report revealed that Resident #504 received a hematoma (a pocket of blood, hemorrhage) to her right wrist. Staff Member #9, the CNA who assisted Resident #504 to the bathroom, was interviewed on 6/6/2011 at 11:25 AM. She said that Resident #50 had put on her call light. CNA #9 said that she did not know that Resident #504 was not compliant with the use of her call light or that Resident #504 had dementia. She said that she did not look at Resident #504's CNA care card before she assisted Resident #504 to the bathroom. She said that the other two CNA's were busy when Resident #504 put her call light on; so she went in to assist Resident #504. She said that when she entered Resident #504's room Resident #504's daughter told her that Resident #504 needed to use the bathroom. She said that Resident #504's daughter left and she assisted Resident #504 to the bathroom. CNA #9 said that she took Resident #504 to the bathroom gave her the call light and told her to push the call light when she was done. She said that Resident #504 agreed to do just that. CNA #9 said that she then left the room and went to assist another resident. She said that she wondered why Resident #504 had not called, so she went into her room to check on her and found her on the floor. CNA #9 said she did not know that Resident #504 could not be left alone while up on the toilet. CNA #9 said that she was told to never leave a fall risk resident alone. She said that she was terminated due to the incident. Record review of a "disciplinary Action" form dated 4/15/2011 revealed that CNA #9 was suspended due to leaving Resident #504 alone in the bathroom unattended, which resulted in Resident #504 falling. LPN #7 was interviewed on 6/6/2011 at 11:52 AM. She said that CNA #9 left Resident #504 alone in the bathroom while she went to assist another resident. LPN #7 said that per facility protocol residents who were assessed to be a high risk for falls were not to be left unattended in the bathroom. Record review of the facility policy and procedure titled "Fall Prevention" dated 3/2011 revealed under "Implementation, Other Measures Used to Prevent Residents From Falling" section a. "Do not leave fall risk residents who are not independent in the bathroom unattended." ( )