Every finding on record at Chesaning Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen. Findings include:On 12/09/2025 at approximately 11:30 AM during lunch observation with the Certified Dietary Manager E, the rag sanitizer bucket solution was tested with Hydrion QT-40 test strips, and the result was zero. On 12/09/2025 at approximately 11:30 AM during lunch observation with the CDM E, when interviewed on the chemical solution of the rag sanitizer bucket, the CDM E stated that the bucket needed to be changed out, and it is changed when it's visibly soiled or every 2 hours. When asked what the range the chemical solution should be, the CDM E stated it should be 200ppm. According to the 2022 Food Code, 3-304.14 Wiping Cloths, Use Limitation, Cloths in-use for wiping counters and other equipment surfaces shall be .Held between uses in a chemical sanitizer solution at a concentration specified under S 4-501.114 and The sanitizing solution must be changed as needed to minimize the accumulation of organic material and sustain proper concentration. Proper sanitizer concentration should be ensured by checking the solution periodically with an appropriate chemical test kit.

Based on observation, interview, and record review, the facility failed to 1). have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), 2). ensure 2 of 2 residents' (Resident's #3 and #35) meet the facility criteria for infections, and 3) do infection control environmental rounds of the main dining room, resulting in the potential for increased risk of respiratory infection among all residents in the facility, an increased unnecessary use of antibiotic therapy, and an unsafe dining room environment. Findings include:Resident #3: Review of the Face Sheet, Minimum Data Set (MDS dated 1/25), care plans (dated 9/23/25), and progress notes (dated 9/25), revealed Resident #3 was 67 years-old, admitted to the facility on [DATE], alert and able to make healthcare decisions. The residents' diagnosis included, diabetes, unsteadiness, weakness, and methicillin resistant staphylococcus aureus infection/MRSA (resistant to most antibiotics wound infection). Review of Resident #3's MRSA care plan (dated 9/23/25), stated Give medications as ordered and monitor/document for effectiveness, side effects. Review of the residents' Nurse Practitioner/NP L's order (dated 11/10/25), stated Bactrim (antibiotic) Oral Tablet 800-160 MG, give 1 tablet by mouth two times a day for wound infection for 10 days. Review of the facility infection time line for November, 2025, revealed Resident #3 had documentation that the residents' infection did not meet the McGeer infection criteria, yet was still ordered an antibiotic. The residents' McGeer infection sheet was left entirely blank, no documentation was found of any signs/symptoms of a wound infection. Review of the facility Antibiotic Time Out form (dated 11/11/25), revealed no documentation from the prescribing physician, or Infection Preventionist F regarding why the resident received Bactrim, when they did not meet the facility McGeer infection criteria, or risk versus benefit done for the use of the antibiotic. Review of NP L progress notes (dated 11/11/25), stated Wound to left ankle-stalled due to infection; treatment changed for this week until infection resolves, wound culture positive for MRSA, started on Bactrim. No signs or symptoms of a wound infection was documented in NP L notes. Review of the facility Revised McGeer Criteria for Infection Surveillance Checklist for Resident #3 dated 11/25, revealed this document was completely left blank; no documentation at all. The McGeer Checklist listed under wound infection stated Positive superficial wound swab culture (wound culture) is not sufficient evidence to establish a wound infection. The resident did not have any documentation of a wound infection or risk versus benefit for antibiotic usage. During an interview done on 12/10/25 at 8:35 a.m., Infection Preventionist, LPN F stated It does not meet our criteria (Resident #3's wound & Skin infection), it would benefit if it was on there (a risk versus benefit for antibiotic usage when it does not meet facility infection criteria) because it would be easier for me. Infection Preventionist F said she did not talk with the NP or the physician regarding appropriateness of ordering an antibiotic without meeting the facility criteria for a wound and skin infection, or not about filling out a risk versus benefit. Resident #35: Review of the Face Sheet, MDS (dated 3/25), care plans (dated 3/17/25), and progress notes (dated 11/25), revealed Resident #35 was 89 years-old, admitted to the facility on [DATE], dependent on staff for Activities of Daily Living/ADL's, and was put on an antibiotic for a urinary tract infection/UTI without any signs or symptoms documented. The residents' diagnosis included, Dementia, chronic lung disease, with a history of UTI's. Review of the physician order dated 11/7/25, revealed the resident was prescribed Macrobid (antibiotic) 100mg two times a day for 7 day's (given for a UTI). Review of the facility infection control tracking sheet dated 11/25, revealed no documentation of any signs or symptoms of a UTI. During an interview done on 12/10/25 at 8:35 a.m., Infection Preventionist F said a urine dip stick used to confirm the resident had a UTI, and did not send the urine to the lab for a urinalysis/UA prior to starting an antibiotic, and stated Her family complained she had a UTI, they dipped her urine at their home and said it was positive, we did not re-dip. Infection Preventionist F said the facility did not have a policy for dipping urine. Review of Nurse Practitioner/NP L's progress notes dated 11/11/25, stated Patients family took her home over weekend, during her stay they dipped her urine and it was positive for UTI, staff had difficulty getting a clean catch with the urine sample in the facility (staff did not get a urine sample in the facility). Macrobid Oral Capsule give 100 mg by mouth two times a day for urinary tract infection, site not specified for 7 days. No documentation of any signs or symptoms was found in NP L's documentation. Review of the facility Revised McGeer Criteria for Infection Surveillance Checklist for Resident #35 dated 11/25, revealed documentation that the residents' UTI did not meet the facility McGeer criteria for UTI infection. During an interview done on 12/10/25 at 9:00 a.m., Infection Preventionist F stated yes, I marked it as not meeting our criteria. Review of the facility Antibiotic Time Out form (dated 11/10/25 and signed by NP L on 11/28/25), revealed no documentation from the prescribing physician, or Infection Preventionist F regarding why the resident received Macrobid, when they did not meet the facility McGeer infection criteria, or risk versus benefit done for the use of the antibiotic. Review of the infection control data dated 10/25, revealed no documentation regarding a plan (education, audits, demonstrations) to address any concerns or issues found. During an interview done on 12/10/25 at 9:00 a.m., Infection Preventionist F said she did not have November's analyzing completed because she worked the floor. Infection Preventionist F stated From now on, I will put how I plan to do it (a plan to address concerns found during the month). Main Dining Room: Observations made on 12/11/25 at 7:40 a.m., revealed several of the resident chairs had rust on the bottom, white paint chipping off, and were uneven when they sat down, rocking back and forth. Also, an extremely large new stove was in the corner of the dining room and covered with a clear plastic wrapping that was tearing off with sections on the floor and several light yellow spots on the top. Residents used this area for three meals per day and for activities. During an interview done on 12/11/25 at 9:15 a.m., Infection Preventionist F stated I don't document my walk throughs for the dining room. Infection Preventionist F said the stove had been in the dining room for months. Review of the facility Infection Prevention and Control Program (un-dated), stated This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines (as the McGeer infection criteria for antibiotic usage). On 12/09/2025 at 1:04pm-2:00pm, during the environmental tour with the Maintenance Director D, observed a water softener in the basement that appeared to be not in use. On 12/09/2025 at 1:04pm-2:00pm when interviewed on the usage of the water softener, the Maintenance Director D answered the water softener is not in use, the valves are shut off, and it's been that way for a while. When questioned about the dead-end plumbing policy, the Maintenance Director D answered there isn't a policy. On 12/09/2025 at 1:04pm-2:00pm when interviewed on whether chlorine residual is tested on site, the Maintenance Director D answered they have never done chlorine residual testing, but they do test for pH levels. According to the facility's Water Management Plan, under Legionella Water Management Infection Control Program, Decide where control measures should be applied and how to monitor them. Also, Apply control measures to reduce the hazardous conditions, wherever possible, to prevent Legionella growth and spread. Weekly and bi-annual testing will be completed by maintenance. In addition, Monitor that the program is running as designed and is effective. Testing protocols will include where and when necessary: physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. And it states, Interventions when control measures are not met: Document results of testing and corrective action when control limits are not maintained. According to Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Eliminate dead legs, which are sections of no- or low-water flow and Ensure disinfectant residual is detectable throughout the potable water system. According to the State Operations Manual under Water Management, Facilities must be able to demonstrate its measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program and Measures to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them.

Based on observations, interviews, and record review, the facility failed to protect residents' rights to be free from neglect for 3 residents ( #7, #14, #49) of 18 residents reviewed for dignity and the confidential Resident Council group, resulting in verbalizations from the council group of anger regarding call lights not being answered timely, frustration regarding not being able to reach call lights, and a heavy smell of urine in the back hall. Findings Include:Review of the facility's Maintaining Dignity policy, dated 12/25, stated It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances quality of life. Respond to requests for assistance in a timely manner. Call Light Availability and Response Time: Review of the facility Call Lights policy (dated 12/25), stated Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to resident's while in their bed. All staff members who see or hear an activated call light are responsible for responding. Resident #7: Review of the face Sheet, Minimum Data Set/MDS (dated 10/24), physician orders (dated 9/24), and care plans (dated 10/24), revealed Resident #7 was [AGE] years old, admitted to the facility on [DATE], required assistance with Activities of Daily Living/ADL and supervision and observation due to behaviors. The residents' diagnosis included, chronic lung disease, heart failure, muscle wasting, and delusions.Review of the residents' Impaired respiration, behavior, and falls care plans (dated 10/24), revealed he was a fall risk and required close monitoring and behavior modification.Review of the resident's Activities of Daily Living care plan dated 10/24, stated Keep frequently used items within reach (including call light).During an interview done on 12/10/25 at 2:20 p.m., alert Resident #7 said that second and third shift staff take an hour or more sometimes to answer his call light. He said it does not happen on days.Resident #14:Review of the Face Sheet, MDS (dated 5/25), and care plans (dated 4/25), revealed Resident #14 was 63 years-old, admitted to the facility on [DATE], alert and interviewable with a BIMS of 10 (cognitive assessment, interviewable), and required total assistance with all ADLs. The residents' diagnoses included, sepsis, back pain, muscle weakness, seizures, difficulty walking, epilepsy, respiratory failure, traumatic brain injury with explosive disorder and hemiplegia of left side (weakness). Review of the resident's Falls care plan (dated 4/25/25), stated Keep frequently used items within reach (including call light).Observation made on 12/20/25 at 12:54 p.m., revealed the resident's call light was on the floor, it was not within reach.Resident #49: Review of the Face Sheet, Minimum Data Set (dated 5/25), and physician orders (dated 12/4/25), revealed Resident #49 was 82 years-old, was admitted to the facility on [DATE], was confused, not able to answer questions due to condition and cognition, and was receiving Hospice services. The resident's diagnoses included malnutrition with adult failure to thrive, diabetes, encephalopathy, chronic kidney disease, and had a history of a fall with fracture. Review of Resident #49's Activity of Daily Living and falls care plans (dated 12/4/25), revealed she was to be totally assisted with bed mobility, bathing, and dressing. She was also a fall risk and required supervision to maintain safety. Observation made on 12/10/25 at 8:04 a.m., revealed the resident was in bed with her call light clipped on the privacy curtain halfway to the top, approximately 4 feet from her low bed. The resident was unable to reach her call light. During an interview done on 12/10/25 at 8:10 a.m., Nurse, LPN C came in the resident's room and stated Ya, they (staff) clip the call lights to the curtains, they can't reach them. During a second observation done on 12/12/25 at 9:49 a.m., the resident again was in her bed, and her call light was clipped to the bedside privacy curtain. During an interview done on 12/12/25 at 10:00 a.m., the Director of Nursing/DON walked in the resident's' room and stated They (staff) should not put the call light on the curtain. The DON walked directly out of the residents' room without removing the call light from the curtain. During an interview done on 12/12/25 at 10:05 a.m., Family Member #2 stated It takes about 45 minutes for them (staff) to answer the call lights on second shift. Resident Council: A confidential Resident Council Group meeting was held on 12/10/25 at 1:06 p.m., in the main dining room; with a total of 6 alert residents were in attendance. 2 of 6 resident's verbally had complaint's regarding their call lights not being answered timely on second and third shifts. A confidential Resident stated, it takes up to one hour and a half for them to answer (the call lights). One confidential resident said he had an accident (incontinence episode) due to no one timely answering his call light. Review of the facility Resident Council meeting notes (dated 7/2/25), stated Second and third shift call lights taking up to an hour to be answered. Heavy Urine Smell: Observation done on 12/12/25 at 9:49 a.m., in the back resident hallway (rooms 5 through 12) was noted by this surveyor to have a heavy smell of urine. During an interview done on 12/12/25 at 10:00 a.m., the DON walked down the back hallway and confirmed a heavy urine smell. The DON stated, I can smell it, I will send someone down. During an interview done on 12/12/25 at 10:10 a.m., Nursing Assistant/CNA A was asked what she was supposed to do if there was a smell of urine in a resident's room and she stated, I am supposed to strip their bed.

Based on observation, interview, and record review, the facility failed to follow policy and procedures for 1) Medication labeling and storage in 2 of 2 medication carts, 2) Storage and handling of medications for one medication room of one reviewed, and 3) Consistently monitor the medication refrigerator temperature in accordance with acceptable pharmaceutical standards of practice, for 11 residents (R3, R8, R10, R12, R19, R28, R35, R37, R40, R42, R50) of 11 sampled residents Findings include: Medication cart for Residents rooms 1-12:Observation and interview on 12/09/2025 at 12:28 PM with Licensed Practical Nurse (LPN) C of Medication cart rooms 1 through 12. Observation on 12/09/2025 at 12:35 PM of Resident R42 Lantus 100unit/ml multi-dose 10ml vial/bottle with the seal off/used with no date on the vial and the box not dated. LPN C reviewed vial/bottle and then wrote a date on the bottle, although she did not open the vial. Observation on 12/09/2025 at 12:40 PM with Licensed Practical Nurse (LPN) C of Resident R50 had Albuterol Sulfate inhalation 200-meter doses, count of 148 doses left on inhaler. The inhaler was not dated with no pharmacy label. Licensed Practical Nurse (LPN) C stated that she had no idea what's going on with that inhaler. Observation on 12/09/2025 at 12:41 PM of Medication Cart Resident R19 medication Trelegy Ellipta inhalation aerosol powder 200 mcg/62.5 mcg/25 mcg Ellipta 30 doses device with 26 doses left and was not dated. Observation on 12/09/2025 12:44 PM of Resident R28's Ketorolac injection 60mg/2ml bottle open seal removed placed back into the plastic bag with 2 other sealed bottles, no date opened. Medication cart for Residents rooms 13-20:Observation and interview on 12/09/2025 at 11:52 AM with Registered Nurse G of the medication cart for resident rooms 13 through 20 revealed Resident R3 medication Lyumjev Injection 100 unit/ml vial top was removed with no date on vial or box. RN G did not know when the insulin vial had been opened. Observation of Resident R35 medication of Stiolto Respimat tiotropium Bromide and olodaterol aerosol inhaler used and not dated on device or box not dated. A random Ventolin HFA 90mcg 200 doses 198 doses left on the device with no date on the bottle or box was also located within the medication cart. Observation of the medication cart supply of opened Blood sugar sticks were not dated. Observation on 12/09/2025 at 12:59 PM with Registered Nurse G of the medication cart for resident rooms 13 through 20 revealed Resident R8 albuterol sulfate 0.083% inhaler was opened and not dated on inhaler or box. Observation on 12/09/2025 at 1:01 PM Resident R10 medication Ipratropium spray 0.06% nasal spray was used and opened not dated on bottle or box. Observation on 12/09/2025 1:02 PM of Resident R40 medication Fluticasone Propionate nasal spray 50mcg with no open dates on bottle or box. Treatment Cart: Observation on 12/10/2025 at 8:40 AM revealed Treatment cart was found unlocked in hallway. The state surveyor was able to access and review ointments and treatment creams: Unsampled Resident R36 had Diclofenac Sodium topical gel 1% open and used with no open date on a 3.53oz tube, no date on box or tube. Resident R12 had hydrocortisone cream 1.05oz opened used, squeezed with no dates note. Unsampled Resident R20 had Mupirocin 2% ointment for scalp, opened and tube squeezed with no date on box or tube. Observation and interview on 12/10/2025 at 9:13 AM of the treatment cart in hallway with Registered Nurse (RN) I revealed that the treatment is usually open, the nurses use it, and the Infection Control nurse does wound care. Observation of multiple-multi-dose ointments and creams opened and used; tubes are squeezed/dented from use by staff upon observation of medications. There are no open dates noted on tubes or boxes. In an interview on 12/10/2025 at 10:20 AM with Licensed Practical Nurse/Infection Control Preventionist/Wound Care Nurse F revealed that the medication carts and the treatment cart are to be always locked when not in use. In an interview on 12/10/2025 at 12:05PM with the Director of Nursing (DON) discussion of Treatment carts should be locked? The don acknowledged that the treatment cart should be locked when not in use. Every time she goes by the cart she must lock the cart. The state surveyor asked about multi-dose medications dated. The DON stated that vials/bottles/pens or containers should be dated when opened because you must discard within 30 days or earlier per the pharmacy recommendations or manufacturer. Discussion of the tube feeding process/label: DON stated that the product should have a resident name, time hung, rate of infusion, amount to be infused and the product name. Refrigerator Temperature log:Observation and interview on 12/11/2025 at 8:36 AM with Licensed Practical Nurse (LPN) C Review of medication room Refrigerator temperature log reviewed with missing daily temperatures on 12/8/25, 12/9/25. Observation in the refrigerator of Floor stock Afluria influenza vaccine multi-dose 5ml dose vial, not dated seal is missing from the top of vial. Located on the bottom of the refrigerator floor was Resident #37 Ativan/lorazepam 10ml vial/bottle injectable with no date seal gone from vial top, no date on the bag either, bottle with 3 quarters full. The surveyor Had LPN C look for dates on all items in refrigerator with no dates found. Record review of the facility 'Daily Temperature Log' form dated December 2025 noted that nursing check temperatures on the first and second shift. Normal range is 36-46 degrees . Record review of the first shift log revealed that on the dates of 12/8/2025 and 12/9/2025 were noted to be blank. Record review of the facility 'Monitoring of Cooler/Freezer Temperature' dated 12/11/2025 revealed 1) Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the refrigerator unit . a.) Temperatures will be checked and logged at least twice per day by designated personnel. Observation and interview on 12/11/2025 at 8:44 AM with the Director of Nursing (DON) of the medication room refrigerator of pneumonia vaccine box with on syringe with the cap removed, with a needle on the syringe. The DON stated that it should have been thrown away and not kept. There was no date on the open syringe. Observation of Resident #37's Lorazepam 10ml vial/bottle with the seal off, no date on vial, no date on bag. The DON could not give a date of when the vial was opened and used. Review of Afluria influenzas vaccine multi-dose 5ml vial seal off the top and not dated on vial or box. Record review of the pharmacy 'Medication Dating and Storage Guide' undated revealed that multi-dose vials should be discarded in 30 days from open date, Insulin products should be discarded with 28 days from open date, nasal products should be discarded within 6 weeks from open date, and glucometer strips/sticks should be discarded 90 days from open date. Record review and interview on 12/12/2025 qt 8:05AM with the Director of Nursing of Resident #37's Lorazepam injectable 2mg/ml-'controlled substance proof-of-use record' noted that the medication was received by the facility on 11/15/2024 and the first dose was signed out as administered on 12/6/2024. The lorazepam 10ml was in the medication cart reviewing the pharmacy-controlled substance proof-of-use record last used 2/7/2025. The DON could not account for why the medication was in the refrigerator opened and used for over a year. Record review of the facility 'Multi-dose Vials' policy dated 12/10/2025 revealed it is the policy of the facility to ensure proper and safe use of multi-dose vials of medication, 2.) Multi-dose vials will be re-labeled with beyond use date, 28 days after the vial is opened or punctured. 3.) The medication label will also include the initials of the nurse who opened the vial. 5.) Visually inspect the vial before each use to double check the expiration date, beyond use date if previously opened, and ensure there is no visible contamination . 7.) Unit manager will perform random checks of opened multi-dose vials for appropriate dating.

Based on interview and record review, the facility failed to implement Mood/Behaviors care plan interventions for 1 resident (Resident #14) of 18 residents reviewed for care plans, resulting in lack of documentation of any interventions for mood or behaviors and a lack of follow-up with intervention effectiveness. Findings Include:Resident #14:Review of the Face Sheet, MDS (dated 5/25), and care plans (dated 4/25), revealed Resident #14 was 63 years-old, admitted to the facility on [DATE], alert and interviewable with a BIMS of 10 (cognitive assessment, interviewable), and required total assistance with all Activities of Daily Living/ADL's. The residents' diagnosis included, sepsis, back pain, muscle weakness, seizures, difficulty walking, epilepsy, respiratory failure, traumatic brain injury with explosive disorder and hemiplegia of left side (weakness).Review of resident #14's Aggressive/ Behavioral care plan dated 5/7/25, stated Monitor & Document observed behavior and attempted interventions in behavior log (on the Activities of daily Living/ADL sheets).Review of the residents' facility Mood/Behavior ADL sheet dated 11/25 (documentation of behaviors), revealed on 11/13/25 Repeated movements, on 11/19/25 yelling, abusive language, rejection of care, and on 11/26/25, Yelling, screaming and threating behaviors. No documentation was found on the behavior log regarding interventions or follow-up for each of the behaviors listed. Review of progress notes for the month of 11/25, revealed no documentation of any interventions or follow-up done regarding interventions effectiveness was found.On 12/11/25 at 11:20 a.m., a review of the residents' electronic medical record (nursing notes, physician notes, care plans, and behavior documentation on ADL sheets for 11/25) was done with the Director of Nursing/DON and Social Service H, revealed no documentation at all of any behavioral interventions done on the targeted dates of 11/13/25, 11/19/25, and 11/26/25, regarding resident behaviors. The DON and Director of Social Service H both agreed there was no documentation at all of interventions for targeted behaviors for the month of 11/25.During an interview done on 12/11/25 at 11:40 a.m., the DON stated The nurses should have documented interventions and effectiveness (of the interventions), I think we need to monitor the progress notes are done. During an interview done on 12/11/25 at 11:40 a.m., Social Service H stated I did not document anything, we did discuss residents with behaviors in our morning meetings but no one documented what they did about it. We need a better procedure, it's important. Review of the facility Behavioral Health Services policy dated 12/11/25 (same date the residents behaviors were reviewed), stated Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident. The Social Service Director shall serve as the facility's contact person for questions regarding behavioral services provided by the facility.

Based on observation, interview and record review, the facility failed to update care plan interventions for one resident (Resident #2) of 4 sampled residents reviewed. Findings include:Resident R2:Interview and observation on 12/09/2025 at 10:31 AM of Resident #2 (R2) refused to respond to questions but was triggered as a wound infection on the CMS 802 form, so I will need further review. R2 was observed with a blanket pulled over her head and not receptive to conversation from surveyor. Record review of the facility provided CMS 802 form dated 12/9/2025 identified Resident #2 (R2) as not having any pressure ulcer but was identified as having a wound infection. Record review of Resident #2 Minimum Data Set (MDS) quarterly 11/7/2025 revealed an elderly female with moderately impaired cognitive abilities with decisions poor, requiring cues and supervision. Section GG- Functional abilities of dependent with eating, oral hygiene, toileting, bath/showers, dressing, and personal hygiene. Resident non-weight baring, mechanical lift assist for mobility. Bowel bladder functions with indwelling catheter and colostomy. Medical diagnosis included: Medically complex conditions, anemia, seizure disorder, and bipolar disorder. Section M- Skin conditions noted no unhealed pressure ulcers/injuries. In an interview on 12/09/2025 at 2:19 PM with a family member stated that Resident #2 (R2) has a new pressure area in the crack of her butt, with redness on the lower butt area. The family member was told that they are going to try Silvadene to dry the skin and get it to heal. The resident had a pressure ulcer when she first came to the facility and they should be aware of that, so she is concerned with a new area or re-opening of a skin injury/wound. They should be doing better. Observation and interview on 12/12/2025 at 8:36 AM of Resident #2 (R2) sacrum pressure/injury with Registered Nurse I and Certified Nurse assistant (CNA) I. R2 was observed to be lying in bed and was positioned flat on the back. Observation of Foley Catheter with a right leg strap in place dated 11/27/25, right abdomen colostomy intact. R2 was repositioned rolled onto the left side by CNA I. Observed an estimated 8 inch by 8-inch heart shaped foam boarder dressing to the sacrum/coccyx area dated 12/11/2025. The sacrum/coccyx dressing peeled back, and wound packing fell out of the wound. Observation of the wound was estimated to be 2cm in length x 1cm wide, depth was visible with a beefy red base of the wound. Observation of surrounding skin was noted with red area fungal in appearance with irregular boarders. Record review of Resident #2 (R2) nursing care plans pages 1-16 revealed Resident #2 had an actual skin impairment upon admission and is at risk for reopening and new skin disruption dated 9/8/2023. Goal: Resident will not develop any new areas of skin disruption, target date 2/5/2026. Record reviewed interventions: the last skin impairment intervention added to the care plan was dated 12/9/2024, over a year prior. In an interview and record review on 12/12/2025 at 9:37 AM with the Director of Nursing (DON) reviewed all Resident #2's care plans with the state surveyor. Record review of skin impairment care plan, last revision 2023, no added interventions with new development of skin pressure/injury. Intervention of Air mattress added 12/9/2024. DON stated that Resident #2 has now developed stage II to the sacrum, wound nurse calling it a skin tear. The DON reviewed medical record and care plan intervention. The DON stated that staff did start to only get the residents up for a limited number of hours daily like 6 hours, but it's not on the care plan either. There is a physician order for strict turning every 2 hours is on the treatment record but not on the care plan either. Record review of the facility 'Comprehensive Care Plans' policy dated 11/11/2025 revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents rights, that include measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Professional standards of quality means that care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by particular clinical discipline or in a specific clinical situation or setting . The comprehensive care plan will be reviewed and revised by the interdisciplinary team .

