Every finding on record at Evergreen Health and Rehabilitation Center

This citation pertains to Intake Number: 3030704Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety and maintain the kitchen in a sanitary manner. This deficient practice has the potential to result in foodborne illness to all residents who consume food from the kitchen.Findings include:On 8/24/26 at 8:55 AM, an initial observation of the kitchen was conducted with Dietary Manager (DM) 'J'. DM 'J' was assisting at the facility and was employed by a sister facility. The following was observed:The hand washing sink between the area where the three-compartment sink was located and the cooking area, did not have a trash receptacle that was accessible without touching it. The foot pedal on the trash receptacle did not work to open the top of the trash can. In the walk-in refrigerator, a five-pound opened container of sour cream was labeled with an opened date of 8/11/26. According to DM 'J', dairy products were discarded seven days after opening. A container of grated parmesan cheese was labeled with an open date of 8/14/26. An opened one-gallon container of French-style salad dressing was labeled with an opened date of 6/26/26. According to DM 'J', salad dressing was discarded 30 days after opening.On 8/24/26 at 10:20 AM, additional observations of the kitchen were made. In the dishwashing area, a broken tile was observed near the floor drain. The broken tile was filled with cloudy water, trash, and food debris. The floor drain was observed to have a large amount of trash inside of it. On 8/24/2026 at 11:35 AM, an observation of food preparation and the tray line for lunch service was observed. Dietary [NAME] (Cook 'M') was observed taking temperatures of already cooked food. [NAME] 'M' was taking the temperature of a container of Loaded Turkey Chili. [NAME] 'M' continued to take the temperature of other prepared and cooked foods prior to putting them on the steam table. [NAME] 'M' took the temperature of pureed chili which was 125 degrees Fahrenheit. [NAME] 'M' said they had to put it into the steamer to heat it up more. [NAME] 'M' used the same thermometer without sanitizing it and placed it into the container of green beans. [NAME] 'M' continued taking temperatures of other foods (vegetarian chili, steamed carrots, and hot dogs) without cleaning the thermometer between each food.An observation of the drain to the side of the kitchen cooking/prep area was observed to have large amounts of solidified yellow colored grease inside of it. Do you know where to find the org chart for our bureau? At 11:56 AM and 12:03 PM, [NAME] M' continued to take food temperatures without cleaning the thermometer. [NAME] 'M' was observed to take the temperature of one food, wipe the thermometer on their apron and put it into the next food. At that time, Assistant Dietary Manager (ADM 'L' ) instructed her to use an alcohol wipe.On 8/24/26 at 12:08 PM, at the start of the tray line for lunch service, foods such as chicken, mashed potatoes, gravy, and hamburgers were observed in the steam table. [NAME] 'M' was asked what their temperatures were prior to putting them on the steam table since those food temps were not observed, [NAME] 'M' said she did not write them down and had them in her head. On 8/24/26 at 12:34 PM, [NAME] 'M' was observed to wash their hands at the hand-washing sink. [NAME] 'M' turned the faucet off with their clean, bare hands, and then dried them with a clean paper towel instead of using the paper towel to turn off the faucet after drying their hands.On 8/25/26 at 7:36 AM, an interview was conducted with the Administrator. The Administrator reported they were made aware of the concerns in the kitchen with sanitation of the thermometer between taking food temperatures, disposal of expired foods, and the lack of cleanliness of the drains. The Administrator acknowledged there was work to be done in the kitchen to make improvements. The Administrator reported if drains were not clean, they should be cleaned per the schedule but also as needed if they were dirty. According to the 2022 Food and Drug Administration (FDA) Food Code section 2-301.12, .Cleaning Procedure. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under S 5-202.12 and Subpart 6-301. P (B) FOOD EMPLOYEES shall use the following cleaning procedure in the order stated to clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands and arms: .(5) Immediately follow the cleaning procedure with thorough drying using a method as specified under S 6-301.12. P (C) TO avoid recontaminating their hands or surrogate prosthetic devices, FOOD EMPLOYEES may use disposable paper towels or similar clean barriers when touching surfaces such as manually operated faucet handles on a HANDWASHING SINK or the handle of a restroom door.According to the 2022 FDA Food Code section 3-501.17, .Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.According to the 2022 FDA Food Code section 4-602.11, .Equipment Food-Contact Surfaces and Utensils. (A) Equipment food-contact surfaces and utensils shall be cleaned: (4) Before using or storing a FOOD TEMPERATURE MEASURING DEVICE.According to the 2022 FDA Food Code section 6-501.12, .Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean.A review of a facility policy titled, Trayline Food Temperatures, revised 8/1/24, revealed, in part, the following, .Use cleaned and sanitized thermometer, sanitizing between each use to avoid cross contamination.