Based on observation, interview, and record review, the facility failed to prevent the development of Stage II pressure ulcer for one resident (Resident #2) of 1 resident reviewed for pressure ulcer/injury, resulting in Resident #2 developing a facility-acquired Stage II pressure ulcer. Findings include: Resident #2 (R2):Interview and observation on 12/09/2025 at 10:31 AM of Resident #2 (R2) refused to respond to questions but was triggered as a wound infection on the CMS 802 form, so I will need further review. R2 was observed with a blanket pulled over her head and not receptive to conversation from surveyor. Record review of the facility provided CMS 802 form dated 12/9/2025 identified Resident #2 (R2) as not having any pressure ulcer but was identified as having a wound infection. Record review of Resident #2 Minimum Data Set (MDS) quarterly 11/7/2025 revealed an elderly female with moderately impaired cognitive abilities with decisions poor, requiring cues and supervision. Section GG- Functional abilities of dependent with eating, oral hygiene, toileting, bath/showers, dressing, and personal hygiene. Resident non-weight baring, mechanical lift assist for mobility. Bowel bladder functions with indwelling catheter and colostomy. Medical diagnosis included: Medically complex conditions, anemia, seizure disorder, and bipolar disorder. Section M- Skin conditions noted no unhealed pressure ulcers/injuries. In an interview on 12/09/2025 at 2:19 PM with a family member stated that Resident #2 (R2) has a new pressure area in the crack of her butt, with redness on the lower butt area. The family member was told that they are going to try Silvadene to dry the skin and get it to heal. The resident had a pressure ulcer when she first came to the facility and they should be aware of that, so she is concerned with a new area or re-opening of a skin injury/wound. They should be doing better. Record review of Resident #2's March 21, 2025 'Skin & Wound Evaluation' form noted a skin tear, category 1- epidermis and dermis are pulled in one layer from supporting structures. In-house acquired new wound measurements: length 1.6cm X width 0.5cm X depth 0.1cm. Photo of wound reviewed and noted at the coccyx/sacrum region, old scar tissue noted in photo to the area. Record review of Resident #2's physician progress note dated 3/21/2025 noted only a wound to the resident left heel. On 3/21/2025 there were no nursing progress notes that identified that the sacrum wound occurred, measurements, treatments or notification of physician/responsible party. Record review of Resident #2's 'Skin Impairment' care plan noted that there were no new interventions for treatment or prevention of sacrum wound development. On 3/25/2025 at 1:49PM 'Skin/Wound Note' by the Infection Control Preventionist/Wound care nurse F noted: Sacrum has resolved and no longer being followed. Record review of Resident #2's physician progress note dated 7/18/2025 at 8:51PM noted open wound of lower back pelvis without penetration into retroperitoneum. On 7/18/2025 there were no nursing progress note that identified that the sacrum wound re-occurred, measurements, treatments or notification of physician/responsible party. Record review of Resident #2's July 22, 2025 'Skin & Wound Evaluation' form noted a skin tear, category 1- epidermis and dermis are pulled in one layer from supporting structures. In-house acquired new wound measurements: length 2.5cm X width 0.8cm X depth 0.2cm. Larger than the previous March wound. Photo of wound reviewed and noted at the coccyx/sacrum region, the wound is open with a beefy red base to the wound. Record review of Resident #2's 'Skin Impairment' care plan noted that there were no new interventions for treatment or prevention of sacrum wound development in the month of March 2025. Record review of Resident #2's 'Skin/Wound Note' dated 7/22/2025 at 2:07PM documented by the Infection Control Preventionist/Wound care nurse F noted: Old wound on Sacrum reopened, NP (Nurse Practioner) notified and currently being monitored. Record review of Resident #2's Nurse Practioner note dated 7/22/2025 at 6:12PM noted: Pressure ulcer Stage II to coccyx- not improving measuring deeper and larger in width. Wound treatment: Coccyx clean with saline, apply Collagen sheet- Endoform and Allevyn Dressing, change every 2 days and as needed on time a day for wound. Strict turning schedule; Must be every 2 hours. Record review of Resident #2's 'Skin Impairment' care plan noted that there were no new interventions for treatment or prevention of sacrum wound development in the month of July 2025. Record review of Resident #2's Nurse Practioner note dated 8/26/2025 at 2:40PM noted: Pressure ulcer Stage II to coccyx- unchanged. Nursing only putting on dry gauze on wound and saying they can't find the ordered treatment dressings even though they are in the wound cart that is fully accessible to them. Nursing noncompliance with dressing changes. Wound treatment: Coccyx clean with saline, apply collagen sheet- Endoform and Allevyn foam dressing, change every 2 days and as needed one time a day for wound. Record review of Resident #2's Nurse Practioner note dated 9/16/2025 at 2:08PM noted pressure ulcer Stage II to coccyx- closed. Record review of Resident #2's Nurse Practioner note dated 9/30/2025 at 10:00 AM noted wound to sacrum reopened and worsened= patient up in wheelchair throughout the day which is a benefit to her physical function, but she may need to be alternated between WC and bed multiple times throughout the day as able to relieve pressure points and get air to her skin. Wound treatment: Cleanse with soap and water, dry completely, Calcium Alginate (debride enzyme) with silver to wound bed, do not cover. Apply calmoseptine to buttocks every day shift for wound treatment. Record review of Resident #2's Nurse Practioner note dated 11/11/2025 at 10:0AM noted: Open wound to sacrum, improving since (urinary) catheter placement, measuring smaller, 100% granulation, surrounding skin intact and not moist, wound culture positive for MRSA (Methicillin Resistant Staph Arius), start on Bactrim for 7 days. Bactrim DS oral tablet 800-160mg give 1 tablet by mouth two times a day for MRSA in wound for 10 days until 11/21/2025. Coccyx wound stalled and still with odor. Record review of Resident #2's Nurse Practitioner note dated 12/2/2025 at 10:52AM noted: Open wound to sacrum not improving this week , turn schedule in place but patient not being turned according to schedule, indwelling catheter placed in mid-October to help with moisture and acidity exposure related to urinary incontinence, wound is measuring three times in length, again with bloody drainage, 100% gran tissue, surrounding skin hyperpigmentation is improving, but skin is moist . Coccyx wound was cultured on 11/6/2025 and positive for MRSA, resident completed 10 days Bactrim (antibiotic). New order: Linezolid (antibiotic) 600mg tablet take one tab by mouth twice daily for 7 days for wound infection. Record review of Resident #2's Nurse Practitioner note dated 12/9/2025 at 10:00AM noted: open wound to sacrum improving, patient is now being turned according to schedule, indwelling catheter placed in mid-October to help with moisture and acidity exposure related to urinary incontinence, wound is measuring smaller, no drainage, 100% gran tissue, surrounding skin hyperpigmentation, moist and starting to break down. Start metronidazole (Flagyl- antibiotic) 500mg tablet take one tablet daily for 5 days for fungal skin infection. Record review of the facility 'Pressure Injury Prevention and Management' policy dated 12/12/2025 revealed the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. 'Pressure Ulcer/Injury' refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate . Modification of Interventions: Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include new onset or recurrent pressure injury development, lack of progression towards healing . Observation and interview on 12/12/2025 at 8:36 AM of Resident #2 (R2) sacrum pressure/injury with Registered Nurse I and Certified Nurse assistant (CNA) I. R2 was observed to be lying in bed and was positioned flat on the back. Observation of Foley Catheter with a right leg strap in place dated 11/27/25, right abdomen colostomy intact. R2 was repositioned rolled onto the left side by CNA I. Observed an estimated 8 inch by 8-inch heart shaped foam boarder dressing to the sacrum/coccyx area dated 12/11/2025. The sacrum/coccyx dressing peeled back, and wound packing fell out of the wound. Observation of the wound was estimated to be 2cm in length x 1cm wide, depth was visible with a beefy red base of the wound. Observation of surrounding skin was noted with red area fungal in appearance with irregular boarders. Record review of Resident #2 (R2) nursing care plans pages 1-16 revealed Resident #2 had an actual skin impairment upon admission and is at risk for reopening and new skin disruption dated 9/8/2023. Goal: Resident will not develop any new areas of skin disruption, target date 2/5/2026. Record reviewed interventions: the last skin impairment intervention added to the care plan was dated 12/9/2024, over a year prior. In an interview and record review on 12/12/2025 at 9:37 AM with the Director of Nursing (DON) reviewed all Resident #2's care plans with the state surveyor. Record review of skin impairment care plan, last revision 2023, no added interventions with new development of skin pressure/injury. Intervention of Air mattress added 12/9/2024. DON stated that Resident #2 has now developed stage II to the sacrum, wound nurse calling it a skin tear. The DON reviewed medical record and care plan intervention. The DON stated that staff did start to only get the residents up for a limited number of hours daily like 6 hours, but it's not on the care plan either. There is a physician order for strict turning every 2 hours is on the treatment record but not on the care plan either. Record review of the facility 'Comprehensive Care Plans' policy dated 11/11/2025 revealed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with residents rights, that include measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Professional standards of quality means that care and all services are provided according to accepted standards of clinical practice. Standards may apply to care provided by particular clinical discipline or in a specific clinical situation or setting . The comprehensive care plan will be reviewed and revised by the interdisciplinary team .

Based on observation, interview and record review, the facility failed to ensure that the enteral tube feeding (TF) solution was labeled with the resident's name, date, and rate of infusion for one resident (Resident #6) of 1 sampled resident. Findings include: Resident #6:Observation and interview on 12/09/2025 at 9:24 AM during the screening process at the beginning of the survey of Resident #6 was observed to be lying in bed. Observation of the bedside revealed an empty bottle/container and tubing of Glucerna 1.5 cal. solution with no resident name, rate, time, date or duration of infusion of feeding material. Observation of the Hospice Registered Nurse M providing care in the room to Resident #6. RN M stated that hospice does not hang feeding tube solution. The state surveyor had the hospice RN M observe the feeding tube bottle and tubing for a name, date, rate. RN M stated Yes, it is empty, and it does not tell you who's it is or how long or rate to run it. Observation and interview on 12/09/2025 at 9:26 AM with Registered Nurse (RN) F were brought into Resident #6's room to observe the Glucerna 1.5cal, feeding tube solution hanging at bedside that was empty. RN F reviewed the feeding tube bottle with no date, to time, no resident name, no rate of infusion, and the bottle is empty. Registered Nurse F stated that the feeding tube solution is hung by the night shift and runs all night long. Record review of Resident #6's 'Medication Administration Record (MAR)/Treatment Administration Record (TAR)' for the month of December 2025 revealed that on 12/8/2025 in the evening: Glucerna 1.5 cal. oral liquid (Nutritional Supplement) give 150 ml via PEG-tube in the evening for dysphagia continuous via pump, run from 7:00PM to 5:00AM water to run concurrently with enteral feeding at 100ml/hr. was signed out by a night shift nurse. Record review of the facility 'Medication Administration via Enteral Tube' dated 12/10/2025 revealed it is the policy of the facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines. Procedure: b.) Ensure residents' name, date, dosing, are present on the waster bag and tube feeding bottle. Record review of the facility 'Care and Treatment of Feeding Tubes' policy dated 12/10/2025 revealed it is the policy of this facility to utilize feeding tubes in accordance with current clinical standard of practice, with interventions to prevent complications to the extent possible. 1.) Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush.

Based on observation, interview and record review, the facility failed to assess and monitor a post-dialysis pressure dressing for 1 resident (Resident #3) of 1 sampled resident, resulting in Resident #3 to be observed with a pressure dressing to the fistula access sites with no date on the dressing or documented nursing assessment. Findings include: Resident #3:In an observation and interview on 12/09/2025 at 9:01 AM with Resident #3 was seated up in a wheelchair in her room. Resident #3 stated that she goes to hemodialysis, on Monday, Wednesday, and Fridays. The state surveyor observed two pressure dressings to left upper arm, with 4x4 gauze folded and applied with tape, no dates noted on the dressings. Resident #3 stated that I take the dressings off, and if it starts to bleed again i go to the nursing station and tell them. The nurses put a dressing on the area. I also Go to the wound clinic for my left ankle wound. I got the wound at a previous nursing home. it's better now, getting smaller, less painful. Observation and interview on 12/09/2025 at 11:45 AM with Resident #3 were still seated up in her room in WC able to propel self, eating red peppers snacks in a baggie, denied any needs. Observation of the residents Left upper arm dialysis dressing now with a piece of tape with date 12/8/2025 with initials, back dated to the dressing site to the day of dialysis treatment which was on Monday 12/8/2025. The state surveyor tracked down the nurse initials and brought in Licensed Practical Nurse/ Infection Control/ Wound Care Nurse F into resident room to observe the dialysis dressing site, LPN F appeared flustered and stated that she forgot the date. LPN F reviewed Resident #3's nursing progress notes dated 12/8/2025 and stated that the nurse should have assessed the dressing site from dialysis and dated the dressing for 12/8/2025. The nurse was to take a clean piece of tape and write the date on and apply it to the dialysis pressure dressing. There were no nursing progress notes documented for the day. Record review of Resident #3's dialysis communication form dated 12/8/2025 at 12:00PM post dialysis notes by Registered Nurse (RN) G documented shunt location/status: left upper arm. Bruit/thrill present: yes. Bleeding: no. General condition of resident: good- Norco given for pain. Vital signs: BP:144/65, Pulse: 53, Resp. 18, Temp: 97.4, Pain:7 SPO2 96% room air. There was no assessment or documentation of the left upper arm pressure dressings placed by the dialysis center. Record review of Resident #3's Nursing progress notes revealed that there were no documented notes on 12/8/2025 for the entire day. There were no notes or assessments related to the dialysis pressure dressings noted. Record review of Registered Nurse (RN) F's 'Licensed Nurse Orientation/Annual Competency Checklist' dated 5/21/2025 had no skills related to dialysis pre/post therapy assessments or dialysis pressure dressing monitoring post treatment.

Based on interview and record review, the facility failed to ensure that the Infection Control Preventionist Licensed Practical Nurse F completed an annual nursing skills competency evaluation for 1 of 2 nurses reviewed. Findings include:Staffing review task: In an interview and records review on 12/11/2025 at 10:57 AM with the Human resource staff member N revealed that there were 4 Registered Nurses, seven Licensed Practical Nurses, and 24 Certified Nursing Assistants available for scheduling. The Staff member N prepared and submitted the PBJ (Payroll Based Journal) quarterly. The facility had a full time Director of Nursing. Record review on 12/11/2025 during the staffing task of the survey of professional licensed nurses' annual competencies/skills checklist for the year 202 was not completed for Licensed Practical Nurse (LPN)/Infection Control Preventionist/Wound Care nurse F. Human resource staff member N stated She did not have an annual competency check list for 2025 for LPN F and did not know why she does not have one. The former Director of Nursing (DON) did not do it. LPN/ICP was hired in August 2023 and should done one. Record review of LPN/IPC employee file by Human resource staff and state surveyor looked through the employee file, binders and piles of papers in office. No annual competency for 2025 was located. On 12/12/2025 at 9:48 AM the Director of Nursing (DON) presented the state surveyor with a 'Licensed Nurse Orientation/Annual Competency Checklist' form dated 12/11/2025 for Licensed Practical Nurse (LPN)/Infection Control Preventionist/Wound Care nurse F. The state surveyor asked Why did LPN/ICP/Wound care not have an annual competency evaluation for 2025 until the state agency inquired? THE DON stated that LPN/ICP/Wound care nurse F also worked the resident care floor as nurse when needed. The DON stated the LPN F did not have 2025 annual skills/competency and did not know why. THE DON stated that she was the MDS assessment nurse until November of 2025 and had recently become the DON. The DON stated that No one said anything to her about it, and that LPN F should have known as she was a part of the management team and it should have been done. The DON stated that she did sign off on the new annual competency checklist dated 12/11/2025. The DON when asked about performing all of the required skills on the checklist form in one day replied that we did most of skills/procedures she thinks.

Based on observation, interview and record review, the facility failed to identify targeted behaviors, medication classifications, and the duration of therapy on the informed consents for 3 residents (R5, R6, R22) of 5 sampled residents. Findings include: Resident #5:Record review of Resident #5's Minimum Data Set (MDS) date 11/30/2025 revealed an elderly resident who was his own responsible party. Review of section I: active medical diagnosis included: debility, heart failure, diabetes, anxiety, depression, bipolar and post-traumatic stress disorder. Section N: Medications identified that the resident received antipsychotic, antidepressant, and anticonvulsant medications. Record review of Resident #5's 'Medication Administration Record' (MAR) for December 2025 revealed medications administered of aripiprazole (Abilify) antipsychotic medication 2mg tablet by mouth in the evening for mood stabilizer. Escitalopram (Lexapro) antidepressant medication 10mg tablet by mouth one time a day for depression. In an interview and record review on 12/11/2025 at 9:07 AM with Social Worker (SW) H regarding Resident #5's medications. Social worker H revealed Resident #5 was on Lexapro 20mg every day for depression, Abilify 2mg at night for mood stabilizer, and Tramadol 50mg twice daily for pain. On 12/11/2025 at 9:17 AM with the SW H of Resident #5's physician orders and interview revealed that the facility had Resident #5 Sign his consent on September 12, 2025. Record review of the 'Psychoactive Medication Informed Consent' form dated 9/12/25 did not identify which medication was for depression and which medication was used for mood stabilizer. The form did not identify clinically significant side effects potentially associated with the medication's classification. The consent form expected benefits from the medication intervention included was blank. There were no targeted behaviors identified. Record review of medications Abilify (antipsychotic) and Lexapro (antidepressant) consent dated 9/12/2025 did not identify triggered behaviors to be treated, identify which classification of medication and significant side effects associated with the medications was being consented too. Record review of Resident #5's behavior 30-day monitoring task from 11/12/2025 through 12/12/2025 identified triggered behaviors of repeats movement, and grabbing. Resident #6:Record review of Resident #56s Minimum Data Set (MDS) date 10/2/2025 revealed an elderly resident who was his own responsible party. Review of Section I: active medical diagnosis included: progressive neurological condition, coronary artery disease, hypertension, peripheral vascular disease, diabetes, cerebrovascular accident/stroke, seizure disorder, anxiety, depression, and psychotic disorder. Section N: Medications identified that the resident received antipsychotic and antidepressant medications. Record review of Resident #6's 'Medication Administration Record' (MAR) for December 2025 revealed medications administered of risperidone antipsychotic medication 0.5mg tablet via peg-tube in the evening for depression. mirtazapine (Remeron) antidepressant medication 15mg tablet by via peg-tube in the evening for depression. In an interview and record review on 12/11/2025 at 9:20 AM with Social Worker (SW) H regarding Resident #6's medications Risperidone 0.5mg for depression in the evening, Remeron 15mg in evening for depression and appetite. Record review of 'Psychoactive Medication Informed Consent' form dated 11/22/2024 revealed medications of duloxetine (Cymbalta) antidepressant, risperidone antipsychotic, and mirtazapine (Remeron) antidepressant medications were listed on the consent. Record review of the consent form was completed by the Director of Nursing (DON) and signed the consent and did not identify the targeted behaviors of treatment. The form did not identify clinically significant side effects potentially associated with the medication's classifications. The consent form expected benefits from the medication intervention statement was blank. There were no targeted behaviors identified. Record review of Resident #6's behavior 30-day monitoring task from 11/12/2025 through 12/12/2025 identified triggered behaviors of repeats movement, pushing and grabbing. Resident #22:Record review of Resident #22's Minimum Data Set (MDS) date 9/18/2025 revealed an elderly resident who was his own responsible party. Review of section I: active medical diagnosis included: non-traumatic brain dysfunction, cancer, anemia, atrial fibrillation, coronary artery disease, hypertension, non-Alzheimer's dementia, anxiety, and depression. Section N: medications identified that the resident received antipsychotic, antianxiety, and antidepressant. Record review of Resident #22's 'Medication Administration Record' (MAR) for December 2025 revealed medications administered olanzapine (Zyprexa) antipsychotic medication 5mg tablet by mouth on time a day for major depressive disorder recurrent with psychotic symptoms. Trazodone antidepressant medication 50mg tablet by mouth in the evening for insomnia. Venlafaxine (Effexor) antidepressant medication 75mg capsule by mouth in the morning for depression. Buspirone (Buspar) antianxiety medication 10mg tablet by mouth two times a day for anxiety. Clonazepam antianxiety medication 0.5mg tablet by mouth three times a day for anxiety disorder. In an interview and record review on 12/11/2025 at 12:32PM with Social Worker (SW) H regarding Resident #22's medications. Social worker H reviewed Resident #22 'Psychoactive Medication Informed Consent' form dated 9/12/25 identified mirtazapine (Remeron) antidepressant, olanzapine (Zyprexa) antipsychotic, clonazepam benzodiazepine, trazadone antidepressant was listed on the consent. did not identify which medication was for depression and which medication was used for mood stabilizer. The form did not identify clinically significant side effects potentially associated with the medication's classification. The consent form expected benefits from the medication intervention included was blank. There were no targeted behaviors identified. Record review of medications Abilify (antipsychotic) and Lexapro (antidepressant) consent dated 9/12/2025 did not identify triggered behaviors to be treated, identify which classification of medication and significant side effects associated with the medications was being consented too. Black box warnings for antipsychotic medications were not identified on the consent. Record review of Resident #22's behavior 30-day monitoring task from 11/12/2025 through 12/12/2025 identified triggered behaviors of frequent crying, yelling and swearing, and rejection of care. Record review of the facility 'Use of Psychotropic Medications' policy dated 12/11/2025 revealed that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of initiation or increase.

This citation pertains to intake Number 2585037.Based on observation, interview and record review, the facility failed to ensure a clean, safe, and homelike environment involving the Therapy room and 5 residents' rooms (Rooms 2, 3, 4, 14, and 19) of 20 rooms in total, resulting in the protentional for injury (therapy equipment stored in the therapy area, increases risk of tripping and falling), resident and family complaint's regarding the environment, anger, dissatisfaction and depression.Findings Include: Self-tour of facility on 8/19/2025 at 9:30AM noted Strong urine odors in the back hall noted coming from room [ROOM NUMBER]. Noted 2 male residents to reside in room, Resident #106 the bed by the window was noted with urinal on nightstand with yellow urine noted with no top on it, half full, next to white Styrofoam drinking glass with a straw. Observations on 8/19/2025 throughout the day of the survey, the urinal was noted to be left on the nightstand not emptied and next to the Styrofoam drinking glass. Observation and smells on 8/20/2025 at 8:08AM during a self-tour of the back hall, noted odors of the urine smell and body odors. Observation and smell on 8/20/2025 at 8:55AM of the back hallway on the north side of the building tour noted room [ROOM NUMBER] with smells of body odor coming from room. Observed a large male resident lying in bed. Observation of room [ROOM NUMBER] was noted with Kleenex and paper items on the floor on top of fall matt. Observation on 8/20/2025 at 9:00AM as surveyor walked down hallway strong odors of urine noted in room [ROOM NUMBER]. Resident #106 male residents with urinal half full noted at bedside nightstand with urine waiting to be dumped. Observation and interview on 8/20/2025 at 10:00AM with Certified Nurse Assistant (CNA) L on tour of room [ROOM NUMBER] strong smell of urine noted in hallway. CNA L stated that it is an ongoing issue with the room. Observation of room double occupancy Resident #101 next to the door and Resident #106 bed next to window. Observed Resident #106 seated up in a soft cloth Recliner in room with nightstand and 2 Styrofoam cups with straws and the surveyor Noted a half full urinal of urine with no lid noted at table side. Toured bathroom and room, sink in resident room area. Resident #106 was seated up in recliner and stated that he likes his room. Resident #106 requested more ice for his cup and CNA L took the cup from the nightstand and did not offer or empty the urinal next to the cups. Resident #101 was lying in bed stated having a lazy day. Observed that each male resident has a clothe soft recliner noted at bedside with urine odors smelled. Observation on 8/20/25 at 12:07PM the state surveyor observed a half-filled urinal in room [ROOM NUMBER], right next to Styrofoam glasses on nightstand, still not dumped. Strong odors noted in room. Recliner chair of resident #106 with strong urine smell noted. Both Residents were observed eating the noon meal chicken parmesan in the main dining room. Observation of the facility environment was done on 8/19/25 from 10:00 a.m. through 11:00 a.m.; the following concerns were noted: room [ROOM NUMBER]: No towels in the room by sink. room [ROOM NUMBER]: The trash container was full under sink and a wet washcloth was sitting in pink basin on the floor under the sink. room [ROOM NUMBER]: The room was very cluttered. A urinal was sitting on the sink with no name or bed number. Clothing was being stored on the floor stored under the sink. room [ROOM NUMBER]: A large black fan was blowing on bed 1; dust was noted on the cover, which was blowing directly on the resident in bed. room [ROOM NUMBER]-1: At 11:30 a.m., resident in bed, urinal had urine in it, and it was sitting on the floor. The resident’s breakfast tray was sitting on the bedside table, not touched at all. On the second observation done on 8/19/25 at 12:00 p.m., breakfast tray (with eggs, cheese, bread, oatmeal and 2 sausage links) was not touched and still sitting on tray next to bed (potentially hazardous foods sitting out approximately 4 hours). 2 urinal’s were sitting on the floor next to the bed, with one about 1/4 full of urine. Also, observation of the resident’s wheelchair that was sitting in the hallway, had the oxygen tubing and nasal cannula sitting on the seat, not in a bag for protection; the tubing has a piece of paper on it dated 8/9 (should have been changed on 8/16/25 per oxygen policy dated 11/12/25, weekly). During an interview done on 8/19/25 at 3:00 p.m., the Administrator stated, “We change the oxygen tubing every Sunday.” Observation of the therapy room was done on 8/19/25 at 11:00 a.m.; accompanied by OT “I and the following concerns were noted: Approximately half of the therapy room was being used for the storage of therapy equipment. -x8 wheelchairs -x3 wheeled walkers -x9 to x10 walkers, 1 lift, several [NAME] -several wheelchair foot rests in a large box -x1red power scooter -x1 box of wheelchair cushions The parallel bars have several wheelchairs and walkers in the middle of it; staff had to stop therapy and move the items and then when therapy was completed, move the wheelchairs and walkers back. During a second observation done on 8/20/25 at approximately 9:00 a.m., the therapy room had, x4 wheelchairs, a stand-up lift, a wheeled walker, a red power scooter, a ceiling vent by the air conditioner that had rust on it, and a air conditioning unit that was humming and did not work. During an interview done on 8/19/25 at 11:00 a.m., OT I stated I just started last week, if I want to use the plinth (bed for resident therapy use) is completely covered with equipment, papers, lefts, and parts of therapy equipment. I have to clean it off, wipe it down, and then use it. I had to move the chairs around when I had to use the parallel bars (has several wheelchairs stored by it and on side of it). During an interview done on 8/19/25 at 12:20pm, CNA “K stated I told them (management) about that (unclean environment), but no one did anything until today; they made me help them put the equipment not being used in the basement. During an interview done on 8/20/25 at 9:00 a.m., PT “O stated “There is to much equipment in the room, the air conditioner does not work it needs Freon; I have to move everything to do therapy and then put it back after.” During an interview done on 8/20/25 at 8:50 a.m., the Infection Control Nurse, LPN “C stated “I do rounds and I get things addressed then, right away; I do not go in therapy.” During an interview done on 8/19/25 at 10:56 a.m., Social Worker “G stated I do gets complaints on this building being dirty about 3 times a week, mainly odors. Our new OT has addressed that room being cluttered, and she can't get to the equipment she needs (parallel bars) to do certain therapy with resident's. Review of the facility Interdepartmental Infection Control Rounds sheets dated 5/25, 6/25, and 7/25, revealed surveillance rounds had been done in resident’s rooms monthly. During an interview done on 8/20/25 at 10:00 a.m., Director of Maintenance “P stated “yes the air conditioner is broken; I have had trouble getting people in here to fix it; it needs freon. I did tell them about the therapy room the day before you came in (on 8/18/25) at the morning meeting.” Review of morning meeting notes dated 8/18/25, written by the Administrator stated “W/C (wheelchair) storage basement.” During an interview done on 8/19/25 at 11:20 a.m., the Administrator stated We talked about the storage yesterday for therapy, (Director of Maintenance #P) said he was going to put it downstairs in the basement. It's not acceptable to me, I have seen it once when I walked around there about 2 months ago. Urinals, they should have names on); if not in use I would put it in a plastic bag. Oxygen nasal cannulas are stored when not in use in bags, tubing is changed every Sunday. During an interview done on 8/20/25 at 8:36 a.m., the Administrator said she was also Director of Nursing and Supervisor of Housekeeping. When this surveyor asked when the housekeepers come in and start work daily she stated “They come in at 7:00 a.m., they can get started on the rooms and the hallways while the resident’s are eating; I am supposed to be checking the room’s, we don’t have a list for a housekeeping supervisor (to fill out for resident room checks).” During an interview done on 8/19/25 at 10:56 a.m., Social Worker “G stated I do gets complaints on this building being dirty about 3 times a week, mainly odors. Our new OT has addressed that room being cluttered, and she can't get to the equipment she needs (parallel bars) to do certain therapy with resident's. During an interview and observation done on 8/19/25 at 11:58 a.m., in the hallway near the smoking door, room [ROOM NUMBER]-1 was seen wheeling his wheelchair from the exit door (smoking door) to the hallway with his urinary catheter bag and tubing uncovered (not in a privacy bag) and dragging on the floor. The catheter bag was wet from being outside dragging on the ground and got the floor wet, also it was not in the privacy bag that was hanging on his wheelchair. During an interview done on 8/19/25 at 11:58 a.m., Nursing Assistant/CNA J stated “yes, I see it (the catheter dragging on the floor), he just came in from outside, it should not be on the floor.” During a phone interview done on 8/19/25 at 11:14 a.m., Family Member #1 stated My dad said the Therapy room is dirty and smells, he said it was disgusting. The halls smell and the place is dirty.

This citation pertains to intake Numbers: 2590687, 2577760, and 2581464. Based on observation, interview and record review, the facility failed to prevent a decline in the quality of life for one resident (Resident #101) of 6 residents reviewed, resulting in Resident #101 having a change in demeanor of a decrease in activity with an increase in depression of tearfulness. Findings include: Record review of Resident #101's Minimum Data Set (MDS) dated [DATE] quarterly assessment revealed an elderly male resident with medical diagnoses of: Heart failure, Diabetes, anxiety, depression and respiratory failure. Record review of Resident #101's physician orders for the month of August 2025 revealed medications of Abilify (antipsychotic), Lexapro (antidepressant), daily for mood and mental stability. Observation and interview were conducted on 8/19/2025 at 9:55AM with Resident #101 seated up in Wheelchair in the dining room, drinking coffee with other residents. He is interacting with staff members and enjoying himself. The interview revealed that he is just friends with staff nurses and nothing more. But did not want to talk about it. stating It's ridiculous we just joke around and try to have some fun here. I don't have a problem with living here; this is a quiet place. Facility reported incident and hotline complaints received to the state agency identified concerns of a resident and staff inappropriate relations. Investigation of the alleged incident identified that Resident #101 was spoken to by management staff about the relationship with talking to staff members regularly on 08/01/2025. Record review of the investigative file revealed that a signed 3101 form dated 8/1/2025 revealed: Resident #101 was taken into the conference room to have a private area to discuss the details of an allegation by staff that he is having an inappropriate relationship with a unit manager. Resident #101 was questioned to the nature of the relationship he stated, We are just friends, she's a good lady. Resident #101 was asked about a romantic relationship. Resident #101 stated No. They had never kissed, and they were just joking around stating they were getting married. Resident #101 was explained not to go and sit in front of the office door of the unit manager so the manager can complete her work. Record review of Resident #101's nursing progress notes dated 7/29/2025 at 6:40PM of Nurse Practitioner noted no mention of depression or that the resident was having a mood change. Record review of Resident #101's late entry physician progress note, not dated 7/31/2025 at 8:47PM noted that Resident #101's chart was reviewed and patient examined, further note to follow. Hemodynamically and clinically stable, some intermittent mild depressive symptoms, will follow with social worker, psychiatry, and staff for further symptoms. Record review of Resident #101's nursing progress notes late entry on 8/1/2025 at 9:30 AM revealed: Allegation of resident abuse by staff regarding resident's inappropriate relationship with unit manager. Investigation initiated. Record review of Resident #101's 8/1/2025 at 3:30PM nursing progress note revealed: (physician) saw resident and ordered abdominal Xray due to resident complaint of discomfort to area, no report of discomfort to this write. Appetite remains good. Resting quietly in bed at the time. Record review of Resident #101's 8/1/2025 at 5:50PM nursing progress note revealed: Resident has been lying in bed since 2:30PM. He refused his 4pm med stating he doesn't care about it and refuses to get up out of bed. Refused dinner as well. Denies pain and will continue to monitor. Record review of resident #101's 8/1/2025 at 8:28 PM nursing progress note revealed: Resident has been tearful and lying in bed since 2:30PM. He refused all nighttime medications times 3. He stated he did not care. He refused dinner as well. Record review of Resident #101's 8/1/2025 Medication Administration Record (MAR) noted Ativan 1mg Intramuscular injection (IM) one time daily for 1 day. Ativan medication was administered at 8:21PM by the Nursing Home Administrator/Director of Nursing. In an interview on 8/20/2025 at 11:35 AM, the Nursing Home Administrator/Director of Nursing about the Ativan IM injection stated that Resident #101 was just upset that he was going to get a staff member fired, and he did not like the other staff talking about it. He couldn't sleep at night, and I called (physician) and got the Ativan order for IM injection and gave it myself. Record review of Resident #101's Nurse Practitioner's note dated 8/4/2025 revealed investigation initiated 8/1/2025 for allegation of patient abuse by staff regarding patient's inappropriate relationship with a staff member. The nurse spoke with patient on 8/4/2025 in regard to the incident on 8/1/2025. He stared he was not happy staff reported this and stated he wants to get out of here as soon as possible. Patient currently working for community placement. Patient has been tearful related to incident, refusing showers, meds, and to get out of bed .Record review of the facility 'Promoting/Maintaining Resident Dignity' policy, undated, revealed it is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.

This citation pertains to Intake Numbers 2590687, 2577760, and 2581464. Based on observation, interview and record review, the facility failed to get a signed informed consent for anti-anxiety medication prior to administering it for one resident (R101), resulting in Resident #101 receiving the medication with no written or verbal consent. Findings include: Record review of Resident #101's Minimum Data Set (MDS) dated [DATE] quarterly assessment revealed an elderly male resident with medical diagnosis of: Heart failure, Diabetes, anxiety, depression and respiratory failure. Record review of Resident #101's physician orders for the month of August 2025 revealed medications of Abilify (antipsychotic), Lexapro (antidepressant), daily for mood and mental stability. Observations and an interview were conducted on 8/19/2025 at 9:55AM with Resident #101, who was seated up in Wheelchair in the dining room, drinking coffee with other residents. He is interacting with staff members and enjoying himself. The interview revealed that he is just friends with staff nurse and nothing more. But does not want to talk about it. Stating It's ridiculous we just joke around and try to have some fun here. I don't have a problem with living here. I lived in Oscoda, and this is a quiet place. Facility reported incident and hotline complaints received by the state agency identified concerns of a resident and staff inappropriate relations. Investigation of the alleged incident identified that Resident #101 was spoken to by management staff about the relationship with talking to staff member regularly on 8/1/2025. Record review of the investigative file revealed that a signed by resident #101 form dated 8/1/2025 revealed: Resident #101 was taken into the conference room to have a private area to discuss the details of an allegation by staff that he is having an inappropriate relationship with a unit manager. Resident #101 was questioned of the nature of the relationship he stated, We are just friends, she's a good lady. Resident #101 was asked about a romantic relationship. Resident #101 stated No. they had never kissed and that they were just joking around with stating they were getting married. Resident #101 was explained not to go and sit in front of the office door of the unit manager so the manager can complete her work. Record review of Resident #101's nursing progress notes dated 7/29/2025 at 6:40PM of Nurse Practitioner noted no mention of depression or that the resident was having a mood change. Record review of Resident #101's late entry physician progress not dated 7/31/2025 at 8:47PM noted that Resident #101's chart was reviewed and patient examined, further note to follow. Hemodynamically and clinically stable, some intermittent mild depressive symptoms, will follow with social worker, psychiatry, and staff for further symptoms. Record review of Resident #101's nursing progress notes late entry on 8/1/2025 at 9:30AM revealed: Allegation of resident abuse by staff regarding resident's inappropriate relationship with unit manager. Investigation initiated. Record review of Resident #101's 8/1/2025 at 3:30PM nursing progress note revealed: (physician) saw resident and ordered abdominal Xray due to resident complaint of discomfort to area, no report of discomfort to this writer. Appetite remains good. Resting quietly in bed at the time. Record review of Resident #101's 8/1/2025 at 5:50PM nursing progress note revealed: Resident has been lying in bed since 2:30PM. He refused his 4pm med stating he doesn't care about it and refuses to get up out of bed. Refused dinner as well. Denies pain and will continue to monitor. Record review of resident #101's 8/1/2025 at 8:28 PM nursing progress note revealed: Resident has been tearful and lying in bed since 2:30PM. He refused all nighttime medications times 3. He stated he did not care. He refused dinner as well. Record review of Resident #101's 8/1/2025 Medication Administration Record (MAR) noted Ativan 1mg Intramuscular injection (IM) one time daily for 1 day. Ativan medication was administered at 8:21PM by the Nursing Home Administrator/Director of Nursing. In an interview on 8/20/2025 at 11:35 AM, the Nursing Home Administrator/Director of Nursing about the Ativan IM injection stated that Resident #101 was just upset that he was going to get Staff member fired, and he did not like the other staff talking about it. He couldn't sleep at night, and I called (physician) and got the Ativan order for IM injection and gave it myself. Record review of facility 'Use of Psychotropic Medications' policy undated, revealed it is the intent of the policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms . (1.) A psychotropic drug is any drug that affects brain activities associated with mental process and behavior. Psychotropic drugs include but are not limited to the following categories: Antipsychotics, antidepressants, anti-anxiety, and hypnotics. (3.) Other medications not classified as antipsychotic, antidepressant, antianxiety, or hypnotic medications but can affect brain activity should not be used as a substitution for another psychotropic medication unless prescribed with a documented clinical indication for use consistent with accepted clinical standards of practice. (9.) Prior to initiating or increasing a psychotropic medication, the resident, family, and/or representative must be informed of the benefits, risk and alternatives for medication, including and black box warnings for antipsychotic medications, in advance of such initiation or increase. (11.) The facility will document that the resident or resident representative was informed in advance or the risk and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use. (e.g , written consent form, narrative note, etc.)Record review and interview on 8/20/2025 at 11:55AM with the Social Worker G reviewed Resident #101's point click care medical record of Resident #101's consent dated 8/19/2025 for Ativan IM was not dated and placed into the PCC on 8/19/2025. The Social Worker G stated that she should have dated the consent form; the nurse administered the medication. Record reviews of progress notes revealed that there was no verbal consent documented, and no written consent documented. The Social worker G stated that Ativan is an antianxiety medication and not used for sleep aid.

This Citation Pertains to Intake Number MI00151360. Based on observation, interview and record review, the facility 1) Failed to ensure accurate orders for a feeding tube and 2) Failed to ensure maintenance of the feeding tube, including water flushes, for 2 residents (Resident #1 and Resident #2) of 2 residents reviewed for feeding tubes. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: History of a stroke, left sided weakness, tongue and throat cancer, feeding tube, chronic pain syndrome, depression, weakness, hypertension and atrial fibrillation. The MDS assessment, dated 02/08/2025, revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with all care. On 3/26/2025 at 11:29 AM, during an interview with Nurse B, she said Resident #1 had a feeding tube that he had recently started using. The nurse said the tube had recently been replaced (the resident was transferred to the hospital on 3/11/2025 and returned 3/13/2025), because the previous feeding tube became dislodged. She said the resident had encountered severe pain when he received an attempted bolus of tube feeding, but the new tube was working well for him. Nurse B said Resident #1 was receiving Radiation and Chemotherapy treatments for oral and throat cancer and went to a Cancer Center 5 days a week for treatment. She said the feeding tube was initially placed in preparation for a time he might need it. He had been eating orally prior to discomfort in his mouth from the radiation treatments. A record review of the physician orders for Resident #1 identified the following: Regular Diet, chopped texture, thin consistency (liquids), start date 1/4/2025. Clean PEG (feeding tube) site with saline and apply 4x4 gauze daily and PRN (as needed), start date 1/30/2025. Flush PEG with 20cc of normal saline, start date 1/29/2025. Six times a day for painful swallow/unable to meet needs orally relate to tongue cancer, Bolus 250 ml Jevity 1.5 with an additional 200 ml water with PEG, start date 3/10/2025 and end date 3/19/2025. Enteral feed at bedtime, give dual system Jevity 1.5 @100 ml/hr with H2O 80 ml/hr total feed 1200 ml, start date 3/13/2025 and end date 3/19/2025. Enteral feed at bedtime. Give dual system Jevity 1.5 @ 100 ml/hr with H2O 80 ml/hr total feed 1200 ml, start date 3/19/2025. A review of the Medication Administration Record/MAR and Treatment Administration Record/TAR for Resident #1, revealed there was no documentation of Jevity being provided until 3/21/2025 until 3/21/2025. On 3/10/2025, an order was written for a bolus of Jevity 1.5, there was no documentation on the March 2025 MARTAR for Resident #1 that a nurse had attempted to provide the bolus of Jevity 1.5 to him. The 3/10/2025 order overlapped an additional order written 3/13/2025 for Jevity 1.5 to be given at 100 ml/hour. They were both discontinued on 3/19/2025. On 3/19/2025 an additional order was written for Jevity 1.5, which was the same as the 3/13/2025 order. A review of the MAR/TAR indicated there was no documentation by the nurses that Resident #1 had received or refused the Jevity 1.5 until 3/21/2025. The MAR/TAR for March 2025 did not mention the resident received water flushes to his feeding tube until 3/21/2025. A review of the February 2025 MARTAR for Resident #1 did not identify water flushes for the feeding tube. There was no indication the feeding tube had been flushed to keep it patent and in working condition. On 3/11/2025 the resident had severe abdominal pain when Nurse D attempted to bolus the Jevity 1.5 through Resident #1's feeding tube. He was transferred to the hospital and the feeding tube was replaced. He returned to the facility on [DATE]. On both the February and March 2025 MAR/TAR an order was identified as follows: Flush PEG with 20cc of Normal Saline three times a day for PEG tube care, order date 1/29/2025. The resident's Peg tube was placed 1/28/2025. The nurses were occasionally documenting that they were flushing the Peg tube with the 20cc of Normal Saline. On 3/26/2025 at 10:25 AM, Nurse E was asked about the 20cc Normal Saline flush of the Peg tube for Resident #1 and said the 20cc was a small amount and it would not flush the tube. She said she had not seen the order and did not do anything with the Peg tube. On 3/26/2025 at 2:24 PM, Registered Dietitian L was interviewed and said she had input the order on 3/10/2025 for Resident #1 to have a bolus of Jevity 1.5 with a water flush. She said it was discontinued when the resident had pain and had the tube replaced. On 3/27/2025 at 9:15 AM, Resident #1 was interviewed with Nurse B also present. He was sitting in wheelchair in his room and had recently been assisted by staff with his morning care. The resident said he was now using his feeding tube since it has been replaced and receives tube feeding and water flushes. He said the tube was working well and he wasn't having any issues with the new tube. The resident showed his abdomen; there was a gauze dressing over the peg tube insertion site. He said there was no redness or drainage. He said the first time they tried to use the other tube, he had so much pain they had to stop and send him to the hospital to have it replaced. During an interview with Nurse D on 3/27/2025 at 12:05 PM, she said on 3/11/2025 Resident #1 had severe abdominal pain when she attempted to bolus (a single large dose) the Jevity 1.5 through Resident #1's feeding tube. He was transferred to the hospital and the feeding tube was replaced. He returned to the facility on [DATE]. On 3/27/2025 at 2:45 PM, Nurse C was interviewed about the order for water flushes for Resident #1. She looked at the 3/10/2025 order for Jevity 1.5 and a water flush in the electronic medical record and she said the box was not checked to send it to the MAR or TAR when the order was placed; so, it did not show on the MAR/TAR for the nurses to document whether they had provided the care. A review of the Care Plans for Resident #1 identified the following: (Resident #1) has nutritional problem .1/25 PEG placed for use as needed . 3/10/25 (Resident) wanted to start using PEG for feeding/water flush due to oral pain preventing his ability to meet needs orally, date revised 3/10/2025 with Interventions including: Tube feeding and water flushes as ordered, date initiated 3/10/2025. There was no additional Care Plan addressing care and monitoring of Resident #1's feeding tube. Resident #2: A record review of the Face sheet and MDS assessment indicated Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Parkinson's, diabetes, COPD, history of a stroke, difficulty swallowing, a feeding tube, fibromyalgia, heart disease, anxiety, depression chronic pain and an autonomic condition. The MDS assessment dated [DATE] revealed the resident had full cognitive ability with a BIMS score of 14/15 and he needed assistance with all care. On 3/26/2025 at 10:25 AM, Resident #2 was observed lying in bed. Nurse C was present and showed the resident's abdomen had 2 peg tube sites: an old now unused site and a new site with the Peg tube. The old site had some redness surrounding it and dried dark drainage. The gauze dressing on the site was very damp and had no date or initials when it was changed. Nurse C said she had not yet changed it that day and she wasn't sure who had placed the dressing. She said the resident's tube feeding was currently off, but would start again at 1:00 PM. She said she would start it and also provide the water flush. A review of the physician orders for Resident #2 revealed the resident had tube feeding and a pureed texture diet with pleasure foods dated 1/26/2025 and: Water to run via PEG@ 100/hr concurrently (1500 ml total per day,: two times a day for hydration water to run concurrent with enteral feeding at 100 ml/hr; 1 PM to 8 PM and 10 PM to 6 AM, dated 3/22/2025. Glucerna 1.5 Cal oral liquid (Nutritional Supplements) Give 100 ml via PEG-Tube in the afternoon for dysphagia continuous via pump, run from 1 PM to 8 PM, order date 12/17/2024 and discontinued 3/21/2025. Glucerna 1.5 Cal Oral Liquid (Nutritional Supplements) Give 120 ml via PEG-Tube at bedtime for dysphagia Glucerna to run at 100/hr from 10 PM to 6 AM (800 ml total), order date 3/21/2025. Glucerna 1.5 Cal Oral Liquid (Nutritional Supplements) Give 120 ml via PEG-Tube in the afternoon for dysphagia continuous via pump, run from 1 PM to 8 PM, order date 3/21/2025. The physician orders did not mention water flushes of the feeding tube. A review of the MAR/TAR for March for Resident #2 revealed the nurses were documenting they were administering the tube feeding, but there were not entries for flushing the feeding tube to keep it patent (clear/open/unclogged). A review of the Care Plans for Resident #2 identified the following: (Resident #2) has potential nutritional problem related to dysphagia, history failure to thrive, Parkinsons, (diabetes), GERD, (no teeth) and refuses to wear his dentures. Potential for weight loss. Feeding tube . Hospice, date initiated 10/25/2025 and revised 1/8/2025. The interventions do not mention a water flush to maintain the PEG tube. There was no Care Plan for maintenance of the feeding tube for Resident #2. On 3/27/2025 at 2:50 PM, Nurse A was asked about the Normal Saline flush of the Peg tube for Resident #1 and she said she was not familiar with flushing the Peg tube with Normal saline. She said she spoke with the physician and the order was discontinued. Reviewed with Nurse A there was a lack of documentation that the feeding tube was being flushed with water, as Nurse C had identified the orders were not pulling over to the MAR/TAR for the Resident's (#1 and #2). She said they would fix it. A review of the facility policy titled, Care and Treatment of Feeding Tubes, date implemented 3/26/2025 provided, It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible . Feeding tubes will be utilized according to physician orders which typically include: the kind of feeding and its caloric value, volume, duration, mechanism of administration, and frequency of flush . The resident's plan of care will address the use of feeding tube, including strategies to prevent complications . Direction for staff on how to provide the following care will be provided: . Frequency of and volume used for flushing, including flushing for medication administration, and what to do when a prescriber's order does not specify .

This Citation Pertains to Intake Number MI00151360. Based on observation, interview and record review, the facility failed to follow accepted standards of practice for obtaining a physician's order, assessment and monitoring of a Central Venous Catheter/CVS Mediport IV for one resident (Resident #1) of 1 resident reviewed for IV catheters. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: History of a stroke, left sided weakness, tongue and throat cancer, feeding tube, chronic pain syndrome, depression, weakness, hypertension and atrial fibrillation. Resident #1 was receiving chemotherapy and radiation therapy for the cancer. The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status/BIMS score of 15/15 and the resident needed some assistance with all care. On 3/27/2025 at 9:20 AM, Resident #1 was interviewed with Nurse B present. He was sitting in a wheelchair in his room and had recently been assisted by staff with his morning care. The resident said he was receiving chemotherapy and radiation at the Cancer Center. He pointed to his chest and said his IV was there. Nurse B confirmed the resident had a Central line IV catheter for chemotherapy. A review of the physician orders for Resident #1 provided the following: Refer patient to vascular surgery for mediport placement, dated 12/31/2024. There was no further mention of an IV, Central line Mediport (a surgical implanted port for IV medications) in the physician orders. A review of the Medication Administration Records/MAR and Treatment Administration Records/TAR for Resident #1 for February and March 2025 indicated there was no mention of the IV Mediport, where it was located or if it as monitored by the nurses. A review of the progress notes identified the following: A provider note dated 1/14/2025, . Having mediport placed this week . A provider note dated 1/7/2025, . Mediport placed on 1/3/25-site appears stable . There were no additional notes or assessments of the Mediport site or dressing to the site. On 3/27/2025 at 2:05 PM, Nurse C was interviewed about Resident #1's Central Line IV that was being used for chemotherapy. She said only the staff at the Cancer Center used the Mediport and changed the dressing. Nurse C was asked if Resident #1's nurses at the facility were monitoring to ensure the dressings were intact, there was no bleeding through the dressing or redness, pain or warmth around it. She said they were not. Reviewed the physician orders and MAR/TAR for Resident #1 with Nurse C and she said there was no mention of the Mediport. A review of the Care Plans for Resident #1 identified the following: The resident has actual impairment to skin integrity of the surgical incisions: Mediport and (PEG tube insertion on 1/24/2025), date initiated 11/22/2024 and revised 1/25/2025, with 2 interventions: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short, date initiated 11/22/2024; Keep skin lean and dry. Use lotion on dry skin, both interventions initiated on 11/22/2024. Prior to the resident having the Mediport implanted. The Care Plan was not specific to the Mediport. There were no additional Care Plans that mentioned the Mediport Central Line. On 3/27/2025 at 2:55 PM, Nurse A was interviewed about the lack of physician orders, monitoring and documentation of the Mediport for Resident #1. She said she would look into it. The facility provided a policy for flushing, locking and removing a Central line, but not for management of a Central line, including monitoring for adverse effects.