Based on observation, interview and record review, the facility failed to follow infection control practices related to Transmission Based Precautions, Enhanced Barrier Precautions, and hand hygiene for four residents (R14, R1, R79, and R177) of four residents reviewed for infection control. Findings include:On 8/24/26 at 1:00 PM, R1's room door was observed to have a sign that indicated they were on contact isolation precautions, which required staff to don an isolation gown, and gloves prior to entering the room. On 8/24/26 at 1:02 PM, an observation of lunch tray delivery on the 100 unit was conducted. At that time, Certified Nurse Aide (CNA) 'G' was observed to enter R1's contact isolation room with a lunch tray. CNA 'G' was not observed to don an isolation gown or gloves prior to entering the room. Once in the room, CNA 'G' was observed from the hallway to set up R1's meal. CNA 'G' then exited the room, went to the meal cart in the hallway and grabbed another meal tray. CNA 'G' was not observed to perform hand hygiene after exiting R1's isolation room. CNA 'G' then took the second meal tray and delivered it to R79's room. CNA 'G' was observed from the hallway setting up R79's tray and exiting the room, they were not observed to perform hand hygiene after exiting. CNA 'G' then proceeded to the cart and grabbed a third meal tray and delivered it R177's room down the hallway. On 8/25/26 at 3:30 PM, an interview was conducted with the facility's Director of Nursing. They were made aware of the observations of CNA 'G' entering and exiting resident rooms (including a contact isolation room) without donning PPE (personal protective equipment) or performing hand hygiene and they said PPE should have been donned, and hand hygiene should be performed after exiting every room. A review of a facility provided policy titled, Infection Control-Standard and Transmission-Based Precautions reviewed 2/2026 was conducted and read, .Contact precautions include: Hand hygiene (hand washing with soap and water or use of an alcohol-based sanitizer) Personal protective equipment (PPE): Gloves-apply before entering and remove before leaving the resident's room and perform hand hygiene. Gown-Apply gown upon entering and before leaving the resident's room and perform hand hygiene . R14 On 08/24/2026 at 9:42 a.m., R14 was observed in their room, laying in their bed. R14 was observed to have a low air loss mattress and was asked if they had any wounds and R14 indicated they had a wound on their backside. R14 was asked if staff had worn gowns when providing care to them and they indicated they had not. R14's door was observed to not have any signage indicating staff were to utilize enhanced barrier precautions (EBP) when providing care that involved direct contact. On 8/25/2026 at approximately 8:47 a.m., R14 was observed in their room, lying in their bed. R14's room still did not have any EBP signage/instructions on their door that indicated the staff should have been utilizing EBP when providing care for R14. R14 was asked if staff had put on gowns when providing care to them the previous day and reported they did not. On 8/24/26 the medical record for R14 was reviewed and revealed the following: R14 was initially admitted to the facility on [DATE] and had diagnoses that included Pressure ulcer of sacral region and Protein Calorie-Malnutrition. A review of R14's MDS (minimum data set) with an ARD (assessment reference date of 8/9/26 revealed R14 needed assistance from facility staff with most of their activities of daily living. A review of R14's Physician orders did not reveal any orders for Enhanced Barrier Precautions. A review of R14's comprehensive plan of care did not reveal any interventions for Enchanted Barrier Precautions as part of their plan of care. A skin issues note dated 8/4/26 revealed the following: Skin Issue: #001: New skin Issue. Location: Sacrococcygeal. Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcer staging: Unstageable pressure ulcer / injury. (full-thickness wound where dead tissue completely covers the wound bed, preventing clinicians from determining its true depth and severity.) Unstageable ulcer due to slough ( tissue that is soft, moist, and often cream, yellow, tan, gray, green, or brown in color) and / or eschar (tissue that is dry, hard, leathery, and typically black or brown.) Wound was present on admission. Length (cm -centimeters): 1.64. Width (cm): 1.35. Depth (cm): 0.2 Area (cm2): 1.84 A skin issues note dated 8/24/26 revealed the following: Skin Issue: #001: Skin issue has been evaluated. Location: Sacrococcygeal. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure ulcer / injury. Wound was present on admission. Length (cm):1.03. Width (cm):. 1.43. Depth (cm) . On 8/26/26 at approximately 10:25 a.m., Infection Control Nurse Y (ICN Y) was interviewed pertaining to R14 not having any orders for enhanced barrier precautions. ICN Y indicated that they were informed of residents who had wounds by the wound care team and they were never made aware of R14's need for Enhanced Barrier Precautions until the previous afternoon on 8/25/26 by the Nurse Practitioner. ICY Y was queried if R14 should have had EBP as part of their plan of care and indicated R14should have had EBP due to their wound. On 8/26/26 a facility document titled Enhanced Barrier Precautions was reviewed and revealed the following: Policy Overview-The purpose of this policy is to provide guidelines for the use of enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. (MDROs) .Enhanced barrier precautions are an infection control interventions designed to reduce transmission of multidrug-resistant organisms .Enhanced barrier precautions involve gown and glove use during high-contact resident activities for residents know to be colonized with a CDC (Center for Disease Control) targeted MDRO (where contact precautions do not apply) as well as those residents at increased risk of MDRO acquisition, such as chronic wounds or indwelling medical devices .Wound-in relation to [EBP] .It refers to more chronic wounds with skin openings (s) that require a dressing including but not limited to: Stage 3,4 or unstageable pressure injuries Procedure-Residents admitted to the facility with or during their stay at the facility acquire a wound and/or an indwelling medical device will be place in enhanced barrier precautions. A Physician order is obtained .Enhanced barrier precautions signage will be posted on the door or wall outside of the resident's room. Gown and gloves will be available outside the resident room .

This citation pertains to intake(s): 2966229 & 2803135.Based on interview and record reviews the facility failed to complete Braden assessments per the facility policy, failed to accurately/timely implement wound orders and failed to ensure timely reporting of abnormal changes to wounds for two (R's 304 & 305) of three residents reviewed for pressure wounds. Findings include:R304A review of a complaint submitted to the SA documented a concern of a wound to have developed while inpatient at the facility.A review of the medical record revealed that R304 was admitted to the facility on [DATE] with diagnoses that included: a closed fracture and repeated falls. R304 was dependent on staff assistance for all activity of daily living (ADL). The resident was discharged from the facility on 6/26/25.A review of an admission Evaluation dated 5/20/25 at 3:39 PM, documented in part . Clinical Evaluation Integumentary (Skin). Left hip- Pressure- Stage II (partial-thickness loss of skin with exposed dermis). Coccyx- suspected DTI (Deep Tissue Injury- Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue).A review of an admission Braden assessment dated [DATE] at 3:39 PM, documented a Score of 17.0 At Risk. This was the only Braden assessment completed in the medical record.A review of a facility policy titled Skin and Wound Guidelines revised 2/4/26, documented in part . upon admission or readmission to the facility with a head-to-toe skin evaluation and completion of the Braden Scale for Predicting Pressure Sore Risk. Using the Braden Scale For Predicting Pressure Sore Risk., weekly X 3 after admission for a total of 4 weekly evaluations, then quarterly.Review of the progress notes revealed the following:A wound consultation note dated 6/1/25 at 11:55 AM, documented in part . Date of Service: 2025-05-27. Referred by medical team to consult regarding shoulder hip leg heel and facial coccyx wounds. left hip unstageable ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) 5.0 x 3.1 by UTD (unable to determine) minimal amount of serosanguineous drainage no clinical evidence infection surrounding tissue is intact base is covered with tight nonviable tissue. coccyx DTPI (deep tissue pressure injury) 6.4 x 3. 9 cm (centimeters) area of dark nonblanching tissue that is beginning to surface scant amount of serosanguineous drainage ( watery, clear, or slightly yellow/tan/pink fluid) no clinical evidence of infection open areas are granular. Assessments/Plans. Pressure ulcer of left hip, unstageable. Recommend treatment: Apply Medihoney cover with foam dressing change 3 time a week. Pressure-induced deep tissue damage of sacral region. Recommend treatment: Apply thin layer of Triad to entire area daily.On 5/28/25 at 11:46 PM, a Nursing note documented in part . Resident has an open area to coccyx. Ordered Triad paste and wound consult. Logged for dr. (doctor).Further review of the progress notes revealed a Medical Doctor (MD) examined R304 on 5/29/25 at 9:57 AM and noted . SKIN: heels soft, coccyx area not examined today. A Physician Assistant (PA) examined the resident on 5/30/25 at 9:22 AM and noted . Skin care: Continue decubitus ulcer precautions. Defer to IM (internal medicine) as well as wound care team. A D.O. (Doctor of Osteopathic Medicine) examine the resident on 6/2/25 at 2:13 PM and noted . Skin care: Continue decubitus ulcer precautions. Defer to IM as well as wound care team.A review of a wound consultation note dated 6/3/25 at 10:22 AM, documented in part . left hip unstageable ulcer. coccyx previous DTPI has now surfaced to a stage III (full-thickness loss of skin, in which subcutaneous fat my be visible in the ulcer and granulation tissue and rolled wound edges are often present) ulcer measuring 2.7 x 1.8 x 0.1 cm scant amount of serosanguineous drainage. Assessments/Plans. Pressure ulcer of left hip, unstageable. Recommend treatment: Apply Medihoney cover with foam dressing change 3 time a week. Pressure ulcer of sacral region, stage 3. Recommend treatment: Apply Medihoney cover with dry dressing change daily.A review of the June 2025 MAR (Medication Administration Record)/TAR (Treatment Administration Record) and Physician orders documented the Medihoney to be applied to the left hip and coccyx every day, despite the wound clinician order to have the medihoney applied to the left hip three times a week.A review of the record revealed no documentation on why the wound clinician recommendation was not implemented.A review of a Wound consult dated 6/22/25 at 8:51 PM, noted a Date of Service: 2025-06-17 documented in part . Chief Complaint: Seeing patient regarding left hip and coccyx wounds. Pressure ulcer of left hip, unstageable. Recommend treatment: Apply Medihoney cover with foam dressing change 3 time a week. Pressure ulcer of the sacral region. Recommend treatment: Apply Medihoney cover with dry dressing change daily.A review of a Physician Team note completed by a NP dated 6/17/25 at 10:08 AM, documented in part . CHIEF COMPLAINT: Follow up pain. Pressure Ulcer to Coccyx, buttocks: Pt c/o (complaint of) pain to coccyx/buttocks. Has three areas to the coccyx and buttocks, coccyx has slough(non-viable yellow, tan, gray, green or brown tissue) covering the wound bed. Areas are sore with lying on back. Pt positioned off coccyx in bed, spoke to NM (Nurse Manager) about getting LALM (Low Air Loss Mattress).A review of the Physician orders revealed the low air loss mattress was implemented don 6/17/25. There was no documentation in the medical record on why this intervention was not implemented previously. R305A review of a complaint submitted to the State Agency (SA) documented concerns of R305's wound to have worsened while inpatient at the facility due to the lack of poor care.A review of the medical record revealed R305 admitted to the facility on [DATE] with