This Citation Pertains to Intake Number MI00151360. Based on observation, interview and record review, the facility failed to ensure that 1) Physician's orders for dialysis services; 2) Post- Dialysis assessment and monitoring were completed and 3) Dialysis communication forms were complete and included pre-dialysis and post-dialysis assessment, including location and assessment of the dialysis access site for one resident (Resident #4) of 1 resident reviewed for Dialysis care. Findings Include: Dialysis Resident #4: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Chronic kidney disease, receives dialysis, Diabetes, obesity, anemia, gout, hypothyroidism. Hypertension and bipolar disorder. The MDS assessment dated [DATE] revealed the resident full cognitive abilities. On 3/27/2025 at 11:42 AM Nurse C was interviewed about Resident #4 receiving dialysis services, she said the resident did not have a physician order for dialysis services. She said there was also no orders for the dialysis access site or monitoring. The nurse said the resident had a dialysis access device in the left arm and it was supposed to be assessed and monitored. On 3/27/2025 at 12:50 PM, Resident #4 was interviewed. She said she had just returned from dialysis; she said she had dialysis on Tuesday, Thursday and Saturdays. She said she had a fistula in her right arm for dialysis. The resident said today at the dialysis center they had a hard time with the fistula as it was bleeding, and they had to place extra dressings on top of it. A record review of the physician orders for Resident #4 revealed there was no mention that Resident #4 had a dialysis access site or fistula. A review of the Medication Administration Records/MAR and Treatment Administration Records/TAR for March 2025 indicated there was no mention of a dialysis catheter access device/fistula or monitoring for adverse events. A review of the dialysis communication forms used for communication of assessment information before (by the facility), during (by the dialysis center) and after dialysis (by the facility) services identified that the forms were not always completed by the facility. On occasion the Pre-dialysis assessment information was incomplete or blank, but the Post-dialysis assessment information that the facility was to complete after the resident returned from the dialysis center was often blank. Post dialysis form assessment information includes: Date/time; shunt location/status; Bruit/thrill present: Yes, No, N/A; Bleeding: Yes, No; General condition of resident: Vital Signs; Nurse Signature. From 2/25/2025 to 3/22/2025, 9 of 10 Dialysis communication forms were incomplete and 8/10 had no post dialysis assessment information completed by a nurse- the section was blank. A review of the Care Plans for Resident #4 revealed there was no Care Plan for dialysis services or that mentioned her dialysis access device, location, assessment, or monitoring. A review of the progress notes revealed there was one progress note with assessment information related to Resident #4 receiving dialysis services: 3/6/2025 at 7:22 PM, Resident returned from dialysis at 12:30 PM, shunt has pressure dressing in place no bleeding observed at this time. Positive bruit and thrill. Resident denies any pain or discomfort at time of arrival. Vital signs were monitored. A review of the facility policy titled, Hemodialysis, dated August 2024 provided, This facility will provide the necessary care and treatment consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility . Ongoing assessment and oversight of the resident before, during and after dialysis treatments .Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services .

Based on observation, interview and record review, the facility failed to meet professional standards of care regarding implementation of COVID preventive measures in a timely manner during a COVID outbreak emergency, resulting in 11 residents (Resident's #6, #7, #14, #16, #23, #24,#25, #28, #35, #90) and 10 staff members (Nursing Assistant/CNA O, CNA P, CNA Q, CNA R, CNA S, Nurse, LPN G, Social Worker E, Dietary Aide N, Nurse, CNA H, and Dietary Manger A) testing positive for COVID, resulting in one resident's (Resident #7) hospitalization , resulting in rapid spread of COVID throughout the facility and staff members with the likelihood for the continued spread of COVID, resident and staff illness and the hospitalization of (Resident #7. Findings Include: Review of the facility Pandemic COVID-19, Infection Control New Admission's policy dated 2020 (from the facility Emergency Preparedness program-the only COVID policy in the Emergency book found), stated Early prevention of COVID-19 outbreak consists of the following measures: Training clinical staff in the modes of transmission of the COVID-19 virus, training residents, families and non-clinical staff on the symptoms, early detection of COVID-19 cases in the facility, isolation of infected residents in private rooms or cohort units. The following triggers shall prompt an investigation as to whether an outbreak exists: A sudden cluster of infections on a unit or during a short period of time (i.e. three or more cases), a single case of a rare or serious infection (this included Coronavirus, an outbreak will be reported to the local and/or state health department. Review of the facility Infection Control Prevention and Control Program dated Oct. 2022, revealed isolation protocol were to be as recommended by current CDC guidelines and on page 5 of 5, the facility will conduct an annual review of the infection prevention and control program, including associated programs and policies and procedures based upon facility assessment which includes any facility and community risk, following review, the infection and prevention control program will be updated as necessary. Review of the facility Infection Control Droplet Precautions policy dated 2022, stated A private room is preferential, but if not available, the resident can be cohorted with a resident with the same infectious agent. If unable to follow CDC (Center for Disease Control) guidance as to cohorting, private room accommodation and/or assigned units and staff will wear a fit-tested N95 or higher-level respirator and other appropriate PPE (personal protective equipment) while delivering care to the resident. During an interview done on [DATE] at 11:25 a.m., Infection Control Nurse T revealed the facility did not fit-test any staff members with N95 masks. The facility had no fit-testing equipment to fit-test anyone. Review of the facility Infection Control Transmission-Based (Isolation) Precautions policy dated 2022, stated Visitors coming to visit a resident who is on transmission-based precautions or quarantine, will be informed by the facility of the potential risk of visiting and precautions necessary when visiting the resident. Education is provided to residents and their representatives or visitors on the use of transmission-based precautions. During an interview done on [DATE] at 11:25 a.m., Infection Control Nurse T said she had no documentation of visitor education being done (as of [DATE]). Observations, Interviews and Record Review done on day [DATE]: Review of the facility line listing of COVID positive resident's given to this surveyor on [DATE], consisted of a total of x 5 resident's (resident's #1, #14, #16, #26, and #91 (#1 and #91 was a false positive due to double expired test equipment used by facility). During an interview done on [DATE] at 9:20 a.m., Infection Control Nurse/IC Nurse, LPN stated We have 3 empty rooms. The facility did not put any COVID positive residents in the empty rooms because per IC Nurse T, I didn't think about the rooms being empty. IC Nurse T said 4 of the COVID positive residents were on the Rehab Hall and 1 COVID positive resident was on the Long-Term Hall. -At 7:30 a.m., resident #91 (who was on this date a positive COVID) was observed wheeling in his wheelchair in the hallway with his surgical mask over his mouth on his nose area only, and he was coughing. This resident was going outside to smoke at the time. The facility transferred this resident to the hospital due to medical concerns on [DATE]. -At 7:40 a.m., CNA L was observed giving care in Resident #16's room with a surgical mask on; no N95 mask. -At 7:45 a.m., during an interview done on [DATE], CNA L stated I was told we didn't have to wear a N95. -At 10:16 a.m., Resident #16's (+ COVID) room door was fully open, and the resident was in the room. Another resident was in the hallway and several staff member was also in the hallway. -At 10:17 a.m., Resident #14's (+ COVID) room door was fully open, and the resident was in the room. Another resident was in the hallway and several staff member was also in the hallway. -At 10:20 a.m., during an interview done on [DATE], IC Nurse T stated they can be open (the doors or residents who are COVID positive). -At 10:28 a.m., during an interview done on [DATE], Nurse, LPN G stated I would think you should close the doors. -At 10:28 a.m., on the Rehab Hall, was observed a small black plastic fan running that was sitting on top of the medication cart as medications were being passed. Doors of COVID positive residents were fully open on this hallway at the time. -At 10:29 a.m., during an interview done on [DATE], Nurse RN L stated It sounds reasonable to close the doors. -At 10:30 a.m., during an interview done on [DATE], the IC Nurse, LPN T stated I don't think you have to close the doors. -At 10:35 a.m., during a second interview done with the IC Nurse T, she stated Yes, the doors have to be closed. -At 11:00 a.m., during an interview done on [DATE], Nurse, LPN L stated I was not told I had to wear one (a N95 mask), we had no education. -At 11:03 a.m., during an interview done of [DATE], CNA H stated No COVID education was done. -At 11:04 a.m., Nurse, LPN V stated I did not get any education on COVID. -At 11:43 a.m., when asked if any education or handouts on COVID had been done or given to staff from [DATE] through [DATE], Activity Director K stated We did not sign anything or get handouts, it was all word of mouth. -At 9:30 a.m., 10:50 a.m., 12:00 p.m., and at 4:00 p.m., observations were made of the facility front door entrance. No signs/symptoms sheet, no thermometer was available for visitors, venders or staff. Review of the COVID Plan dated by the Director of Nursing/DON [DATE], had documented the facility did not close resident's doors, educated staff for airborne precautions and PPE (personal protective equipment), inform the local Health Department of COVID at the facility, instruct staff to wear N95's in COVID positive resident rooms, discontinue communal dining and group activities, put visitor, vendor and staff COVID screening assessment sheet at entrance door, and remove running fans on the Rehab Hall from resident's rooms and the top of the medication cart. Observations, Interviews and Record Review done on [DATE]: -At approximately 8:00 a.m., during an interview, the IC Nurse T stated On ,d+[DATE], there were 2 residents positive for COVID, on [DATE], there were 4 residents positive, the hospital called and said (Resident #91) was not positive for COVID, it was a false positive. So, we retested all the residents. We used the test kits at first that were expired (the tests were expired with the second date of expiration). When we re-tested , (Resident #26) was negative for COVID. -At 8:38 a.m., during an interview done on [DATE] with the Administrator, Director of Maintenance W, and Infection Control Nurse T revealed the facility was using expired (month first expired on 15-Dec-23 with a secondary expired date of 15-Jul-24) COVID tests for all residents from [DATE] through [DATE] at 8:38 a.m. Review done on [DATE], of the facility line listing revealed, a total of 4 (Resident's #14, #16, #25, and #34) positive COVID residents (from [DATE] to [DATE]). -Observations made throughout the day on the Rehab Hall, revealed non-COVID resident's doors wide open randomly throughout the day. -Observations made throughout the day revealed staff were in all hallways walking around with surgical masks on. Observations, Interviews and Record Review done on [DATE]: During an interview done on [DATE] at approximately 10:20 a.m., with Infection Control Nurse T it was revealed by the Infection Control Nurse T, that Resident's #35 and #90 were added to the resident COVID positive count, which totaled 7 (included Resident #7 who tested COVID + in the hospital). -At 10:15 a.m. on [DATE] per interview with HR B and per review of the facility COVID Employee Log dated ,d+[DATE], revealed Staff Member S had reported being COVID positive, which brought the total to 5 staff members COVID positive. -At 10:00 a.m. on [DATE], Infection Control Nurse T stated I educated staff on [DATE]; I have not educated today or yesterday (on [DATE] or [DATE]). Review of staff education list (dated [DATE]) done by IC Nurse T and this surveyor revealed a total of 19 of 53 staff members had been educated on COVID preventive measures on [DATE]. -At 9:35 a.m. on [DATE], an observation was made of 2 CNA's talking next to a clean linen cart in the Rehab hallway. One of the CNA's had her surgical mask down under her chin as she was talking. This was right across from a COVID positive room and 2 doors down from another COVID + room. -At 12:48 p.m., on [DATE] an interview was done with Infection Control Nurse T. IC Nurse T stated that as of [DATE], all doors of resident's with COVID are shut 100%. -At 1:15 p.m., Nurse, LPN G informed this surveyor that Resident #7 who was transferred to the hospital on [DATE], had tested positive in the emergency room for COVID. Review of the Face Sheet, Diagnosis Sheet dated [DATE], revealed Resident #7 was [AGE] years-old, admitted to the facility on [DATE], and required staff assistance for all activities of daily living. The residents diagnosis included, Diabetes, anemia, multiple myeloma not in remission, cancer of rectum urinary tract infection history and low food and fluid intake. Review of Resident #7's Hospital Records dated [DATE], stated Patient presenting with acute alteration of mental status and UA (urinary tract infection lab) is consistent with urinary tract infection. COVID-19 status: Active, toxic metabolic encephalopathy, acute on chronic anemia (and) hyponatremia (low sodium). Pulmonary interstitial edema noted. Observations, Interviews and Record Review done on [DATE]: During an interview done on [DATE] at 8:40 a.m., this surveyor requested a total number of residents at the facility who had tested positive for COVID. The Infection Control line list was the same as the one on [DATE], still a total of 6. When this surveyor informed IC Nurse of Resident had tested COVID + at theER on [DATE], she said she was not aware of that information. IC Nurse T stated, I will add them on when they are back to the facility. -During an interview done at 10:16 a.m. on [DATE], Admission Staff Member X stated Yesterday ([DATE]) afternoon, I called (the hospital) and they said she (Resident #7) was admitted to the floor with altered mental status, UTI (urinary tract infection) and COVID. -During an interview done at 12:00 p.m., on [DATE], the Administrator stated, We are now (as of [DATE]) using N95 masks for all staff all the time, everybody is getting in-serviced today ([DATE]). -During an interview done at 1:10 p.m. on [DATE], IC T stated I don't have documentation of current COVID staff immunizations, I have to get them from pharmacy. No documentation at all was available upon request of staff COVID immunization status as of [DATE]. Observations, Interviews and Record Review done on [DATE]: -At 7:25 a.m. on [DATE], during an interview the DON stated, We have a total of 11 resident's with COVID now. -At 7:37 a.m. on [DATE], during an interview the IC Nurse T revealed the facility had a total of 11 resident's COVID positive and 10 staff members COVID positive. -At 7:38 a.m., HR B said the facility had a total of 10 staff members who were positive for COVID as of [DATE]. Interviews and Record Review done on [DATE]: -During an interview done on [DATE] at 7:25 a.m., the DON and IC Nurse T revealed during the weekend a total of 4 resident's (Resident's #6, #23, #24, and #28) were tested to be positive for COVID; bring the total of facility resident's to 11 positive for COVID. Also, the facility had an increase of positive staff, bring the total staff members to 10 Staff members, (Nursing Assistant/CNA O, CNA P, CNA Q, CNA R, CNA S, Nurse, LPN G, Social Worker E, Dietary Aide N, Nurse, CNA H, and Dietary Manger A) testing positive for COVID). As of [DATE], 11 residents and 10 staff members had tested positive for COVID. On [DATE] at 9:00 a.m., during an interview, the DON stated I think they were not following the precautions the way they should have. We now got refocused on what needed to be doing. On [DATE] at 9:05 a.m., the Administrator stated We talked about the positive residents and what we needed to do and how we needed to do it, including the Health Department. I don't think it was done to the extent it needed to be done. Review of the facility Infection Preventionist job description dated 2023, stated that the duties and responsibilities of the IC Preventionist included, Establishes facility-wide systems for the prevention, identification, reporting, investigation, and control of infections and communicable diseases of residents, staff, and visitors. Provides education related to infection prevention and control principles, policies and procedures to staff, residents, and families; ensures public health is notified of reportable diseases.

Based on observation, interview and record review, the facility failed to ensure that accurate resident information was completed on the Resident Roster Matrix (802) for five residents (Resident #1, Resident #14, Resident #16, Resident #26, Resident #140) of 12 sampled residents, resulting in COVID-positive residents and the likelihood of unmet care needs. Findings include: Record review of the facility 'MDS/CRC Coordinator' job description copyright 2024 The Compliance Store, LLC. position purpose was to conduct and coordinate the completion of the required Resident Assessment Instrument (RAI) and be responsible for the implementation and ongoing evaluation of each resident's comprehensive plan of care and auditing of medical records for the presence of supporting documentation for all items coded on the MDS. Upon entrance to the facility on [DATE] at 08:30 AM, the surveyors were notified by facility's Social Worker that the facility was having a COVID-positive outbreak and to wear a facial mask. Observations on 10/14/2024, during the entrance tour of the survey, noted isolation signs to stop and check with nursing staff before entering a particular room. The sign read that Strict Isolation Precautions are in place (the type of Isolation was not identified, contact, airborne etc .) on room [ROOM NUMBER], where Resident #26 resided and on room [ROOM NUMBER], where Resident #14 and Resident #140 resided and room [ROOM NUMBER] where Resident #16 resided and all were located within the small rehab back unit of the facility. Observations of the facility during the entrance tour revealed that all the residents' room doors were open, and residents were moving about and eating breakfast in the main dining room. Record review of the facility-provided CMS-802 form, dated 10/14/2024, revealed assessment heading of Infections: (M, WI, P, TB, VH, C, UTI, SEP, SCA, GI, COVID, O). There were no identified COVID infections noted on the form. In an interview on 10/16/24 at 09:02 AM, Licensed Practical Nurse (LPN) T, who is the Minimum Data Set/Infection Control Preventionist T stated that she did give the state surveyors the CMS-802 Form- Resident Matrix. LPN T did acknowledge that she was the MDS assessment nurse and generated the Minimum Data Set (MDS) and CMS-802 forms. LPN T stated that she should have identified COVID residents on the CMS-802 since the Covid outbreak began on Thursday, 10/10/2024.

Based on observation, interview and record review, the facility failed to ensure that care plans were updated and revised appropriately with new interventions for four residents (Residents #7, Resident #8, Resident #17, Resident #27) of 12 sampled residents, resulting in revision and interventions necessary for care and services not being care planned with the likelihood for unmet care needs. Findings include: Record review of the facility 'Comprehensive Care Plans' policy, dated 8/2024, revealed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. (5.) The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Resident #7: In observations and an interview on 10/14/24 at 11:26 AM, Resident #7 revealed that she was on an antibiotic a week ago or so because her stomach hurt. Her stomach still hurt, and she did not feel well. Resident #7 was observed to be laying across her bed with her hand over her abdomen. Resident #7 stated that the nurses know about her stomach. Record review of Resident #7's quarterly Minimum Data Set (MDS), dated [DATE], noted urinary incontinence and frequent bowel incontinence. Record review of Resident #7's urine culture dated 9/25/2024 revealed organism of Escherichia coli and Proteus Mirabilis. Rocephin 9/28-10/3 was written on the bottom of the form. Record review of Resident #7's progress notes, dated 9/27/2024 at 12:45 PM, noted Resident #7 to have dysuria, bed wetting and being tired. Urine analysis was collected, and results were positive for a urinary tract infection (UTI). Doctor ordered lab work and Rocephin 1 gram intramuscularly for 5 days. Record review of Resident #7's September 2024 Medication Administration Record (MAR) revealed ceftriaxone (Rocephin) antibiotic 1 gram intramuscularly one time a day for UTI (Urinary Tract Infection) for 5 days. It was started on 9/28/2024 through 10/2/2024. Antibiotic therapy was completed for the facility-acquired urinary tract infection. Record review of Resident #7's progress note, dated 10/15/2024 at 9:50 PM, revealed that the resident was sent to the hospital at 9:00 PM. While doing rounds a nurse went into the resident's room and she was lying in bed unable to speak, not making eye contact and unable to respond to any questions or even her name. Record review of Resident #7's progress note, dated 10/15/2024 at 1:29 PM, revealed that the resident was reviewed by the Nurse Practitioner (NP) during the day. Later in the evening, the Nurse Practitioner received a call from nursing stating that the patient was very lethargic and staring off into space. Resident #7 was sent to the hospital. Record review of Resident #7's progress note, dated 10/17/2024 at 9:51 AM, revealed that the resident tested positive at the hospital for Covid and had a urinary tract infection. Record review of Resident #7's hospital record Active Problems list, dated 10/16/2024, noted acute metabolic encephalopathy secondary to multiple infections including a urinary tract infection, and Covid. Record review of Resident #7's care plans, pages 1-10, revealed there was no urinary tract infection care plan found and no interventions for the monitoring of sign/symptoms of infection or antibiotic treatment adverse reactions. Resident #8: Record review of Resident #8's Minimum Data Set (MDS), dated [DATE], revealed an elderly female with Brief Interview of Mental Status (BIMS) score of 3 out of 15 indicating severe cognitive impairment. Section G: functional abilities noted staff assist with toileting. Section H: Bladder & Bowel noted frequent incontinence. In an observation on 10/14/24 at 01:14 PM, Resident #8 was noted to be seated in a wheelchair in her room. The Surveyor was able to pick up a Styrofoam cup and noted an empty water glass. Record review on 10/15/24 at 12:53 PM of Resident #8's electronic medical record revealed a urine analysis, dated 8/22/2024, which revealed Protus Maribilis less than 100,000. Record review of Resident #8's August 2024 Medication Administration Record (MAR) revealed that Antibiotic Macrobid 100 mg two times a day for 7 days for urinary tract infection was administered from 8/21/24 (prior to culture) through 8/27/2024 for facility-acquired urinary tract infection. Record review of Resident #8's Care plans, pages 1-30, revealed there was no urinary tract infection care plan found and no interventions for monitoring of sign/symptoms of infection or antibiotic treatment adverse reactions. Resident #17: Observations and an interview on 10/14/24 at 12:12 PM of Resident #17 revealed a thin-appearing male with a urinary catheter seated at the edge of his bed. Resident #17 revealed that the meals are just OK, and that he had lost some weight. Record review on 10/15/24 at 01:50 PM of Resident #17's weight log revealed various inconsistent weights: 7/1/2024 weight 149.4 pounds, 7/12/2024 weight 142.2 pounds, that was a 7.2-pound loss in 11 days. Three days later 7/15/2024 weight 147.2 pounds that was a 5-pound gain. On 7/29/2024 weight 140.0, that was a 7.2-pound loss. Record review of Resident #17's progress notes for the month of July 2024 revealed that a physician's progress note, dated 7/12/2024, made no mention of a 7.2-pound loss. A physician's progress note, dated 7/19/2024, made no mention of a 5-pound gain noted on 7/15/2024. A physician's progress note, dated 7/23/2024, made no mention of the weight fluctuation noted. A physician's progress note, dated 7/26/2024, mentioned that the resident's weight was stable. A physician's progress note, dated 7/30/2024, noted weight on 7/29/2024 of 140 pounds (weight on 7/15/2024 147 pounds) noted patient with recent 7-pound weight loss. Record review of Resident #17's care plans, pages 1-22, revealed a care plan for potential nutritional problems related to diabetes Type II, dysphasia, oropharyngeal phase, Alzheimer's and chronic kidney disease Stage 4. Review of interventions showed that they were last updated on 7/19/2024, prior to the 7/29/2024 7-pound weight loss. Resident #27: Observation on 10/15/24 at 08:29 AM with Licensed Practical Nurse (LPN) M during Resident #27's morning medication pass revealed a thin male with no shirt on and oxygen dependence. Resident #27 was seated up at the edge of his bed with his breakfast meal tray on the bedside table and few bites taken. Record review of Resident #27's weight log revealed various inconsistent weights: 8/26/2024 weight 143 pounds standing. 8/30/2024 weight 137.2 pounds chair, that's a 5.8-pound loss triggered a 3% change from last weight comparison -4.1%, -5.8 Lbs. 9/8/2024 137.2 pounds chair. 10/3/2024 148.4 pounds chair, that's a 11.2-pound gain. There was no triggered change in weight generated from the electronic medical record. Record review of Resident #27's care plans, pages 1-8, revealed a care plan for potential nutritional problem related to diabetes Type II, chronic obstructive pulmonary disease, anxiety and depression initiated on 8/29/2024. Review of interventions were last updated on 9/2/2024, prior to the 10/3/2024 weight loss of 11 pounds.

This Citation pertains to Intake Number MI00138042. Based on observation, interview and record review, the facility 1) Failed to provide care following professional standards of practice and facility policy to prevent the development of avoidable pressure injuries, 2) Failed to accurately measure and stage residents' pressure injuries, and 3) Failed to promptly identify and provide necessary treatment for a deteriorating pressure injury for four residents (Resident #192, Resident #6, Resident #13, and Resident #26) reviewed for pressure injuries, resulting in R192 requiring emergent surgical intervention for sepsis and acute osteomyelitis of a Stage 4 sacral wound. Additionally, this deficient practice placed all residents residing in the facility at risk for the development of avoidable pressure injuries, a delay in wound treatment, the potential for delayed wound healing, infection, and the high likelihood for overall deterioration in health status. Findings include: Resident #192 (R192): Review of an Admission Record revealed R192 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: stroke. R192 was a Full Code (all resuscitative procedures implemented). Review of a Minimum Data Set (MDS) assessment for R192, with a reference date of 11/29/22 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated R192 was severely cognitively impaired. Review of the Functional Status revealed that R192 required extensive 2 person physical assistance with bed mobility, transferring, and toileting. During an interview on 10/11/23 at 12:15 PM, Family Member (FM) T reported that she was not notified of the extent of R192's sacral/coccyx wound until she was admitted to the hospital. FM T reported she was aware of some skin breakdown on R192's buttocks approximately 2 weeks prior to the hospitalization and stated, I thought it was just a diaper rash and reported she had not seen the wound herself. FM T reported that family would visit R192 and report back to FM T that they could smell her wound and had noticed that R192 wasn't turned and would be in the same position all day long. FM T reported that her niece visited R192 on 1/21/23 and was concerned that R192 was going to die and didn't feel R192 was receiving proper care and wound treatment. FM T was concerned and brought it to management's attention and was told that skin breakdown could be fast moving at times. FM T reported that between 9-10 AM on the morning R192 was sent to the hospital (1/23/23) she spoke with Wound Care Nurse (WCN) H regarding her concerns, and he reported he would assess her wound. FM T reported WCN H was shaken and reported R192 would be transferred out to the hospital. Review of R192's Admission Skin assessment dated [DATE] revealed no documentation of skin breakdown and/or injury on R192's buttocks. R192 had a suspected deep tissue injury to her left heel and unstageable vascular injury to her left great toe. Review of R192's Braden Scale for Predicting Pressure Sore Risk dated 11/28/22 and 12/18/22 revealed R192 was at risk. Review of R192's Braden Scale for Predicting Pressure Sore Risk dated 12/30/22 revealed a score of 13 indicating R192 was moderate risk. Review of R192's Care Conference Note dated 11/28/22 revealed, .Risks: At risk for skin breakdown d/t (due to) limited mobility. Skin .no issues identified . (No other Care Conference documentation received prior to survey exit). Review of R192's Behavior Symptoms from admission 11/22/22 to discharge 1/23/23 revealed R192 did not display behaviors and did not refuse care and wound treatments. Review of R192's Physician Order dated 11/22/22 revealed, Skin Assessment weekly (Day) every day shift every Mon for skin. Review of R192's weekly Skin Observation Tools from 11/23/22 to 1/16/23 revealed the following: There was no documentation of skin breakdown and/or injury on R192's buttocks until 1/9/23. There were no wound measurements documented in any Skin Observation Tool assessments. There was no weekly Skin Observation Tool completed on 12/12/22. There was no weekly Skin Observation Tool completed on 12/26/22. There were no additional Skin Observation Tools completed prior to R192's transfer to the hospital on 1/23/23. Review of R192's weekly Skin Observation Tool dated 12/19/22 revealed .Left Heel pressure sore, Left great toe Vascular, right heel pressure . A new area of facility acquired pressure injury identified on R192's right heel. Review of R192's Electronic Health Record revealed no documentation that the physician and R192's Power of Attorney (POA) were notified of the new pressure area. Review of R192's Physician Progress Note dated 12/25/22 revealed, .Patients skin observation tool reviewed from 12/19/2022, no new skin issues noted . Confirming the provider was unaware of the new pressure injury on R192's right heel. Review of R192's Skin and Wound Evaluation dated 12/27/22 revealed .Left Ischial Tuberosity (no descriptive documentation: type of wound, stage of wound, etc.) Wound Measurements-Length 1.0 cm x Width 0.9 cm. Review of R192's Electronic Health Record revealed no documentation that the physician and R192's Power of Attorney (POA) were notified of the new skin breakdown. (Wound measurements are to be completed weekly and should have been documented on 1/3/23, 1/10/23, and 1/17/23). Review of R192's Physician Order dated 12/27/22 revealed, Calmoseptine Ointment 0.44-20.6 % (Menthol-Zinc Oxide) Apply to buttock/sacrum topically two times a day for wound management. Review of R192's Consultation Physician Progress Note dated 1/3/23 revealed, Reason for Consultation: Evaluate for rehabilitation needs .She denies any pain, however, she does have a new sore to the medial malleolus of her left ankle that is starting to open and seems painful when pressing on it. The RN (Registered Nurse) on staff states he will have her attending look at it and address today. She also has a wound on her left big toe that looks as if it may be opening up .Patient has a newly developed superficial skin wound to the medial malleolus of her left leg, erythematous and painful with palpation. Beginning to open up . Review of R192's Skin and Wound Evaluation dated 1/3/23 revealed a facility acquired right medial malleolus pressure injury documented as identified on 12/28/22 and measuring-Length 0.5 cm x Width 0.3 cm. and a facility acquired right heel pressure injury measuring-Length 1.6 cm x Width 0.3 cm. Review of R192's Electronic Health Record revealed no documentation that the physician and R192's Power of Attorney (POA) were notified of the new pressure injuries. Review of R192's Skin and Wound Evaluations revealed no subsequent wound measurements (Wound measurements are to be completed weekly and should have been documented on 1/10/23 and 1/17/23). Review of R192's Consultation Physician Progress Note dated 1/6/23 revealed, Reason for Consultation: Evaluate for rehabilitation needs .me and the RN assisted her in sitting up and boosted her up so she can eat. We also positioned her with a pillow under her bottom because she was stating she was having discomfort on her bottom. She is still complaining of pain to her left ankle and foot due to newly developed sores. RN states (facility medical doctor) will be rounding today and will assess the wounds and need for oral antibiotics .Patient has a newly developed superficial skin wound to the medial malleolus of her left leg .starting to develop more than one wound on the same foot/lower leg. The pain in R192's buttocks indicated the beginning of a pressure injury and the need for facility nursing staff to assess the area and implement interventions to prevent the formation of and/or the worsening of the pressure injury. Review of R192's Physician Progress Note dated 1/6/23 revealed, .3. Coccyx wound (stage 2 pressure) . There were no measurements documented. Review of R192's Physician Order dated 1/6/23 revealed, Medihoney Wound/Burn Dressing .apply to bilateral feet/ankles topically one time a day every other day for wounds. bilateral feet/ankles apply betadine moistened gauze to necrotic tissue, cover with Medihoney, dry dressing, wrap with kerlix, tape to secure. Review of R192's January Treatment Administration Record revealed the treatment was not completed until 1/7/23. Review of R192's Electronic Health Record revealed no documentation of R192's Stage II coccyx wound with measurements or wound description (Skin Observation Tool or Skin and Wound Evaluation). Review of R192's Physician Order dated 1/6/23 revealed, Aquacel Ag Burn External Pad 4-apply to coccyx topically one time a day every Mon, Wed, Fri for wound cleanser, pat dry . Confirming the provider was not notified of the new wound identified by the consulting provider and reported to facility nurses on 1/3/23. Review of R192's January Treatment Administration Record revealed the treatment was not completed until 1/9/23. Review of R192's weekly Skin Observation Tool dated 1/9/23 revealed the following new areas of facility acquired pressure injuries and skin injury with no measurements or wound description: Left (posterior) ankle-Pressure, Right (posterior) ankle-Pressure, and Coccyx-split. R192's facility provider identified the pressure injury on R192's coccyx as a Stage II (not a split) which would require facility nursing staff to obtain wound measurements (length, width, and depth) and the description of the wound and wound bed. Review of R192's Consultation Physician Progress Note dated 1/10/23 revealed, Reason for Consultation: Evaluate for rehabilitation needs .she states she has pain in her left foot due to her current wound. She was recently put on wound care 2-3 times weekly now .The wounds on her (bilateral) lower ankles have not improved much at this time .Wound getting deeper and opening further . Review of R192's Electronic Health Record revealed no documentation that the physician and R192's Power of Attorney (POA) were notified of the deterioration of R192's wound. Review of R192's Nurses Progress Note dated 1/12/23 revealed, patient has 2 wounds on her left heel and Achilles tendon, they are eschar (dead tissue), and the eschar that was on the heel has sloughed off, however it is draining purulent drainage, her ankles are cherry red and hot to the touch, NP (nurse practitioner) was made aware . Confirming a delay in provider notification of the worsening of R192's wounds (approximately 2 days). Review of R192's Physician Progress Note dated 1/13/23 revealed, Patients coccyx sore and left lateral malleolus are slow to improve due to poor immobility .Patients skin observation tool reviewed from 01/09/2023, no issues noted . Note: measurements of wounds were not documented in the Skin Observation Tools and therefore the provider could not accurately determine if there was deterioration or improvement in the wounds. Review of R192's Consultation Physician Progress Note dated 1/14/23 revealed, She has not had much improvement in the wounds in her (bilateral) ankles and feet .The wounds are holding her back slightly with therapy .Therapy progress as of 1/13/23: off of therapy at this time due to her (bilateral) foot and ankle wounds. Confirming a decline in R192's condition due to the worsening of the wounds. Review of R192's weekly Skin Observation Tool dated 1/16/23 revealed, .Left Heel pressure sore, Left great toe Vascular, right heel pressure, Bil (bilateral) posterior ankles pressure, Coccyx split . No measurements documented. Review of R192's Health Status Note dated 1/17/23 revealed, IDT (Interdisciplinary Team) at risk meeting today reviewed resident for supplementation secondary to wounds. Resident has a vascular appointment scheduled and team will revisit after appointment to reevaluate wounds and ability to heal. R192's sacral/coccyx wound was not addressed during the review. Review of R192's Nurses Progress Note dated 1/19/23 revealed R192 had a vascular appointment. Review of R192's Electronic Health Record revealed no documentation that the IDT completed a risk meeting regarding R192's wounds following the vascular appointment as documented in the Health Status Note on 1/17/23 prior to her discharge to the hospital on 1/23/23. Review of R192's Care Plan revealed Resident to have air mattress. Date Initiated: 01/19/2023. Confirming a delay in treatment for the Left Ischial Tuberosity pressure injury identified on 12/27/22 and the Coccyx Stage II pressure injury identified on 1/6/23. Review of R192's Physician Progress Note dated 1/20/23 revealed, .Patient wound was assessed with Department of Nursing. Skin care to coccyx area, regressing a little bit. We will continue to treat and monitor . Review of R192's Electronic Health Record revealed no documentation that R192's Power of Attorney (POA) was notified of the regression of R192's coccyx wound and no change in the coccyx wound treatment. Review of R192's Pulse Summary revealed R192 had a heart rate of 117 (normal range 60-100). Elevated heart rates are indicative of systemic infection. R192's pulse was not reassessed until the time of her acute transfer to the hospital on 1/23/23 3 days later. Review of R192's Temperature Summary revealed R192 had a temperature of 100.3 on 1/20/23. Elevated temperatures are indicative of systemic infection. R192 was administered Tylenol 650 mg to reduce the fever. Review of R192's Nurses Progress Note dated 1/22/23 revealed, upon cna (Certified Nursing Assistant) changing patient, she called the author to come in and see the patient wound, the patient has a wound on her coccyx, it was oozing pus that is brown and running out of a whole (sic) in the upper part of the wound, it has been documented prior, author proceeded with the treatment that is ordered, and monitored. Review of R192's Electronic Health Record revealed no documentation that R192's wound had purulent drainage/pus drainage prior to this assessment. There was no documentation that the physician and R192's Power of Attorney (POA) were notified of the deterioration and/or change of the condition of R192's wound. The presence of purulent drainage, the deterioration of the coccyx wound, and elevated temperature and heart rate indicated an acute change in R192's condition requiring physician notification and medical intervention. Review of R192's Nurses Progress Note dated 1/24/23 revealed, Resident sent to (hospital name omitted) for possible wound infection with increased drainage and very strong odor, Dr (doctor) and family notified. Pt sent on 1/23/23 (at) 1200 (12:00 PM). Review of R192's Hospital Documentation beginning on 1/23/23 at 2:05 PM revealed, The patient is a 89 y (year old) female with complicated past medical history presenting to the ED (emergency department) via (ambulance) from Chesaning Nursing facility for evaluation of a wound check. Per report the patient has wounds to her feet and coccyx that need to be debrided. Per EMS (Emergency Medical Services) the patient was hypotensive (low blood pressure) in the 80's/40's. Per report the patient also is a little bit more altered than her baseline of being alert and oriented to herself and where she is. Per nursing staff the patient is noted to be in atrial fibrillation with RVR (rapid ventricular response). Skin .Findings: Wound present. Comments: Multiple foul smelling wounds draining a thin brown discharge. 1400 (2:00 PM): This patient has SEPSIS and evidence of END ORGAN FAILURE (altered mental status). Therefore, a CODE SEPSIS was activated. The source of infection is most likely skin .multiple necrotic wounds. We will proceed with surgical debridement of this infected unstageable sacral decubitus ulcer in the OR today. She is a high risk surgical candidate due to her medical comorbidities, but without intervention, I am concerned that she will have worsening sepsis and potential septic shock. Review of R192's Surgical Debridement Procedure dated 1/24/23 revealed, Evidence of necrotic tissue was visualized with foul-smelling purulent drainage (pus) deep to the overlying eschar. The excisional debridement was then performed, which included skin, dermis, subcutaneous tissue, muscle, fascia, periosteum, and ultimately bone, as well as necrotic tissue and abscess tissue. This was performed largely with cautery as well as with sharp dissection .Once the sacral ulcer was completely dissected off the underlying tissue, this was also passed off for pathologic evaluation, and this included the coccyx. The exposed portions of sacral bone also appeared quite unhealthy .The resulting wound measured 15 x 21 x 7 cm. Review of R192's Surgical Pathology Report dated 1/26/23 revealed, NECROSIS AND MARKED ACUTE INFLAMMATION INVOLVING SOFT TISSUE AND BONE MARROW, CONSISTENT WITH ACUTE OSTEOMYELITIS. Osteomyelitis is an infection in the bone requiring urgent medical intervention. The infection can travel into the bloodstream and cause sepsis. Common symptoms include fever and elevated heart rate. Review of R192's Palliative Care Consultation Note dated 1/26/23 revealed, Palliative care consult secondary to infected stage 4 decubitus ulcer of sacrum .presented to the ED 1/23 from Chesaning Nursing and Rehab for wound check .Workup in ED suggests sepsis from wounds .Attending services has updated pt's daughter/DPOA-HC (Durable Power of Attorney-Healthcare) (FM T) and on 1/26 she was made DNAR (Do Not Resuscitate). Hospice or palliative care were also discussed with (FM T) and she expressed interest in palliative care, prompting current consultation. R192 was discharged from the hospital with end-of-life care on 2/7/23. R192 date of death was 2/18/23. R192's Care Plan: Review of R192's Care Plan revealed, Resident is at risk for skin breakdown related to impaired mobility, incontinence Date Initiated: 11/23/2022 . Assess skin during care, report any red, bruised, or open areas promptly to the charge nurse . Resident is to be turned every 2 hours to prevent skin breakdown . Review of R192's Care Plans revealed no documentation for R192's actual skin breakdown identified on admission (left heel and left great toe.) There were no interventions to offload pressure to R192's heels and to prevent continued breakdown to R192's toes. R192's Care Plan did not reflect the facility acquired right heel pressure injury identified on 12/19/23 and 1/3/23 with updated interventions to prevent the worsening of the injury. R192's Care Plan did not reflect the facility acquired Left Ischial Tuberosity identified on 12/27/23 with updated interventions to prevent the worsening of the injury. R192's Care Plan did not reflect the facility acquired Stage II pressure injury to her sacrum/coccyx identified on 1/6/23 with updated interventions to prevent the worsening of the injuries. R192's Care Plan did not reflect the facility acquired left and right posterior pressure injuries identified on 1/9/23 with updated interventions to prevent the worsening of the injuries. Review of R192's Nurses Progress Note dated 12/21/22 revealed, Resident requested for her heel protector boots to be taken off and stated that they make her uncomfortable and she is unable to sleep. Resident encouraged to keep them on to reduce risk of skin breakdown. Will continue to observe. Review of R192's Nurses Progress Note dated 1/4/23 revealed, Resident noted to decline heel boots several times this evening. Resident in agreement to try a heel wedge cushion and stated that it is much more comfortable for her. will notify wound nurse in AM. R192's Care Plan did not reflect that R192's discomfort with heel protector boots was addressed on 12/21/22 with a new intervention implemented. The use of the heel wedge cushion was not implemented on R192's Care Plan. Resident #6 (R6): Review of an Admission Record revealed R6 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, diabetes, heart disease, and gastro-esophageal reflux. Review of a Minimum Data Set (MDS) assessment for R6, with a reference date of 7/4/23 revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated R6 was severely cognitively impaired. Review of the Functional Status revealed that R6 required extensive 2 person physical assist for bed mobility, transferring, toileting, and personal hygiene. Review of R6's Care Plan revealed, (R6) has an actual alteration in Skin Integrity r/t decreased mobility, weakness, incontinence and function .Bridge heels while in bed. Date Initiated: 07/11/2023 .Monitor of s/s of redness/open areas on skin, paying particular attention to bony prominences, notify nurse when identified. Date Initiated: 02/23/2022 .Turn and reposition frequently. Date Initiated: 07/11/2023 . Review of R6's Skin Observation Task completed by facility CNA's revealed a Red Area was identified on 10/2/23 and 10/7/23. No specific locations of the skin integrity concerns documented. Review of R6's Bathing on Monday/Wednesday task completed by facility CNA's revealed an area of Discoloration on 10/2/23, an Open Area on 10/4/23 and 10/9/23, and a Red Area on 10/11/23. No specific locations of the skin integrity concerns documented. Review of R6's Electronic Health Record revealed no documentation of new interventions implemented to prevent the worsening of the pressure injury, and no documentation that R6's family/guardian or the provider were notified. Review of R6's Skin Observation Tool dated 10/4/23 revealed, redness buttocks . No measurements documented. Review of R6's Skin Observation Tool dated 10/12/23 revealed no new areas of skin breakdown (known area to left foot 2nd toe and right foot 3rd toe). During an observation and interview on 10/11/23 at 1:45 PM, CNA Y and CNA U were providing incontinence care (removal of soiled brief and pericare) to R6. Near the top of R6's right buttocks, close to the intergluteal cleft, there was an open area approximately the size of a pencil eraser with a bright pink wound bed. CNA Y and CNA U reported they did not know if it was a new pressure injury. CNA U confirmed the presence of the open area. CNA Y reported she would notify Wound Care Nurse (WCN H) immediately. When incontinence care was completed, R6 was positioned on her back with no offloading devices in place (to prevent the worsening of R6's pressure injury) and R6's heels were not positioned off of the bed. Review of R6's Electronic Health Record revealed no documentation that R6's skin was assessed by a facility nurse or that R6's family/guardian or the provider of the new skin injury. Review of R6's Physician Order dated 10/11/23 revealed, Calmoseptine External Ointment 0.44-20.6 % (Menthol-Zinc Oxide) Apply to bilateral buttocks topically every shift for skin integrity. During an observation on 10/12/23 at 08:33 AM, R6 was in bed on her back with no offloading devices in place. R6's heels were resting on the bed. During an observation and interview on 10/12/23 at 11:54 AM, CNA V and CNA U were providing incontinence care to R6. R6's brief was saturated and smelled strongly of urine. CNA U reported that R6 was to be changed every 2 hours. Near the top of R6's right buttocks, close to the intergluteal cleft, there was an open area approximately the size of a pencil eraser with a bright pink wound bed and there was a deep ruddy red indention from R6's brief. There was a new area of non-blanchable redness under the previously identified open area. CNA U confirmed the presence of the open area. Once incontinence care was complete there was no cream applied to R6's buttocks (as ordered on 10/11/23.) CNA U asked CNA V if there was a pillow that could be used to place behind R6's back to offload pressure, to which CNA V replied no. R6 was positioned on her back with no offloading devices in place and with no devices to bridge heels off of bed. During an observation on 10/12/23 at 01:53 PM, R6 was on her back with no offloading devices in place. R6's heels were resting on the bed. During an observation on 10/12/23 at 03:33 PM, R6 was on her back with no offloading devices in place. R6's heels were resting on the bed. During an observation on 10/13/23 at 04:00 AM, R6 was on her back with no offloading devices in place. R6's heels were resting on the bed. During an interview on 10/13/23 at 04:03 AM, Licensed Practical Nurse (LPN) I reported that she was not aware that R6 had new skin breakdown on her bottom. During an observation on 10/13/23 at 04:49 AM, R6 was on her back with no offloading devices in place. R6's heels were resting on the bed. During an observation on 10/13/23 at 05:31 AM, WCN H reported that the CNA's should have notified immediately upon finding a new area of skin breakdown. During an observation on 10/13/23 at 07:33 AM, R6 was on her back with no offloading devices in place. R6's heels were resting on the bed. During an observation on 10/13/23 at 08:30 AM, R6 was on her back with no offloading devices in place. R6's heels were resting on the bed. During an observation and interview on 10/13/23 at 09:20 AM, WCN H observed R6's buttocks and confirmed a new area of skin breakdown. Resident #13 (R13): Review of an Admission Record revealed R13 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: osteomyelitis (bone infection) in the sacral wound, dementia, and adult failure to thrive. R13 was a full code (all resuscitation procedures to be provided to keep the person alive in the case of a medical emergency). Review of a Minimum Data Set (MDS) assessment for R13, with a reference date of 7/29/23 revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated R13 was severely cognitively impaired. Review of the Functional Status revealed that R13 required extensive 2 person physical assist for b ed mobility, was dependent on 2 people for transferring, and required extensive 1 person physical assistance for personal hygiene and toileting. Review of R13's Care Plan revealed, (R13) has pressure ulcer of sacrum and left shin Date Initiated: 08/01/2023 .(R13) needs assistance to turn/reposition frequently/PRN Date Initiated: 08/01/2023 .Treat pain as per orders prior to treatment/turning etc. to ensure The (R13's) comfort. Date Initiated: 08/01/2023 . During an observation on 10/12/23 at 12:04 PM, R13 was in bed on her back with no offloading devices in place. During an observation on 10/12/23 at 01:54 PM, R13 was in bed on her back with no offloading devices in place. During an observation and interview on 10/12/23 at 03:36 PM, R13 was in bed on her back with no offloading devices in place. R13 reported that staff do not reposition her and she was unable to reposition on her own. R13 was asked if she would want staff to reposition her and she stated she would like that. During an observation on 10/13/23 at 03:58 AM, R13 was in bed on her back with no offloading devices in place. During an observation on 10/13/23 at 07:35 AM, R13 was in bed on her back with no offloading devices in place. During an observation on 10/13/23 at 08:29 AM, R13 was in bed on her back with no offloading devices in place. During an observation on 10/13/23 at 09:29 AM, R13 was in bed on her back with no offloading devices in place. During an interview on 10/17/23 at 11:55 AM, CNA U reported residents that need assistance with bed mobility are to be turned every 2 hours minimum. During an interview on 10/13/23 at 06:38 AM, CNA S reported that it was difficult to provide care as ordered (repositioning and incontinence care) due to insufficient staff on 3rd shift. Resident #26 (R26): Review of an Admission Record revealed R26 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes and depression. Review of a Minimum Data Set (MDS) assessment for R26, with a reference date of 9/4/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R26 was cognitively intact. During an interview on 10/10/23 at 12:16 PM, R26 reported that he had concerns with staffing and the ability of the nurses and the aides to meet the needs of the residents based on the high acuity of the residents residing in the facility. R26 reported that there are many residents that require 2 assist for care and many residents that have behaviors. R26 stated, need to be staffed by acuity not numbers. On 10/13/23 at 10:10 AM a request for list of residents that required 2 person assist for bed mobility, transferring, toileting, and hygiene was sent via email. A list of residents that required 2 person assist for bed mobility was not received prior to survey exit. Review of the Resident Census and Conditions of Residents signed 10/10/23 revealed the following: 16 residents that were dependent on staff and 18 residents that required the assistance of 1 to 2 staff for bathing. 8 residents that were dependent on staff and 24 residents that required the assistance of 1 to 2 staff for transferring. 12 residents that were dependent on staff and 22 residents that required the assistance of 1 to 2 staff for toileting. Review of the facility policy Pressure Injury Prevention Guidelines last reviewed/revised 1/28/23 revealed, .1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics) .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. In the absence of prevention orders, the licensed nurse will utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care, and will notify physician to obtain orders .7. Interventions will be documented in the care plan and communicated to all relevant staff .

This citation pertains to intake #MI00138565. Based on interview and record review, the facility failed to, 1) ensure a complete and accurate nursing assessment was done after a significant change involving 1 resident (Resident #701), and 2) ensure the facility had a policy to follow for assessment regarding signs/symptoms of infection (not feeling well, increased temp, tiredness, nausea), resulting in hospitalization with a diagnosis of urinary tract infection (UTI) and sepsis (extensive infection), antibiotic given, and the likelihood for serious injury. Findings Include: Review of the Face Sheet, Minimum Data Set (dated 2022 and 2023), hospital records dated 5/13/23, physician's and nurse's notes dated 5/1/23 through 5/14/23, revealed Resident #701 was [AGE] years-old, admitted to the facility in 2022 and readmitted on 2023, alert but not able to make healthcare decisions, had a pressure ulcer that required a urinary catheter to be put in place to decrease urinary tract infections (UTI's). The residents diagnosis included developmental delay, history of UTI and pressure ulcer. The resident had increased temperature (Temp.), tired and nausea and stated she did not feel well. She was transferred to the hospital on 5/14/23 and was admitted with a diagnosis of sepsis due to UTI. Review of the facility physician orders dated 4/17/23, revealed staff were to change the resident's Foley catheter every 30 days (due to history of UTI's). Review of the facility nurse's notes dated 5/5/23 revealed no documentation that the resident had an increased temperature or felt ill. Review of the next facility nurse's note's dated 5/12/23, stated Resident does not appear to be feeling well this shift. She was up in her wheelchair for a bit but requested to go back to bed. She also ran a low-grade temp. this afternoon of 100.1. She became nauseous after taking her evening oral medications. Resident is currently in bed. No documentation regarding a nursing complete assessment was found with this change of condition from previous 5/5/23 entry. Review of the facility Physician G notes dated 5/12/23, stated Collaboration with Nursing/patient regarding patient's overall status, changes and concerns. No documentation was found regarding the low grade temperature, or that the resident did not appear to be feeling well. Review of the next facility nurses' note's dated 5/13/23, revealed Patient family member concerned that her patient was sick for 2 days (on 5/12/23 and 5/13/23), today the author assessed patient (no documentation of a complete assessment was found dated 5/13/23), when asking patient does her throat hurt or is it sore, and the patient nod yes, later on in the shift the patient family member wanted patient temp check and said that the patient appeared hot, patient temp is 103, family member said she wanted the patient to be sent out to the hospital. DON (Director of Nursing) is aware. The facility transferred the resident to the hospital where she was admitted with sepsis (infection throughout body) due to UTI. During interviews done on 8/31/23 at 2:00 p.m. and 2:15 p.m., Nurses, LPN C and RN D revealed they should have done a complete and detailed assessment on the resident on 5/12/23 and on 5/13/23, regarding the resident's condition change and increased temperature. Review of the facility physician G notes dated 5/13/23, stated Collaboration with Nursing/patient regarding patient's overall status, changes, and concerns. I have addressed all concerns reported by patient/Nursing. We will continue to monitor overall health via medical staff. No documentation of an increased temperature (101.1 to 103 within 24 hour's) was found. The resident was transferred to the hospital on 5/13/23, and was admitted with sepsis due to UTI. During a phone interview done on 8/31/23 at approximately 3:00 p.m., Physician G revealed he was not informed of the change of condition on 5/12/23 nor on 5/13/23, regarding the residents increased temperature, not feeling well, tiredness and nausea. Review of the hospital notes dated 5/14/23 and hospital labs dated 5/13/23, stated [AGE] year-old female with past history significant for developmental delay who presents to the ED (Emergency Department) with a chief complaint of a fever that's been ongoing for a couple of days. Patient's (family member) reports that the patient has been febrile (have an increased temp.) for the past few days (a temp of 103.3 on 5/14/23 taken in the emergency room ). She had an indwelling Foley catheter placed in September and has a history of frequent UTI's. ED course: Patient was hypotensive with a blood pressure of 103/47, history on arrival to the ED, CBC (complete blood count) revealed leukocytosis with WBC's elevated at 12.1 (signs of infection). Urinalysis (urine test) in the ED is suggestive of infection with (greater then) 100 WBC's (white blood cells, from infection), large leukocyte esterase, rare bacteria, and positive nitrites (infection due to UTI, sepsis indicators). Patient was started on Rocephin (IV antibiotic given for sepsis) and will be admitted to hospitalist service for further evaluation and treatment. Review of the hospital ED report dated 5/13/23, revealed the resident was diagnosed with sepsis and UTI. Review of the facility Sepsis Screener (undated) revealed staff were to fill out with all residents who presented with signs/symptoms of infection (including sepsis/increased temp.). No facility documentation was found dated 5/12/23 or on 5/13/23, regarding a sepsis screener having been filled out for the resident. Review of the facility SBAR-Physician/NP/PA Communication Tool (undated) revealed staff were to fill out with any change of condition. No facility documentation was found dated 5/12/23 or 5/13/23, regarding assessment and informing the Physician of a change of condition and an increased temperature. During an interview done on 8/31/23 at 1:20 p.m., the DON stated We should of done them (the Sepsis Screener and the SBAR), we didn't. We don't have a policy for them. Upon request for nursing education regarding filling out the Sepsis Screener and SBAR, the nursing orientation was the only time the facility had documented educating nursing staff on the need to fill them out. Review of the resident's facility Indwelling Catheter care plan dated 10/2/22, revealed no documentation of monitoring/assessing for signs or symptoms of infection (UTI); the resident had a strong history of UTI's.

Based on observation, interview and record review, the facility failed to implement preventive measures to prevent 2 Stage II (blisters) heel pressure ulcers for 1 resident (Resident #26) of 3 resident's review for pressure ulcers, resulting in 2 bi-lateral Stage II heel pressure ulcers, pain, discomfort, agitation and wound treatments. Findings Include: Stage two pressure ulcer is partial-thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents as an abrasion, shallow center or blister. High risk residents (immobile, bed bound) should be assessed weekly, when a condition, change or as needed and preventive measures should be in place including pressure relieving devices, position changes, and dietary supplements. National Pressure Ulcer Advisory Panel (NPIAP) Resident #26: Review of the Face Sheet, Minimum Data Set (MDS, Resident assessment tool dated 6/22, Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was be bound and often refused to get out of bed, increasing the risk. The resident did not have any redden areas or pressure ulcers on her heels upon admission. Review of the electronic medical record (Nursing and Therapy notes and evaluations dated 6/22) revealed the resident was at risk for development of heel pressures and had bi-lateral foot drop. Review of the resident's admission nursing assessment dated [DATE], revealed Resident #26 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Skin Observation Tools dated 6/30/22, 7/7/22 and 7/14/22, revealed no documentation of any concerns (redness, blisters, open skin, or pressure ulcers) regarding the resident's heels. Review of the facility Skin Integrity care plan dated 6/11/22, up-dated on 7/14/22, stated Bridge heels while in bed, monitor of s/s (signs and symptoms) of redness/open areas on skin, paying particular attention to bony prominence's (including heels), notify nurse when identified. Review of facility physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Two observations made on 7/18/22 at 11:00 a.m. and on 7/19/22 at 7:00 a.m. and at 3:00 p.m., revealed the resident in bed with a pillow under her calves, both heels were directly on the mattress and a pair of black PRAFO boots (for preventive measures, keeps heels off mattress and for foot drop/contractures) were sitting on the bedside stand. The resident had bi-lateral foot drop and verbalized pain with any movement of her feet. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observe for s/s (signs and symptoms) redness/discomfort/skin breakdown. Review of the facility Skin Integrity care plan dated 6/11/22, had no documentation of PRAFO boots as a preventive measure for contractures/foot drop. Review of all the resident's care plan upon admission and dated 6/10/22 to 7/19/22, revealed no documentation of PRAFO boots. A third observation was made on 7/20/22 at 10:23 a.m., again the resident was in bed with a pillow under her calves and her heels were both on the mattress. The pair of black PRAFO were again, sitting on the bedside table. The resident verbalized pain when OT/Director of Rehab N pulled her sheet up to observe her feet. During an interview done on 7/20/22 at 10:08 a.m., Occupational Therapist/Director of Rehab N stated I assess their (residents) positioning for skin breakdown; I ordered her the boots (PRAFO boots), she (resident #26) should have them on when in bed. They should be on her; I will educate staff. Review of the facility Inservice sheet dated 7/20/22, revealed 5 Nursing Assistants had been educated by OT N regarding Resident #26 needing her PRAFO boots on when in bed and to check for signs/symptoms of discomfort, redness, skin breakdown. Take off during bathing and when out of bed. During a second observation done on 7/20/22 at 10:26 a.m., accompanied by the DON/Wound Nurse, The resident had Stage 2 pressure ulcers on both heel (blisters with skin intact). The DON measured the resident's stage 2 pressures to be, the right heel to be 2.4 cm by 2.7 cm, and the left heel to be 2.7 cm by 2.7 cm. Any movement done with the residents feet (by the DON) caused her to yell she was in pain. During an interview done on 7/20/22 at 10:26 a.m., the DON stated, When I was in the room earlier (right after this surveyor observed the resident in bed with the PRAFO boots sitting on her stand for the fourth time) to see her, staff told me to look at her heels. This is when the Stage 2 pressure ulcers were first identified by the facility, on 7/20/22. The DON said Resident #26's bi-lateral heel Stage 2 pressure ulcers were facility acquired. Review of the facility Skin & Wound Evaluation dated 7/20/22, revealed the resident had developed bi-lateral heel Stage 2 pressure ulcers and treatment had been initiated on 7/20/22 (the day this surveyor requested to observe the resident's heels and reported to the DON 3 observations of the resident's PRAFO boots not on the resident, sitting on bedside stand. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Two times a day for wound healing. Rt (right) Heel: cleanse Rt heel with wound cleanser, pat dry, apply skin prep. Two times a day for wound healing. **Keep heels elevated while I bed.** Review of the resident's facility Skin Integrity care plan dated 7/20/22, stated Resident to wear B/L (bi-lateral) PRAFO, contracture/blisters on bilat heels, boots in bed to be worn at all times. Review of the facility Potential Breakdown Policy dated 1/26/16, stated All residents will be assessed to identify risk factors for skin breakdown. Interventions will be implemented to attempt to prevent skin break down.

This Citation Pertains to Intake Number MI 371 Based on interview and record review, the facility failed to assess, monitor and ensure appropriate interventions were ordered and provided to prevent worsening of pressure ulcers for 2 residents (Resident #100 and Resident #102) of 3 residents reviewed for pressure ulcers, resulting in Resident #100 developing a facility-acquired Stage 4 (National Pressure Injury Advisory Panel (NPIAP): Full-thickness loss of skin and tissue with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer .) pressure ulcer on the sacrum with no ordered treatment until 12 days after admission and Resident #102 was readmitted with a right buttock/sacral pressure ulcer (Stage 3: NPIAP- Full thickness skin loss in which adipose (fat) is visible in the ulcer .) without treatment for 11 days after identification, which could lead to prolonged healing, potential for infection and decreased quality of life. Findings Include: Resident #100: A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #100 indicated an admission to the facility on [DATE] with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] revealed the resident had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of ,d+[DATE] and needed assistance with all care. A review of the Admission Assessment for Resident #100 dated [DATE] indicated a Skin Integrity assessment identifying multiple wounds and pressure ulcers including Sacrum: Type- Pressure. There were no measurements or further descriptions of the wounds. A review of the skin assessments for Resident #100 titled, Skin Observation Tool- Licensed Nurse revealed the following: [DATE] Skin Observation Tool- Skin Intact? - 'No'; Pressure areas to bilateral heels and sacrum . Previously identified area? 'Yes'; Site: ' . Sacrum, Type: Pressure'. There was no measurement or further description of the Sacral wound. [DATE] Skin Observation Tool- Skin Intact?- 'No'; Previously identified area? 'Yes'; Pressure areas to bilateral heels and sacrum . Tx (treatment) in place to sacrum and heels. Peri area red. Site: ' . Sacrum, Type: Pressure'. There was no measurement or further description of the Sacral wound. A review of the Skin and Wound Evaluation, assessments for Resident #100 revealed the following: [DATE] Skin and Wound Evaluation- Describe: Pressure; Stage: Unstageable: Obscured full-thickness skin and tissue loss; Due to: Slough and/ or eschar (dead tissue); Location: Sacrum; Acquired: Present on admission; Exact date: [DATE]; Wound Measurements: Area: 37.5 cm; Length: 6.6 cm; Width: 9.0 cm; Depth; Not applicable; Wound Bed: (there was no description- it was blank). There was no documentation related to presence of drainage, odor, or description of the surrounding tissue. There was no documentation of pain related to the wound. Goal of Care: Slow to Heal: wound healing is slow or stalled but stable, little/no deterioration; Treatment: (It was left blank). There was no documentation of wound care. Notifications: The options were Practitioner Notified; Resident/Responsible Party Notified; Dietician Notified; Therapy (PT, OT, ST) Notified. All were blank. A review of the physician orders indicated wound care was not ordered for the pressure ulcer wound on Resident #100's sacrum until [DATE] (12 days after admission). It was discontinued on [DATE]. Another order for Santyl (a [MEDICATION(S)] agent to remove dead/damaged skin) was again ordered on [DATE] and discontinued on [DATE]. The resident was transferred to the hospital for a change of condition on [DATE]. A review of the resident's Medication Administration Record/Treatment Administration Record, for [DATE] indicated there was no documented wound care provided to Resident #100 on the day of admission [DATE]. There was no order on the MAR/TAR for [DATE] for wound care. A review of the resident's Medication Administration Record/Treatment Administration Record, for [DATE] revealed the following: Santyl Ointment 250 unit/gm ([MEDICATION(S)]): Apply to Sacrum topically every day shift for pressure wound **apply nickel width of Santyl ointment on dark tissue, order date [DATE], DC (discontinue) date [DATE]. (The treatment was not documented as provided on [DATE] or [DATE]). Santyl Ointment 250 unit/gm ([MEDICATION(S)]): Apply to Sacrum topically every day shift for pressure wound **Cleanse sacral area with wound cleanser, pat dry apply nickel width of Santyl ointment on dark tissue, cover wound and surrounding area with [MEDICATION(S)] followed with ABD dressing (two), anchor with brief, order date [DATE], DC date [DATE]. The first documented wound care to the resident's sacrum was on [DATE]. Wound care was not documented as provided on [DATE] and the resident was discharged to the hospital on [DATE]. Resident #100 was admitted to the facility on [DATE] with an identified pressure ulcer to the sacrum. No treatment was provided until [DATE]: two weeks later. A review of the Care Plans for Resident #100 provided: Alteration in Skin Integrity related to pain, decreased mobility and function, as evidence by unstageable wound of sacrum . date initiated: [DATE] and revised [DATE] with Interventions: [DATE]- Cleanse skin thoroughly following each incontinence . Encourage/assist with turning and reposition while in bed . Ensure adequate nutrition and hydration . Ensure linens are wrinkle free . Maintain proper body alignment . Offload pressure/shift weight while sitting in chair at a minimum of every 2-hour . Treatments as ordered . Use turn sheet when turning .; [DATE]- Alternating pressure relief mattress, Up in chair w/c (wheelchair) as tolerated for short periods of time, date initiated [DATE] and revised [DATE]. The resident's sacral wound was not mentioned until [DATE]. Treatments as ordered was initiated [DATE], but a treatment was not ordered for the wound until [DATE]. An interview with Confidential Person G on [DATE] at 12:15 PM about Resident #100 provided, She went to the hospital from home and was found to have gallbladder problems. They took care of the issue and then she went to the nursing home (facility on [DATE]). She developed bed sores; they worsened and became infected. She wouldn't participate in therapy. She had a lot of pain and went back to the hospital ([DATE]). They operated on the pressure sore. The doctor at the hospital showed me that it went to the bone. It was black. He said he thought the bone was infected. She went to another facility on hospice and died last week. A review of the Hospital records from [DATE] to [DATE] revealed, Emergency Department Note, admitted [DATE]; Chief complaint: Altered Mental Status . confusion that started [DATE] . Increased confusion and hallucinations since [DATE] . patient received multiple bed sores . patient reports back pain . Exam: Skin- Large sacral wound with superficial ulceration and area of tunneling that is caked in stool. Smaller wound on left posterior distal calf . The ER note identified many abnormal laboratory and diagnostic studies. She was admitted to the hospital for . management of [CONDITION(S)] (urinary tract infection) with [CONDITION(S)] (systemic infection) and altered mental status. A hospital note dated [DATE] at 5:31 PM indicated, Pt (patient) arrived to ER with multiple wounds on body, buttocks and sacral area. The buttocks is macerated bilateral with sacral wound and tunneling noted within . General Surgery Consult Note, dated [DATE], . Wound Care Consult: Pt was having mental status changes and brought to hospital from the rehab facility . pt was noted to have extensive sacral pressure ulcer . 1. Pt has an infected Stage 4 pressure ulcer over the sacral area. This measures about 9 x 9 cm with necrotic (dead), foul smelling tissue present . Assessment and plan: Septic Shock: Status: Acute; Pressure ulcer of sacral region, stage 4; Status: Acute; Assessment and Plan: Pt has large, infected sacral pressure ulcer. This is foul smelling and in need of debridement (surgical removal of the dead tissue). General surgery consulted. I expect this ulcer to be very deep and may never heal . .Patient found to have very deep sacral decub with palpable sacral bone with necrosis. This will not heal spontaneously due to location, size, multiple health conditions . This multi microbial infectious process. Ideally needs muscle flap but very risky. Recommend wound vac . General Surgery Progress Note, dated [DATE], Wound care (follow-up) visit: Pt is s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Sacral ulcer was to the bone . Pt has stage 4 sacral ulcer s/p surgical debridement. Size is approx. 9 x 9 cm with a tunnel that measures 3.5 cm at 8:00 position. Ulcer is to the bone . [DATE]: . Wound culture final report is growing [CONDITION(S)] ([CONDITION(S)] and [MEDICATION(S)]-resistant enterococci (VRE) . [DATE]: . Patient is currently on (IV antibiotics) for [CONDITION(S)] and VRE in the sacral decubitus wound and [CONDITION(S)] (bone infection) of the spine . [DATE]: . Patient discharged to a facility with Hospice services. On [DATE] at 4:45 PM during an interview with the Director of Nursing (DON) about Resident #100's Pressure ulcer, she stated, It never should have happened. I don't know how that was missed. On [DATE] at 1:30 PM during an interview with the Administrator about Resident #100, he said he was aware that the resident was admitted with a pressure ulcer, and it did not receive treatment to promote healing or prevent worsening. A review of the facility policy titled, Skin Ulcer Guideline, dated revised [DATE] provided, The following guidelines are intended to assist the health care team with appropriate identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation should include that the nurse discussed the area with the physician and that agreement was reached as to the type/categorization . Write the treatment order and transfer orders to the treatment MAR (medication administration record) . Care plans should be reviewed . documentation must still be made daily that the dressing is intact and to its integrity. Include the integrity of the skin around dressing. Daily documentation of pain associated with the area is required . Notify and chart that dietary and charge nurse have been notified of the impaired skin condition. Notify and chart that the DPOA or responsible party has been notified of the skin impairment . Resident #102: On [DATE] at 10:55 AM, Resident #102 was observed lying in bed, awake and alert. A wound care observation with Nurse A and Certified Nursing Assistant E, revealed Resident #102 had a large wound on his sacrum. There was no drainage, and the area was pink. Nurse A said the wound dressing was changed daily and was measured on Wednesdays or Thursdays. The nurse was asked how often the residents in the facility skin assessments had completed and stated, On their shower days, unless the aide finds something in between then and I need to look at it. Nurse A said skin assessments and wound care were documented in the electronic medical record. A record review of the Face Sheet and MDS assessment indicated Resident #102 was admitted to the facility on [DATE] with Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] the resident was transferred to the hospital and returned on [DATE] with additional Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] indicated the resident had full cognitive abilities with a BIMS score of ,d+[DATE] and needed 2-person assistance with bed mobility, transfers, dressing, toileting, hygiene and bathing. The MDS Section M- Skin assessment dated [DATE] revealed the resident had a pressure injury, needed clinical assessment, was at risk for developing pressure ulcers/injuries and had an unstageable pressure ulcer (National Pressure Injury Advisory Panel (NPIAP): Pressure Injury and Stages, dated [DATE]: Definition: Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar .). The MDS section M also indicated Resident #102 was receiving Pressure ulcer/injury care. An Admission Assessment, dated [DATE] for Resident #102 provided the following: Skin Integrity: Site: Right Buttock; Pressure; 3 (length), 2.5 (width) . There was no additional wound assessment to describe the pressure ulcer. A review of the Skin & Wound Evaluations for Resident #102 revealed the following: [DATE]: Describe: Pressure; Stage: Unstageable: Obscured full-thickness skin and tissue loss; Due to: Slough and/or eschar; Right buttock; present on admission; wound measurements: Area: 7.9 cm 2; Length 4.1 cm; Width: 2.4 cm; depth not applicable; undermining not applicable; tunneling: not applicable; Slough (amount not specified); Exudate (drainage): Moderate; Type: Serous . Pain on movement; Treatment: Missing; . Stalled wound to right buttock. Depth UTD (unable to determine) related to yellow slough to wound bed. Surrounding skin noted to be fragile in appearance and at risk for further break down. Dressing missing and applied at treatment change. Resident to follow up . at wound healing center . Notifications: (all blank- Practitioner notified, Resident/responsible party notified, Dietitian Notified, Therapy notified. A review of the resident's Treatment Administration Record for [DATE] indicated there was no treatment provided to the resident's right buttock/sacral wound in [DATE]. A review of the physician orders indicated a wound treatment to Resident #102's right buttock wound/sacrum was not ordered until [DATE] and was to begin [DATE]: Calcium Alginate-Silver Pad 2x 2. A review of the February 2022 Treatment Administration Record (TAR) for 2x 2; Resident #102 revealed, Calcium Alginate-Silver Pad - Apply to right buttock topically every day shift for wound management. *** Cleanse right buttock wound with normal saline. Pat dry Apply Calcium Alginate (AG- Silver) to wound bed. Cover with foam, order date [DATE]. There was no documented wound care on [DATE]. The first documented wound care was [DATE]; 11 days after the resident was admitted with the right buttock/sacral wound. There was no documentation of wound care on [DATE] or [DATE]. A review of a Skin & Wound Evaluation, assessment for Resident #102 dated [DATE], Describe: Type: Pressure; Stage: Unstageable: Obscured full-thickness skin and tissue loss; Due to: Slough and/or eschar; Location: Right buttock; Present on admission; Exact date [DATE]; Wound Measurements: Area 9.4 cm 2, Length 4.5 cm, Width 2.7 cm; Slough (no amount documented); Exudate: Moderate; Type: Serous; Surrounding tissue: Excoriated: Superficial loss of tissue, Fragile: Skin that is at risk for breakdown, Intact; Pain: Intermittent; Goal of Care: Healable; Treatment: Missing; Notes: Stalled wound to right buttock. Wound bed noted to be beefy red with yellow slough observed. Surrounding skin intact fragile for further break down with some excoriation . wound center Further review of the Treatment Administration Records for March, April and [DATE] revealed the following: [DATE]: There was no documentation of wound care to the resident's right buttock/sacrum on [DATE], [DATE], and [DATE]. On [DATE] the treatment was changed to Dakins (,d+[DATE] strength) solution 0.25% (Sodium hypochlorite (bleach)): Apply to sacrum ulcer topically every day shift for Ulcer. Cleanse area with wound cleanser. Apply barrier cream around area. Apply ½ strength Dakins moist to dry dressing to ulcer. Change daily, order date [DATE]. [DATE]: Wound care was not documented as administered on [DATE]. A Report of Consultation (Wound consult) dated [DATE] revealed Findings: Sacrum ulcer. ½ strength Dakins moist to dry daily dressing changes, barrier cream around area. Return in 4 weeks. A Wound Consult note dated [DATE] identified the following, Skin On the sacrum is a longitudinally shaped ulcer that is just to the right of midline. There is some necrosis of the right edge. There is some undermining on the 3:00 to 6:00 position. There is minimal amount of slough at the base of the ulcer . Wound Length: 4.2 cm, Wound Width: 1 cm, Wound Depth: 0.4 cm, Undermining ,d+[DATE] o ' clock 1.9 cm . Pressure injury Stage: 3 . He has been using Dakin's wet to moist dressings daily on the sacrum . On [DATE] at 2:45 PM, reviewed with Director of Nursing Resident #102's right buttock/sacral wound noted on the [DATE] readmission nursing assessment and lack of initiation of wound care until 11 days after readmission, ordered [DATE] and began [DATE], she said the nurse completing the initial skin assessment should have obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the Care Plans for Resident #102 provided, Resident has actual alteration in skin integrity with noted open area to sacrum and is at risk for worsening, delayed healing and new skin disruption . dated initiated [DATE] and revision [DATE] with Interventions: Provide treatments as ordered, date ordered [DATE] and revised [DATE].

This citation pertains to Intake Number MI 618. Based on interview and record review, the facility failed to ensure assessment, monitoring and notification to the physician in a timely manner for a resident experiencing a change in condition for one sampled resident (Resident #101) of three residents reviewed for care needs, resulting in Resident #101 exhibiting a change in mental status, a fever, and experiencing confusion. The facility failed to perform continued assessment, monitoring and the evaluation of STAT (immediate) laboratory findings, There was a deterioration in the resident's health status with subsequent death. Findings include: A review, of Resident #101's medical record, revealed an admission into the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status of 15, which indicated intact cognition and the Resident needed extensive staff assistance with transfers, dressing, personal hygiene and toilet use. A review, of Resident #101's medical record, revealed progress notes that included the following: -Dated [DATE] at 11:02 AM, Admission Note, . Resident was diagnosed at hospital with [MEDICAL CONDITION] and tested positive for a UTI (urinary tract infection), treated with PO (oral) abx (antibiotics) . Resident is continent of bowels and bladder, uses urinal and bedpan for elimination . Resident is A&O x 4 (alert and oriented), education provided on use of call light system and bed controls . -Dated [DATE] at 8:34 AM, Nurses Progress Notes, Resident has had increased confusion noted during the night. Has had to be redirected numerous times. He is on oral ABT (antibiotic) therapy for UTI. Per resident days ago when he was more lucid, he was on IV (intravenous) ABT therapy at the hospital, but was changed over to a oral pill. I discussed with the oncoming nurse my concerns about his decline in cognition. Put into the doctor's book, author Nurse K. -Dated [DATE] at 1:37 PM, Nurses Progress Notes, Resident has had increased confusion. Vitals taken this morning included a temp of 100.1. Retake temp at noon was 99.1 tympanic. He continued to have periods of confusion. Skin warm and dry. Alert but has had some times where he was difficult to arouse but when he did he would talk with confused content then would be more with it then confusion again. Meds given. Abdomen has redness. Held [MEDICATION NAME] this afternoon. Spoke with (Doctor E) and received orders for [MEDICATION NAME] 1 gram IM (intramuscularly) daily for 5 days. Stat labs for a CBC (blood count), Chem 7 (basic metabolic panel that included electrolytes and kidney function), U/A (urinalysis), HGB A1C (glucose indicator), PT/INR (coagulation). He is awaiting the DON (Director of Nursing) for Face Time with an iPhone. He gave order for Tylenol 325 2 tabs every 6 hours as needed for fever, author Nurse O. -Date [DATE] at 2:29 PM, Nurses Progress Notes, Resident incontinent of bladder and bowel. Urine had somewhat yeasty odor. [MEDICATION NAME] 1 GM IM and oral Tylenol 650 given per new DO (doctor's order), author Nurse O. -Dated [DATE] at 3:50 PM, Nurses Progress Notes, urine dip was negative. Brat diet started, author DON. -Dated [DATE] at 8:30 PM, Nurses Progress Notes, 2030 (8:30 PM) nurse entered Pt (patients) room and called a code BLUE, Pt was unresponsive, 911 called and CPR (cardiopulmonary resuscitation) started with EAD (AED, Automated External Defrillator) activated. 2043 (8:43 PM) EMT (emergency medical technician) arrives on scene, CPR continues. 2127 (9:21 PM) time of death and ME (medical examiner) called, 2300 (11:00 PM) (Funeral Home) called, remains left building at 23:45 (11:45 PM), Family and D.O.N. notified. Personnel belongings sent with family, author Nurse J. A review, of Resident #101's vital signs in the medical record, revealed one set of vitals on [DATE] at 8:41 AM that included blood pressure of ,[DATE], and oxygen saturation of 95% that was recorded by the nightshift Nurse K. The temperature was recorded in the nurse's progress note that was completed in the morning on [DATE] of 100.1 degrees Fahrenheit and retaken at noon of 99.1 degrees Fahrenheit. There was a lack of vital signs of pulse, blood pressure, oxygen saturation and respirations documented on [DATE] with the ongoing confusion for Resident #101 and a lack of further assessment and monitoring of the Residents condition after Nurse O had notified the Physician of the change in condition at 1:37 PM on [DATE] until the Resident had been found unresponsive at 8:30 PM when CPR had been initiated and the Resident had died . A review, of Resident #101's medical record, revealed laboratory orders dated on [DATE] at 2:00 PM for STAT CBC, BMP (basic metabolic panel), US C&S (urine culture and sensitivity), PT/INR, and Hgb A1C. The laboratory results revealed a collection on [DATE] at 4:41 pm, received on [DATE] at 5:54 PM and a run date on [DATE] at 4:02 AM. Abnormal results included CL (chloride level) low at 93 (normal range ,[DATE]), Gap (anion gap) high 21.4 (normal range ,[DATE]), BUN (blood urea nitrogen) high 68 (normal range ,[DATE]), Creat (creatinine level) high 2.2 (normal range 0XXX,[DATE].3), Est Creat Clear low 32 (normal range greater than 60). An interview on [DATE] at 8:01 AM, with Laboratory Staff P was conducted and revealed that a composite of all the lab results for Resident #101 had been faxed on [DATE] at 4:02 AM. The Laboratory Staff was queried regarding the time frame for STAT orders for test to be completed and reported that the lab has four hours from initiate to collect, receive and run the test results and stated, That's our target window for STATs. A review, of the lab test from Resident #101's medical record, of the run time on [DATE] at 4:02 AM, the Lab Staff indicated the results were sent to the facility and received the scheduled report at that time with all the results. The Lab Staff reviewed communication with the facility and stated that a broadcast had been sent after the tests were run for the individual results and that the broadcast had been sent by fax as the results came in on the completed tests. The Lab Staff reported the glucose was sent at 18:14 (6:14 PM), coagulation test at 18:09 (6:09 PM), and CBC at 17:38 (5:38 PM) and another at 17:41 (5:41 PM). The Lab Staff indicated that had there been any critical results, the Lab Staff would call the facility with the results. On [DATE] at 8:23 AM, an interview was conducted with the Director of Nursing (DON) regarding Resident #101. The DON reported the Resident had increased confusion and agitation the day before the Resident had coded and died . The DON reported the Resident had progressively gotten worse, was found unresponsive and CPR was started, the responsible party was there at the facility and told staff to stop the CPR. The DON was queried if an investigation had been completed and the DON indicated the Doctor had done a chart review. When queried when the stat laboratory results had been received, the DON indicated the lab results had gotten back to the facility the next day and stated, I know for a fact the labs came after he passed, and reported they had reviewed them in the morning on [DATE]. The DON indicated if there were any critical results the Laboratory would call. When queried if the results had come by fax one at a time as the lab had preformed the test, the DON stated, I don't know if they can separate the results. Usually we get them all sent at once. When queried when STAT lab results were to be reported, the DON reported approximately four hours. The DON was queried when a change in condition in Resident status was to be conveyed to the Physician and stated, Any change in condition, they (Nurses) should be notifying (the doctor). When queried why the nightshift Nurse had not contacted the Physician with the change in the mental status and then when the temperature had elevated, the DON stated, I can't speak to why she didn't call the Doctor. The DON reported the nightshift will pass it on in report unless it is critical. The change of condition was passed on to Nurse O in the morning and Nurse O had notified the Physician and stated, that's when he ordered the labs. The DON was queried when Nurse O had notified her of the change in Resident #101's condition and stated, (Nurse O) told me about him at the time she called the doctor. When queried when vital signs were to be done, the DON reported with a change in condition, once a day with skilled charting and reported that temperatures and O2 saturation was completed twice a day during the Covid-19 and stated, That's how (Nurse O) knew he had a fever, temps are done twice a day. When queried regarding a lack of ongoing vital signs, assessment of the Resident's condition and when should vital signs be completed for a Resident with a change in condition, the DON stated, I don't know why there is no vital signs documented. I would have the CNA's (certified nursing assistants) get a set of vital signs because I would want to know what is going on. Nurse O noticed a change in condition got the (elevated) temp and called the doctor. When queried why the Resident was not sent out to the hospital, the DON reported that the confusion was not abnormal for the resident and with the co-morbidities, UTI and because of Covid-19, the doctor thought we should try things in-house first. On [DATE] at 8:58 AM, an interview was conducted with Nurse O who was assigned care of Resident #101 on [DATE]. The Nurse explained she had been asked to work the floor (be assigned resident care) and it had been her third time working the floor after five years. When queried regarding Resident #101, the Nurse explained she had gotten report from the nightshift nurse that the Resident had a change in condition, was confused and ran a temperature of 100.1. When queried why Nurse K had not called the doctor with the Resident's change in condition that was documented as occurring through the nightshift or why she had not called the doctor after report, Nurse O reported Nurse K had a difficult night and was distraught over multiple issues through the night and after report Nurse O reported that she felt she was two hours behind on what needed to be done. The Nurse explained that another day shift nurse was assisting with medication pass and had passed the medications to Resident #101. Nurse K reported she had talked to the DON when she got there in the morning regarding Resident #101 and asked the DON if she should send him out to the hospital and stated, She (DON) said 'I will call the doctor' and I was running like crazy. I asked multiple times if (DON's name) had heard from the doctor but they said she was out to lunch, so I called him (Doctor E) myself and he had not heard from her (the DON). The Nurse reported the doctor did not want to send him out to the hospital and wanted to treat him there at the facility and had ordered lab work, an antibiotic and Tylenol. The Nurse was queried regarding an assessment and vitals and reported staff had been in and out almost every 10 minutes, a set of vitals were taken in the morning and taken again but was unsure why the vital signs had not been documented. The Nurse reported she was done with her shift at 2:30 PM and had given report to the DON on the Residents she was assigned that included Resident #101. On [DATE] at 10:57 AM, a phone call was made to Nurse K but there was no answer and a return phone call was not received prior to the exit of the survey. On [DATE] at 11:04 AM, an interview was conducted with CNA M regarding Resident #101. The CNA reported she had assigned care of the resident on [DATE] and had given him his dinner tray. The CNA explained the Resident was sweating profoundly, had talked to the CNA and said he was not hungry, and she had left the tray in-case he wanted to eat. The CNA further explained that Nurse J had gone in to pass his medication and had called for the crash cart and stated, He (Resident #101) was foaming at the mouth and was purple. He (Nurse J) was unable to find a pulse and he started CPR (Cardiopulmonary Resuscitation) right away. The CNA reported 911 was called and EMS arrived pretty quick and had taken over CPR. The CNA explained the Resident had not eaten any of his dinner. On [DATE] at 11:44 AM, an interview was conducted with Physician E regarding Resident #101. The Doctor was queried regarding when the Doctor was to be notified of a change in condition and reviewed Resident #101 with a change in mental status during the nightshift and a fever and continued confusion on [DATE], the Physician stated, Usually notify right away, text, call right away. When queried when the Physician was available to be notified, the Physician reported he and the Physician's Assistant were available twenty-four, seven. The Physician reported that laboratory tests were ordered right away after notified of the Resident's change in condition. The Physician was queried why the Resident was not sent to the hospital. The Physician indicated the Resident's vital signs were stable, had no signs or symptoms [MEDICAL CONDITION] and with the Covid situation, we try to treat him at the facility. A review of the laboratory results from [DATE] and [DATE] the Physician reported the labs were not to different. On [DATE] at 2:48 PM, an interview was conducted with Nurse J who had assigned care of Resident #101 on [DATE]. The Nurse reported he had said Hi! to the Resident when he had come into work and when he had gone back in at 8:30 PM, to give the Resident his medications, found the Resident unresponsive and started CPR. The Nurse was unable to remember the Nurse he had received report from or the content of the report. On [DATE] at 11:09 AM, an interview was conducted with Nurse I regarding facility policy on notifying a physician or provider with a change in Resident's condition with a change in mental status and elevated temperature. The Nurse reported that changes in a Resident's status would be conveyed to the Physician immediately and stated, It doesn't matter at what time day or night. A review of the facility policy entitled, Notification of Changes, reviewed/revised on ,[DATE], revealed, . compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: 2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status . 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. b. Discontinuation of current treatment due to: i. Adverse consequences. ii. Acute condition. iii. Exacerbation of a chronic condition .

Based on observation, interview and record review the facility failed to assess, monitor, document, treat and/or prevent the development of pressure ulcers or follow the facility pressure ulcer policy for 2 residents (Resident #8 and Resident #13) resulting in a unstable pressure sore for Resident #8 and a Stage II pressure sore for Resident #13. Findings include: Resident #8: According to Resident #8's Minimum Data Set (MDS) assessment, dated 2/23/17, Resident #8 was readmitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. of bowel and bladder and severely impaired for cognitive skills. On 4/21/17 at 11:45 AM, with Director of Nursing B and Registered Nurse N were observed with Resident #8 to have removed Resident's foam dressing, dressing was covered with feces, and not entirely covering the purple red denuded area of skin. As the dressing was removed the skin was noted to started bleeding and skin was pulled away. The Open wound was noted to have been reported by DON B as being approximately 2 x 5 centimeters with 2 dime size areas of scabbed/eschar above the area in the gluteal fold. The surrounding area was noted purple/red demmoided that was reported by DON B to have been approximately 10 cm by 10 cm with scattered areas of small open bleeding areas. On 4/4/17, hospice note stated 3.5 x 1/5 cm right buttock 8 x 6 cm central coccyx, 3.5 x 1.5 (L) lateral buttock cleansed skin prep foam dressing applied. On 4/21/17 at 3:30 PM, DON B was asked about the skin assessments and stated pharmacy were to put the assessments on the (TAR) treatment record, but the pharmacy did not put the on the TAR so we have to audit to make sure they are on the chart. Following the Resident's shower the CNA's are to document in POC (electronic records) and the nurse has to do a skin assessment. Review of the electronic records showed no assessment for the skin assessments by the CNA or the nurse. DON B stated it should be checked and brought to report. An initial skin assessment was asked to be reviewed and DON B stated, It should be in in there. We are not using it to the fullest. We have to do audits, even on the auditor. doctors, NP, nursing, etc. Review of physician progress notes [REDACTED]. On 4/21/17 at 1:00 Nurse Practitioner (NP) I stated, I was not aware Resident #8 had any open areas. NP I was asked about the telephone order signed on 3/14/17 for TX : foam dressing to coccyx area, wash with soap and water, apply foam dressing every 3 days and PRN (as needed). NP I stated, I did not know that. and stated I do not recall seeing or signing the order, but agreed it is my signature. I will have to pay better attention to the orders. Review of Resident #8's weekly skin assessments revealed there was no noted weekly skin assessments following the 3/20/17 skin assessment. Review of Resident's Hospice notes revealed Resident #8 had a Stage II open area on 3/14/17 unstageable coccyx wound. On 3/31/17 Buttock wound appears raw ground hamburger bloody (L) 4.5 x 1 cm & 2.5 x 1 cm centrally, recommend to continue foam dressing not barrier cream, ordered supply, called to update (daughter). On 4/4/17 hospice note stated 3.5 x 1.5 cm right buttock 8 x 6 cm central coccyx, 3.5 x 1.5 (L) lateral buttock cleansed skin prep foam dressing applied. Review of Resident #8's nurse progress notes revealed the following entries: On 3/20/17 Skin assessment Coccyx 8 x 8 cm periwound pin, L inner wound 2 x 1 cm, R inner wound 1.5 x 1 cm. No scabs. irregular borers. foam dressing applied. Per hospice and confirmed with nurse. On 4/4/17 Hospice nurse in to see resident and measured wound to buttocks/sacral area. 3 open areas noted stage 2's. Open area to R buttock noted to be 3.5 x 1.5 L buttock/sacral open area noted to be 8 x 6 and extends past cross line. Open area noted to Left lateral buttock 3.5 x 1.5. Will continue to observe and maintain resident safety. Dressing noted to be changed and 2nd time at approx 3:30 PM R/T being soiled. Hospice nurse notified. The next assessment was dated 12 days later on 4/18/17 Hospice nurse in today from (name hospice) for wound measurements. Per hospice nurse pink/purple non open area noted to be 11 x 8 cm. Open area to central coccyx noted to be 1.5 x 0.5. Small open area noted to R scrotum 0.3 x 0.2 cm. There were no noted documented skin assessments completed by facility nursing staff. According to Resident #8's Care Plan, dated 2/10/17, Resident will be admitted on palliative care. There were no documented interventions. Resident was admitted to Hospice services on 3/14/17 per hospice note. According to Resident #8's Care Plan, dated 2/28/17, Resident is at risk for alteration in skin integrity r/t impaired mobility, impaired sensory perception, incontinent. The care plan was not updated at the time Resident had a Stage II open area on 3/14/17 unstageable coccyx wound, per hospice note. According to the facility policy, Pressure Ulcer, dated 5/23/05, revealed, A Resident having a pressure sore will receive necessary treatment and services to promote healing, prevent infection and prevent new breakdown from developing Procedure: RN/LPN will initiate the pressure ulcer procedure upon verification of a pressure ulcer, either on admission or if newly acquired. Nursing Department will notify the Dietary Department in writing for potential dietary intervention or for dietary assessment.2. Measurement of pressure ulcers will be done upon initial observation and every 7 days and / or sooner if deemed necessary. RN/LPN will initiate the Weekly Pressure Ulcer Progress Report. 3. The RN/LPN identifying the pressure ulcer will notify the legal responsible party and the attending physician and document such in the nurses notes in the treatment book. 4. The RN/LPN identifying the pressure ulcer will initiate a Care Plan for alteration in sin integrity. 5. All treatments / dressing will be initialed and dated. 6. Transparent dressing (Op-site, [MEDICATION NAME], etc.) if ordered when applied should extend at least 1.5 inches past the reddened area and should be changed every 4-7 days or as needed. 7. [MEDICATION NAME] dressings (Duoderm, [MEDICATION NAME], etc.) if ordered when applied should extend 1.5 inches past the reddened area and should be changed every 4 to 7 days or as needed .17. If no improvement is noted after 2 weeks of treatment, the RN/LN will notify physician for possible treatment change. Resident #13: Review of Resident #13's care plans revealed Resident was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no documentation of a care plan for skin/pressure ulcer. On 4/21/17 at 4:30 PM, Director of Nursing B reported that Resident #13 had a Stage II pressure ulcer to the sacral area that he had not been aware of previously. Review of Resident #13's Nurse progress notes, dated 4/21/17 at 1:17 AM, revealed Resident has an open area on her coccyx in the crease. Stage II. Measures 1 inch long by 0.5 cm wide. Treatment wrote for area. Duoderm to area. Change every 5 days and PRN. Cleanse area with NS and pat dry with each dressing change. D/C treatment when area healed. There was no documentation that the physician was notified. There is no documentation that the family was notified.

This citation pertains to MI 620. Based on observation, interview and record review, the facility failed to follow the care plan to toilet a resident every two hours, in order to prevent an avoidable fall for one resident (Resident #1) out of 4 residents reviewed for falls from a total sample of 4 residents, resulting in Resident #1 becoming restless, disengaging her own safety alarm and falling, sustaining a forearm laceration that required surgical intervention and caused ongoing pain for the resident. Findings include: According to a facility face sheet dated 10/10/14 at 11:24 p.m., Resident #1 was an [AGE] year old female admitted into the facility on [DATE] with the cumulative [DIAGNOSES REDACTED]. Review of a facility policy titled, "Fall Prevention Policy" (no date noted) reflected, "It is the policy of the (name of facility) that the resident environment remain as free of fall hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent falls. The intent of this policy is that the facility will prevent falls by providing an environment that is free from hazards over which the facility has control by initiating a falls risk assessment. The definition of a fall is considered to be a sudden, unplanned movement to the ground from a higher elevation ....within 8 hours of admission, all residents will be assessed for the need for any electronic monitoring devices or safety equipment, such as electronic monitoring available with the nurse call light system using a pressure device connected to a light panel at the nurses station." A facility document titled, "Unusual Occurrence Form" dated 11/29/14 at 11:30 p.m., completed by Registered Nurse (RN) "D" reflected, "Resident (#1) observed sitting on floor between (the) bathroom and chair (in Resident #1's room) with shoe laces untied and walker on her (tipped over) legs. Laceration noted on right forearm to elbow. Muscle tissue was noted." A body diagram had the notation: "'R' shape of laceration to right arm." The facility document titled, "Post Investigation of Unusual Occurrence" dated 11/29/14 (no time noted) by RN "D" reflected the time of Resident #1's fall was on 11/29/14 at 8:45 p.m. Resident #1's history and physical from the local acute care facility dated 11/29/14 (no time noted) reflected, "The patient is an [AGE] year old female who fell at a nursing home and lacerated her right forearm." Resident #1's physician discharge summary from the local acute care facility dated 12/1/14 at 10:54 a.m. reflected that Resident #1 was admitted to the facility on [DATE] (no time noted) and discharged on [DATE] (no time noted). This document reflected, "Hospital Course: The patient (Resident #1) was admitted on [DATE] after a fall in which she sustained a complex laceration to her right forearm. The ED (emergency department) was unable to repair the laceration. She (Resident #1) was admitted and scheduled to have the laceration repaired in the OR (operating room). The repair was performed on 11/29/14. The laceration was 28 cm (28 centimeters equals a little over 11 inches) long and involved the skin and subcutaneous tissue (tissue just below the skin but not muscle). The laceration was closed in 2 layers. There were several small areas where there was no skin coverage." Prior to her fall at the facility, Resident #1 was assessed on 11/18/14 for a "Fall Risk Assessment". The facility assessed Resident #1's fall risk score to be "15". The fall assessment tool reflected, "A total score over 10 represents high risk." According to Resident #1's "Functional Limits" facility care plan dated 3/3/14, Resident #1 "will transfer and ambulate with walker and 1 person assist, stand by" and "Assist resident (#1) to toilet every 2 hours and prn (as needed)." Resident #1's facility document titled "Resident ADL (activities of daily living) Care Plan" (no date noted reflected, "Safety device: Alarm chair and bed at all times." This document also had a gold star indicating a high fall risk. Restorative Nurse "C" had signed the back of this document, attesting that this care plan was the care plan in place before Resident #1's fall on 11/29/14. Resident #1 was a known fall risk who required assistance with ambulation and tolieting and this was care planned accordingly. According to a facility document titled, "Post Investigation of Unusual Occurrence" dated 11/29/14 (no time noted) completed by RN "D", this report reflected, "Resident (#1) observed on floor, left leg out and right leg folded in front of her (Resident #1) and walker on top of them (Resident #1's legs). Shoe laces were untied and a box lid was under her side. Laceration noted on right arm, wrist to elbow. Some blood/tissue noted on resident shelf." In this document, Resident #1's explanation for what occurred was documented as: "Resident (#1) attempt(ed) to self-transfer back to chair from bathroom, had taken her shoe and pant(s) off, getting ready for bed. Put shoes back on ... " This document reflected that Resident #1 was last toileted at "6 p.m." with the following questions asked and answered: " Did the alarm activate if in Care Plan? No, battery was lifted at one end. Why did this incident occur? Resident (#1) attempted to self-transfer without using call light, hit arm on white shelf in room causing laceration." During an interview on 12/10/14 at 12:05 p.m., Restorative Nurse "C" confirmed that Resident #1 was care planned to be toileted every 2 hours and as needed. Restorative Nurse "C" stated that Resident #1 experienced loose stools from time to time, requiring that she get to the bathroom quickly at times. Restorative Nurse "C" confirmed that Resident #1's roommate was interviewable, too, but during an interview on 12/10/14 at 10:55 a.m., Resident #1's roommate stated she had gone to bed before the incident, and did not hear anything, because she had taken her hearing aids out. During observation and interview 12/10/14 at 12:25 p.m. in Resident #1's room, Restorative Nurse "C" showed this surveyor how Resident #1's room was set up during the fall that occurred on 11/29/14. Restorative Nurse "C" stated that the pressure alarm control box hung from the enabler bar on Resident #1's bed, to the left of Resident #1's recliner chair, in reach of Resident #1. Restorative Nurse "C" stated the alarm controller had a trap door where the battery was housed with a latch and a spot for a small screw. Restorative Nurse "C" stated the small screw was not in place at the time of the occurrence. Restorative Nurse "C" stated they (the facility) had devised a new system of placing a band (a small dog's leash they had bought) around the bottom of the back of the recliner, forming a loop in which an alarm control box could be hung on the back of the recliner, out of the resident's reach. During an interview on 12/10/14 at 3:11 p.m., RN "D" confirmed she was caring for Resident #1. RN "D" was asked about Resident #1's fall on 11/29/14. RN "D" stated that Resident #1's fall occurred at approximately 8:45 p.m. RN "D" stated she had been alerted by a Certified Nurses Aide (CNA) that Resident #1 needed help. RN "D" stated that Resident #1's door was open a little and, when she got into Resident #1's room, she saw that Resident #1 had a "large laceration." RN "D" stated she did not leave the resident. RN "D" stated she was brought the portable phone, and she called Resident #1's daughter after she gave Resident #1 first aid. RN "D" stated she did not call Resident #1's physician. RN "D" stated she thought faxing the hospital transfer form was "notification." RN "D" stated it was a holiday weekend. RN "D" stated she knew, now, that she needed to call the physician to notify him of the fall and the need for medical attention outside of the facility. RN "D" stated, before Resident #1's fall, Resident #1's alarm had sounded twice that night. The first time was at about 5:30 p.m. and Resident #1 expressed a need to go to the bathroom. The second alarm was at approximately 7:00 to 7:30 p.m. RN "D" stated Resident #1 was "fiddling at the edge of the recliner." RN "D" was asked where the safety alarm control box was located. RN "D" stated that the alarm box control was on the bed mattress, to the left of Resident #1's recliner. RN "D" stated she notified Restorative Nurse "C" that the alarm did not sound when Resident #1 fell . RN "D" stated she noted the battery was "lifted" (the battery trap door was open and part of the battery was lifted up, stopping contact so alarm was not functional). RN "D" was asked what was being done differently now to prevent Resident #1 from falling. RN "D" stated facility staff no longer put the alarm controls where the resident can get to them, and that alarms were now being checked every shift. RN "D" confirmed that Resident #1 was care planned to be toileted every 2 hours. RN "D" confirmed that, the night of the fall, Resident #1 was last toileted at 5:30 p.m. and Resident #1's fall occurred at 8:45 p.m., over 3 hours later. RN "D" stated there was urine in Resident #1's toilet, but it was not certain if it was Resident #1's urine. RN "D" was asked if Resident #1 uses her call light when she needed assistance. RN " D " said Resident #1 "doesn't use her call light, only occasionally " . Resident #1 had shown she was impulsive in trying to toilet herself at 5:30 p.m. and that she didn't use the call light to ask for assistance. The way the staff was alerted at 5:30 p.m. was by the pressure alarm sounding. An "Investigative Report" written by the facility dated 12/1/14 reflected that, "On 11/29/14 at approximately 8:45 (no a.m. or p.m. noted), (name of Resident #1) was observed on the floor in her room (room number and bed). Her (Resident #1) right arm had a laceration from about the wrist to about her elbow. (Name of Resident #1) requires a 1 person assist with walker and gait belt for transfers and ambulation. She (Resident #1) is alarmed at all times. She lacks safety awareness due to short (term) memory deficit." This Investigative Report summary reflected, "(Name of Resident #1) got up without assistance after disconnecting her chair pad alarm. She had her walker with her. She went to the bathroom where she removed her clothing to get ready for bed as evidenced by her clothing on the bathroom floor. She (Resident #1) attempted to return to her bedside. Somehow resident lost her balance and fell catching the corner of a standing shelf unit resulting in a right arm laceration. She was sent to the hospital for treatment. She received sutures to her right arm laceration." An observation on 12/10/14 at 2:25 p.m. was made of Resident #1 in her room in her recliner. Resident #1 was seated in her recliner facing the door. RN "E" was in the room assisting Resident #1 by placing her call light in her lap before RN "E" left the room. While RN "E" was placing the call light, it was noted that the alarm control box was placed on Resident #1's bed mattress, at the head of the bed, to Resident #1's left and within Resident #1's reach. RN "E" was in between the recliner and Resident #1's bed, but RN "E" did not note the placement of the alarm control box and did not move the alarm control box out of Resident #1's reach. During an interview on 12/10/14 at 3:22 p.m., RN "E" was asked if she checked resident alarms. RN "E" stated, "We all do." Restorative Nurse "C" was asked on 12/11/14 at 9:30 a.m. what the expectations were when a nurse or CNA checked the chair and bed alarms. Restorative Nurse "C" stated she expected, on a pressure mat alarm, that the alarm is attached to the call system and alarms both at the nursing station and by a light above the resident room door. and that the placement of the alarm control box is "hung so the resident doesn't have total access to it." Restorative Nurse "C" was asked if placement of the alarm control box for Resident #1 on the head of the bed on top of the mattress was appropriate placement and she stated, "No". A physician prescription for Resident #1 dated 12/1/14 (two days after the resident's fall) reflected that Resident #1 was prescribed Hydrocodone-acetaminophen (Norco, a narcotic pain medication) 5-325 mg (milligrams) every 4 hours by mouth as needed for pain. Review of Resident #1's facility "PRN (as needed) Administration Record" for December 2014 reflected that Resident #1 was being given one Norco: 12/1/14 at 5:00 p.m. 12/2/14 at 2:00 a.m. 12/2/14 at 11:00 a.m. 12/3/14 at 2:00 a.m. 12/4/14 at 5:00 p.m. 12/5/14 at 5:30 p.m. 12/6/14 at 1:00 a.m. 12/6/14 at 6:00 a.m. 12/6/14 at 1:30 p.m. 12/7/14 at 2:30 a.m. 12/7/14 at 7:30 a.m. 12/8/14 at 5:00 a.m. 12/9/14 at 1:30 a.m. 12/9/14 at 6:00 a.m. 12/9/14 at 10:00 p.m. 12/10/14 at 6:00 a.m. Review of Resident #1's facility "PRN (as needed) Administration Record" for December 2014 also reflected that Resident #1 was receiving Tylenol 325 mg two tablets (650 mg) every 6 hours as needed for pain by mouth which was noted to be given twice on 12/1/14, twice on 12/2/14, three times on 12/3/14, once on 12/4/14, once on 12/5/14, twice on 12/6/14, and three times on 12/7/14. According to Resident #1's Medication Administration Record for November 2014, Resident #1 was prescribed Tylenol 325 mg two tablets by mouth once daily, and also Tylenol 325 mg 2 tablets by mouth every 6 hours, as needed for pain, which she had received only on 11/25/14 and 11/29/14. After sustaining her fall on 11/29/14, Resident #1 was experiencing pain that required both a narcotic pain medication and supplemental Tylenol to control the pain that was related to the fall and laceration. According to a nurses note date 12/10/14 at 7:00 a.m., Resident #1 "admitted to having pain then refused Tylenol and admitted to needing something stronger to help. Resident was encouraged to speak up about any pain she may be having." ( )

THIS CITATION PERTAINS TO INTAKE #MI 555. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROTECT 1 OF 5 SAMPLED RESIDENTS (#501), FROM VERBAL AND PHYSICAL ABUSE, RESULTING IN FIVE BRUISES ON HER RIGHT UPPER ARM, AND THE POTENTIAL FOR INJURY TO ALL FACILITY RESIDENTS. FINDINGS INCLUDE: REVIEW OF THE FACE SHEET REVEALED, RESIDENT #501 WAS A [AGE] year OLD FEMALE RESIDENT, admitted TO THE FACILITY 8/24/09, WITH [DIAGNOSES REDACTED]. REVIEW OF THE MDS (MINIMUM DATA SET, RESIDENT ASSESSMENT TOOL) DATED 8/25/10, BEHAVIOR MANAGEMENT REVIEW FORM DATED 5/25/10, AND PSYCHIATRIC EVALUATION DATED 9/7/10, REVEALED RESIDENT #501 WAS MODERATELY COGNITIVELY IMPAIRED, WITH SHORT AND LONG TERM MEMORY PROBLEMS. HER DAILY DECISION MAKING ABILITIES WERE MODERATELY IMPAIRED, SHE HAD PERIODS OF RESTLESSNESS AND WAS RESISTANT TO CARE. SHE WAS DEPENDENT ON STAFF FOR TRANSFERS, TOILETING, PERSONAL HYGIENE, AND DRESSING. REVIEW OF THE ADL (ACTIVITIES OF DAILY LIVING) CARE PLAN DATED 9/1/10, AND THE BEHAVIORAL/ANXIETY CARE PLAN DATED 8/24/10, REVEALED RESIDENT #501 had a history of [REDACTED]. REVIEW OF THE FACILITY INCIDENT REPORT DATED 9/13/10, AND THE INVESTIGATION SUMMARY (UNDATED), REVEALED ON 9/12/10 AT 9:25 A.M., EMPLOYEE #EM100 (ON 9/12/10, CHARGE NURSE ASSIGNED TO THE UNIT THE RESIDENT WAS ON) AND EMPLOYEE #EM200 (ON 9/12/10, NURSING ASSISTANT/CNA ASSIGNED TO THE HALL THE RESIDENT WAS ON), TOILETED THE RESIDENT. IN THE BATHROOM, #EM100 WAS ON THE RESIDENTS LEFT SIDE, AND #EM200 WAS ON HER RIGHT SIDE. #EM200 ATTEMPTED TO ASSIST THE RESIDENT IN PULLING HER PANTS DOWN AT THE SAME TIME SHE WAS PULLING THEM DOWN FOR HERSELF. THE RESIDENT GOT UP-SET AT #EM200 AND SLAPPED AT HIM. #EM200 LET GO OF THE RESIDENTS PANTS, AND "SQUEEZED RES. (THE RESIDENT) RT (RIGHT) UPPER ARM AND SHOOK IT. HE YELLED STERNLY AND LOUDLY IN HER FACE, (TO RESIDENT #501) YOU NEED TO STOP THIS NOW". #EM100 RESPONDED BY CALLING #EM200'S NAME, IN AN ATTEMPT TO MAKE HIM LET GO OF THE RESIDENT AND STOP YELLING AT HER. THEN #EM200 LOOKED DIRECTLY AT #EM100 AND SAID IN FRONT OF THE RESIDENT, "I'M SICK OF GETTING HIT BY THIS WOMEN FOR THE PAST WEEKS". #EM100 INSTRUCTED #EM200 TO LEAVE THE ROOM IMMEDIATELY, AND COMPLETED THE RESIDENTS CARE. WHEN #EM200 LEFT THE ROOM, THE RESIDENT STATED "I'M GLAD HE'S GONE". #EM100 INFORMED #EM200 SHE WAS NOT COMFORTABLE WITH HIM CARING FOR THE RESIDENT, TO PUNCH OUT AND LEAVE THE FACILITY. ON 9/12/10, #EM100 PHONED THE DIRECTOR OF NURSING (DON), AND INFORMED HER OF THE INCIDENT. OBSERVATIONS WERE DONE ON 9/16/10 (8:30 A.M.), AND ON 9/18/10 (2:30 P.M.), OF RESIDENT #501. A TOTAL OF 5 ROUND FAINT LIGHT BROWN/YELLOW COLORED BRUISES, APPROXIMATELY 1/8 TO 1/4 INCHES WERE NOTED, IN THE PATTERN OF FINGER TIPS ON THE RESIDENTS RIGHT UPPER, INNER ARM. THE RESIDENT DENIED PAIN OR DISCOMFORT AT THE SITE, AND WAS UNABLE TO RECALL THE INCIDENT ON 9/12/10. REVIEW OF THE FACILITY BATH AND SKIN REPORT DATED 9/16/10, REVEALED ON 9/13/10 AND 9/14/10, NO BRUISES WERE FOUND ON THE RESIDENTS RIGHT ARM. ON 9/15/10, SEVERAL SMALL BRUISES WERE NOTED ON THE RESIDENTS RIGHT UPPER ARM. PER INTERVIEW DONE ON 9/16/10 AT 12:00 A.M., WITH EMPLOYEE #EM100 (THE NURSE), AND HER WRITTEN STATEMENT DATED 9/12/10, REVEALED ON 9/12/10 AT 9:50 A.M., THE DON WAS NOTIFIED OF THE INCIDENT, AND #EM200 WAS SENT HOME AT 10:00 A.M. #EM100 SAID SHE ASSESSED THE RESIDENT AFTER THE INCIDENT, AND FOUND NO MARKS OR BRUISES ON HER RIGHT UPPER ARM AT THAT TIME. #EM100 STATED "I CHECKED HER ARM ABOUT 6 TIMES THAT DAY (9/12/10), UP UNTIL 4:00 P.M.". #EM100 VERBALIZED TO THE SURVEYOR SHE HAD WORKED WITH #EM200 BEFORE, BUT NEVER SAW THIS TYPE OF BEHAVIOR TOWARD A RESIDENT OR STAFF MEMBER, AND SHE WAS AFRAID OF HIM AFTER THE INCIDENT. AN INTERVIEW WAS DONE ON 9/16/10 AT 11:05 A.M., WITH EMPLOYEE #EM200 (THE CNA). #EM200 STATED "I WAS IN HER BATHROOM TOILETING THE RESIDENT, AND THE RESIDENT WAS COMBATIVE WITH US (THE NURSE AND THE CNA). SHE (THE RESIDENT) ATTEMPTED TO STRIKE AT ME. THE 3 OF US WERE IN THE BATHROOM, WE WERE GETTING READY TO SIT HER DOWN (ON THE TOILET). SHE WAS TRYING TO GET ME AWAY FROM HER; SHE DID NOT LIKE TO BE TOUCHED. SHE WAS PULLING HER OWN PANTS DOWN, I DID NOT KNOW THIS. I USED A STRONG VOICE TO THE RESIDENT. I THINK IT SCARED THE NURSE (#EM100) AND RESIDENT. I DID NOT YELL AT THE RESIDENT, I WAS NEVER ON TOP OF HER RIGHT ARM (HAD HIS HAND ON THE RESIDENTS RIGHT UPPER ARM). THE NURSE LOUDLY TOLD ME TO STOP". #EM200 DENIED SQUEEZING AND SHACKING THE RESIDENTS RIGHT ARM, AND DENIED YELLING LOUDLY AT THE RESIDENT. #EM200 SAID HE TRIED SOMETHING NEW WITH THE RESIDENT TO STOP HER FROM HITTING HIM DURING CARE, BUT IT DIDN'T WORK. #EM200 STATED "I LEFT THE BUILDING ON 9/12/10 AT 11:00 A.M., AND RETURNED ON Monday, 9/13/10 AT 6:00 A.M., THE CHARGE NURSE NEVER TOLD ME DON'T COME BACK TO THE FACILITY". #EM200 DENIED MANAGEMENT OR THE DON CALLED AND INFORMED HIM NOT TO SHOW UP ON Monday (9/13/10) FOR WORK. #EM200 SAID HE WORKED ON 9/13/10, 1 ST SHIFT (6:00 A.M. TO 2:30 P.M.), AND HE WAS ASSIGNED TO THE HALL THE RESIDENT WAS ON. #EM200 STATED "WE WORK IN TEAMS (2 CNA'S ASSIGNED PER HALL), I RECALL DOING PERI CARE, TOILETING, AND DRESSING THE RESIDENT ON 9/13/10". #EM200 SAID THE "DON TOLD ME AT 2:15 P.M. (ON 9/13/10); SHE WANTED TO TALK TO ME". THE DON INFORMED HIM HE WAS NOT SCHEDULED TO WORK AT THE FACILITY, UNTIL THE COMPLETION OF THE INVESTIGATION. REVIEW OF THE FACILITY 1 ST SHIFT ASSIGNMENT SHEETS DATED 9/12/10 AND 9/13/10, AND #EM200'S TIME CARD DATED 9/7/10 THROUGH 9/20/10, REVEALED ON 9/12/10 AND 9/13/10, #EM200 WAS PUNCHED IN AT THE FACILITY ON 1 ST SHIFT, AND WAS ASSIGNED TO THE SAME UNIT RESIDENT #501 WAS ON. AN INTERVIEW WAS DONE ON 9/16/10 AT 2:45 P.M., WITH THE DON. THE DON REVEALED ON 9/12/10 AT APPROXIMATELY 9:45 A.M., SHE WAS NOTIFIED BY PHONE OF THE INCIDENT ON 9/12/10, BY THE CHARGE NURSE (#EM100). THE DON REVEALED #EM200 DID WORK ON 9/13/10, FOR THE ENTIRE SHIFT AND HE WAS ASSIGNED TO THE HALL RESIDENT #501 WAS ON. THE DON REVEALED #EM200 WAS NOT INFORMED HE WAS NOT SCHEDULED AT THE FACILITY UNTIL THE CONCLUSION OF THE INVESTIGATION, UNTIL THE END OF 1 ST SHIFT (2:30 P.M.), ON 9/13/10. THE DON REVEALED THAT SHE ASSESSED THE RESIDENT DAILY FOR BRUISES, AND ON 9/15/10, SEVERAL SMALL BRUISES WERE NOTICED ON HER RIGHT UPPER ARM. THE DON SAID THE BRUISES WERE IN THE PATTERN OF FINGER MARKS. AN INTERVIEW WAS DONE ON 9/16/10 AT 10:00 A.M., WITH EMPLOYEE #EM300 (NURSE MANAGER). #EM300 REVEALED ON 9/12/10, THE DON INFORMED HER BY PHONE OF THE INCIDENT. #EM300 SAID ON 9/13/10 (Monday), SHE WAS AT THE FACILITY AND AT APPROXIMATELY 11:00 A.M., SHE INFORMED THE ADMINISTRATOR THAT #EM200 WAS WORKING AT THE FACILITY (ON 9/13/10), AND WAS ON THE SAME HALL THE RESIDENT WAS ON. #EM300 REVEALED THAT SHE AND THE DON ASSESSED THE RESIDENT DAILY FOR BRUISES, AND ON 9/15/10, SEVERAL SMALL BRUISES WERE NOTED ON HER RIGHT UPPER ARM, IN THE PATTERN OF FINGER MARKS. AN INTERVIEW WAS DONE ON 9/20/10 AT 9:25 A.M., WITH THE FACILITY ADMINISTRATOR. THE ADMINISTRATOR REVEALED HE WAS INFORMED OF THE INCIDENT ON 9/13/10 AT APPROXIMATELY 10:00 A.M. TO 11:00 A.M. AND HE CONFIRMED #EM100 WORKED AT THE FACILITY ON 9/13/10, ON 1 ST SHIFT, AND WAS WORKING ON THE SAME HALL AS RESIDENT #501 WAS ON. AN INTERVIEW WAS DONE ON 9/16/10 AT 1:55 P.M., WITH THE SOCIAL WORKER. THE SOCIAL WORKER REVEALED SHE WAS INFORMED OF THE INCIDENT ON 9/14/10, WHEN SHE CAME BACK TO WORK. THE SOCIAL WORKER SAID SHE INFORMED THE RESIDENTS RESPONSIBLE PARTY ON 9/15/10, OF THE BRUISES FOUND (ON 9/15/10) ON THE RESIDENTS RIGHT ARM. REVIEW OF THE FACILITY NEGLECT, ABUSE, MISTREATMENT AND MISAPPROPRIATION OF PROPERTY POLICY (UN-DATED), STATED "PURPOSE: TO ENSURE THAT RESIDENTS ARE NOT SUBJECT TO ABUSE BY ANYONE, INCLUDING, BUT NOT LIMITED TO, FACILITY STAFF, OTHER RESIDENTS, CONSULTANTS OR VOLUNTEERS, STAFF OR OTHER AGENCIES SERVING THE RESIDENT, FAMILY MEMBERS OR LEGAL GUARDIANS, FRIENDS, OR OTHER INDIVIDUALS. ANY EMPLOYEE SUSPECTED OF ABUSE, NEGLECT, MISTREATMENT, OR MISAPPROPRIATION OF PROPERTY MAY BE REASSIGNED OR SUSPENDED PER THE ADMINISTRATOR PENDING THE OUTCOME OF THE INVESTIGATION". ( )

THIS CITATION PERTAINS TO INTAKE #MI 295. BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION TO PREVENT A RESIDENT FROM FALLING OVER A WHEELCHAIR IN 1 OF 5 SAMPLED RESIDENTS (RESIDENT #500), RESULTING IN A DISPLACED HIP FRACTURE, SURGICAL HIP REPLACEMENT, AND THERAPY FOR AMBULATION TRAINING. FINDINGS INCLUDE: REVIEW OF THE ROSTER REVEALED RESIDENT #500 WAS AT THE FACILITY AT THE TIME OF THE INVESTIGATION (9/16/10 TO 9/20/10). REVIEW OF FACE SHEET, MDS (MINIMUM DATA SET, RESIDENT ASSESSMENT TOOL) DATED 8/25/10, NURSES NOTES DATED 8/27/10 THROUGH 9/2/10, FALLS RAP DATED 8/18/10, AND PHYSICIAN ORDERS [REDACTED]. THE RESIDENTS [DIAGNOSES REDACTED]. THE RESIDENT fell AND FRACTURED HER HIP ON 8/27/10, WAS TRANSFERRED TO THE HOSPITAL WHERE SHE HAD A HIP REPLACEMENT, AND RETURNED TO THE FACILITY. OBSERVATION OF RESIDENT #500 WAS DONE ON 9/16/10 AT 8:30 A.M., IN THE DINING ROOM. THE RESIDENT WAS IN HER WHEELCHAIR EATING BREAKFAST WITH THE ASSISTANCE OF STAFF. THE RESIDENT WAS UNABLE TO BE INTERVIEWED DUE TO DECREASED MEMORY AND COGITATION. REVIEW OF SOCIAL SERVICE NOTES DATED 8/4/09 THROUGH 4/27/10, REVEALED THE RESIDENT HAD BEEN EXTREMELY AGITATED, WANDERING IN OTHER RESIDENTS ROOMS, ATTEMPTING TO ELOPE FROM THE FACILITY, AND COMBATIVE WITH CARE. REVIEW OF THE PSYCHIATRY NOTE DATED 12/11/08, REVEALED THE RESIDENT HAD FALLEN AT THE FACILITY ON 12/8/08, WHEN SHE ATTEMPTED TO GET OUT OF BED, AND HER SHOE LACES WERE NOT TIED. REVIEW OF THE HISTORY DATED 3/13/09, STATED "PRESENT ILLNESS: FALL 3/13 WITH RIB AND BACK PAIN". REVIEW OF THE FACILITY INCIDENT REPORT DATED 8/28/10 AND THE INVESTIGATION REPORT DATED 8/31/10, REVEALED ON 8/27/10 AT 9:10 P.M., RESIDENT #500 TRIPPED OVER ANOTHER RESIDENT'S WHEELCHAIR THAT WAS LEFT BY STAFF IN THE HALLWAY. THE resident sustained [REDACTED]. REVIEW OF THE NURSES NOTES DATED 8/27/10 AT 9:10 P.M., STATED "RESIDENT TRIPPED OVER FOOT/TIP BAR OF A WHEELCHAIR AND fell on TO R (RIGHT) KNEE, R HIP AND R ELBOW. ASSESSED RESIDENT ON FLOOR, C/O (COMPLAINED) PAIN IN R ELBOW, AND R LEG". REVIEW OF THE 72 HOUR NURSING CHARTING DATED 8/27/10, STATED "1-2 CM HEMATOMA (BRUISE) R (RIGHT) ELBOW, 10-12 CM HEMATOMA R KNEE, C/O PAIN IN UPPER LEG, NO BRUISING OR INJURY NOTED". REVIEW OF FACILITY PHYSICIAN ORDER [REDACTED]. REVIEW OF NURSES NOTES DATED 8/27/10 AT 11:30 P.M. TO 12:00 A.M., STATED "X-RAY COMPLETED, NTFD (NOTIFIED) DR OF X-RAY RESULTS, TRANSFER RESIDENT TO HOSPITAL R/T R HIP FX (FRACTURE)". REVIEW OF PHYSICIAN ORDER [REDACTED]. REVIEW OF THE HOSPITAL X-RAY REPORT DATED 8/28/10, STATED "FRACTURE OF RIGHT FEMORAL NECK (RIGHT HIP)". REVIEW OF THE HOSPITAL CONSULTATION DATED 8/28/10, STATED "THIS PATIENT IS AN [AGE] year-old FEMALE admitted THROUGH THE EMERGENCY DEPARTMENT AFTER A FALL IN AN EXTENDED CARE FACILITY. X-RAY HAS BEEN REVIEWED SHOWING A DISPLACED FRACTURE, WE WILL PROCEED AT THIS TIME WITH BIPOLOR ARTHROPLASTY OF THE RIGHT HIP". REVIEW OF THE HOSPITAL SURGICAL PROCEDURE NOTE DATED 8/28/10; REVEALED RESIDENT #500 HAD A RIGHT "BIPOLOR ARTHROPLASTY" (RIGHT HIP REPLACEMENT) DONE ON 8/28/10. AN INTERVIEW WAS DONE ON 9/16/10 AT 10:20 A.M., WITH #EM500 (WITNESSED RESIDENT #500 FALL OVER THE WHEELCHAIR). #EM500 REVEALED SHE WENT WITH THE NURSE (#EM800) WHEN SHE WAS GIVING A RESIDENT HER MEDICATION'S. #EM500 SAID RESIDENT #500 WAS FOLLOWING THEM DOWN THE HALL TO GIVE A RESIDENT HER MEDICATION'S. AS #EM500 WAS LEAVING THE RESIDENTS ROOM, SHE SAW RESIDENT #500 TRIP OVER THE ANTI-TIP BARS OF THE WHEELCHAIR, AND FALL ON HER RIGHT SIDE. #EM500 SAID SHE AND THE NURSE (#EM800) BOTH SAW THE WHEELCHAIR SITTING IN THE HALLWAY WHEN THEY WALKED DOWN THE HALL TO GIVE A RESIDENT MEDICATION'S, AND THEY BOTH WERE AWARE RESIDENT #500 WAS BEHIND THEM AND SHE NEEDED TO BE MONITORED AT ALL TIMES. #EM500 STATED "THAT'S WHY SHE WAS FOLLOWING US; WE HAD TO KEEP AN EYE ON HER". #EM500 REVEALED THE WHEELCHAIR THE RESIDENT TRIPPED OVER SHOULD HAVE BEEN PUT IN THE ACTIVITY ROOM WHEN NOT IN USE. THE CNA'S ASSIGNED TO THE HALL, SHOULD OF REMOVED THE WHEELCHAIR FROM THE HALL, AND PUT IT IN THE ACTIVITY ROOM TO ENSURE RESIDENT'S SAFETY. AN INTERVIEW WAS DONE ON 9/16/10 AT 1:35 P.M., WITH THE CHARGE NURSE (#EM800) ASSIGNED ON 8/27/10, TO THE HALL THE RESIDENT WAS ON. #EM800 REVEALED THE WHEELCHAIR RESIDENT #500 TRIPPED OVER SHOULD NOT HAVE BEEN LEFT IN THE HALLWAY; IT SHOULD HAVE BEEN PUT IN THE ACTIVITY ROOM. WHEN THE SURVEYOR ASKED WHO WAS RESPONSIBLE FOR MAKING SURE WHEELCHAIRS ARE NOT LEFT IN HALLWAYS, #EM800 STATED "IT'S IMPLIED THAT THE CHARGE NURSES FOLLOW-UP ON WHEELCHAIRS LEFT IN THE HALLWAYS". AN INTERVIEW WAS DONE ON 9/20/10 AT 10:00 A.M., WITH #EM600 (ON 8/27/10, CNA ASSIGNED TO THE HALL THE RESIDENT WAS ON). #EM600 REVEALED SHE WAS HALL PARTNER WITH #EM700 (ON 8/27/10, CNA ASSIGNED TO THE HALL THE RESIDENT WAS ON). #EM600 STATED "WE WERE BUSY THAT NIGHT, ME AND (#EM700) PUT (A RESIDENT) TO BED WITH THE HOYER (MECHANICAL LIFT). WE PUT HER WHEELCHAIR IN THE HALL. WE GOT SIDE TRACKED TO (ANOTHER RESIDENT), SHE NEEDED TO BE CHANGED AND TURNED. AFTER WE WERE DONE, WE WERE TAKING OTHERS WHEELCHAIRS'S AND THE SOILED LINEN DOWN. THE WHEELCHAIR (THE WHEELCHAIR RESIDENT #500 TRIPPED OVER) WAS THERE (LEFT IN THE HALLWAY) ABOUT 1 AND A 1/2 HOURS. WE WERE DOWN AT THE NURSES STATION (DOWN THE HALL, OUT OF SIGHT OF THE WHEELCHAIR) DOING CHARTING IN THE ADL (ACTIVITIES OF DAILY LIVING) BOOK, ME AND #EM700. WE WERE TALKED TO ABOUT IT, AND WE WENT OVER THE SAFETY RULES (THE NURSE MANAGER AND THE TWO CNA'S). WHEELCHAIRS ARE TO BE PUT IN THE ACTIVITY ROOM. I THINK THE FALL COULD HAVE BEEN PREVENTED, IT SHOULD NOT OF HAPPENED". AN INTERVIEW WAS DONE ON 9/20/10 AT 9:40 A.M., WITH #EM700. #EM700 REVEALED ON 8/27/10, #EM600 AND HER WERE HALL PARTNERS. #EM700 STATED "WE PUT (THE RESIDENTS WHO'S WHEELCHAIR WAS LEFT IN THE HALL) IN THE HOYER AND PUT HER WHEELCHAIR OUTSIDE THE ROOM, BY THE EXIT DOOR. (#EM300/NURSE MANAGER) TALKED TO ME ABOUT WHAT HAPPENED". INTERVIEWS WERE DONE ON 9/16/10 (AT 10:00 A.M. AND 2:45 P.M.), WITH #EM300 (NURSE MANAGER) AND THE DIRECTOR OF NURSING (DON). THE DON AND #EM300 BOTH AGREERED THE STAFF SHOULD NOT HAVE LEFT THE WHEELCHAIR IN THE HALLWAY, THEY SHOULD HAVE PUT IT IN THE ACTIVITY ROOM WHEN IT WAS NOT IN USE. THE DON AND #EM300 SAID THE RULE IS TO STORE WHEELCHAIRS IN THE ACTIVITY ROOM WHEN NOT IN USE, " IT'S A NON-WRITTEN SAFETY RULE". REVIEW OF ADMISSION NURSING assessment dated [DATE], INTERDISCIPLINARY COMPREHENSIVE ADL FUNCTIONAL REHABILITATION assessment dated [DATE], AND THE MONTHLY SUMMARY DATED 3/17/10, REVEALED RESIDENT #500 WAS INDEPENDENT WITH TRANSFERS AND AMBULATION, WITHOUT SUPPORTIVE DEVICES PRIOR TO HER FALL ON 8/27/10. THE RESIDENT WAS readmitted TO THE FACILITY AFTER HIP REPLACEMENT A 2 PERSON ASSIST, WITH THE USE OF A WALKER FOR TRANSFERS, WITH CONSTANT RIGHT HIP PAIN, AND ORDERS FOR TRANSFER AND WALKING THERAPY TRAINING. REVIEW OF THE FALL RISK ASSESSMENTS DATED 9/22/09, 12/8/09, AND 8/19/10, REVEALED RESIDENT #500 WAS EVALUATED BY THE FACILITY TO BE "#14". REVIEW OF THE FALL RISK assessment dated [DATE], REVEALED THE RESIDENT WAS " #21 ". THE FALL RISK ASSESSMENT SAID IF A PRESIDENT'S SCORE IS 10 OR GREATER, THEY SHOULD BE CONSIDERED AT A "HIGH RISK FOR POTENTIAL FALLS". REVIEW OF THE FACILITY SAFETY RISK CARE PLAN DATED 9/22/09 AND RESIDENT ADL CARE PLAN (UN-DATED), REVEALED THE FACILITY WAS TO "MONITOR THE RESIDENTS WHERE ABOUT'S CONTINUOUSLY". REVIEW OF THE FACILITY FALL PREVENTION POLICY DATED 3/03, UP-DATED 2/9/07, STATED "IT IS THE RESPONSIBILITY OF ALL STAFF TO OBSERVE AND SUPERVISE RESIDENTS WHEREABOUTS AND THE SAFETY OF THE RESIDENT. WHEN DOING DAILY ROUNDS THE ENVIRONMENT WILL BE ASSESSED TO BE FREE OF HAZARDS AS POSSIBLE BY THE ENVIRONMENT TEAM". ( )