diagnoses that included: chronic kidney disease and chronic systolic heart failure. R305 depended on staff assistance for all Activities of Daily Living (ADLs). R305 was discharged from the facility on 3/13/26.A review of an Admission assessment dated [DATE] at 10:37 PM, documented in part . Clinical Evaluation Integumentary (Skin). Left buttock. skin tear. Length- n/a (not applicable) . Width- n/a. Depth-n/a. Stage-N/A.A review of the only Braden assessment completed, dated 3/2/26 (four days after admission) documented a score of 18.0 At Risk.A review of the progress notes revealed the following:A Nursing note dated 2/26/26 at 10:19 PM, documented in part . A small open area was noted to the left buttock. Resident stated she was unaware of the open area. Wound care team has been consulted for further evaluation and management.A Physician note dated 2/27/26 at 12:22 AM, documented in part . Pressure sores L (left) buttock and coccyx, Stage 2-3, No signs of infection, Continue local care, offload. wound care.A Skin Issues note dated 3/3/26 at 3:29 PM, documented in part . Coccyx. Unstageable pressure ulcer/ injury. Unstageable ulcer due to slough and / or eschar (dead or devitalized tissue that is hard or soft in texture).A wound consult dated 3/4/26 at 3:29 PM, documented in part . Date of Service: 2026-03-03. Referred by medical team to consult regarding coccyx/left buttock wound. Skin: Extending from coccyx down left buttock unstageable ulcer 5.2 x 3.7 x 0.1 at the distal end UTD at the proximal end minimal amount serosanguineous drainage. necrotic proximal 50% . Assessments/Plans: Pressure ulcer of sacral region, unstageable. Recommend treatment: Apply thin layer of Triad to entire area daily.A review of a Wound consult dated 3/10/25 at 11:49 AM, documented in part . Assessments/Plans: Pressure ulcer of sacral region, stage 3. Recommend treatment: Apply Medihoney cover with dry dressing change daily.A review of the March 2026 MAR/TAR and Physician orders revealed the Medihoney treatment began three days later on 3/13/26.A review of the medical record revealed no documentation of the reason for the delay implementation of the wound treatment. Further review of the medical record revealed no documentation of identification of changes to the wound by the facility front line staff (nurses or aides), which were identified by the Wound clinician during their weekly consultations/examinations.On 4/6/26 at 3:01 PM, the facility's Wound Nurse (WN) E was interviewed and asked about their responsibilities in the facility. Included in the duties verbalized was the task of completing a second skin check for new admissions. WN E stated they also rounded with the Wound Clinician every Tuesday. WN E stated after rounding with the Wound Clinician they put all new and/or modified orders in the resident charts. WN E explained that the Wound Clinician makes the recommendations and they call the primary physician to confirm the orders and start them. When asked if any of the primary physicians have ever not followed the recommendations of the Wound Clinician, WN E responded . they never said no to the recommendations. WN E was asked about the Braden assessments for new admissions and when they should be completed and WN E stated they believed the protocol is to complete it upon admission and weekly after. WN E was asked if the staff identified changes or worsening of the resident wounds what the protocol was for the staff and WN E stated the staff should call the doctor to obtain an order and if they (WN E) are in the building they would assess the wound. WN E was then asked about the Braden assessments to not have been completed per the policy for R's 304 and 305, the delayed intervention of the low air loss mattress for R304, the identification of the wound change by a nurse on 5/28/25 for R304 and logged in the book for the doctor to see and was seen by multiple doctors after who did not assess the area, until assessed by the Wound Clinician almost a week later. WN E was asked about R304's wound hip order that was noted on 6/3/25 and was supposed to be three times a week but implemented once a day. WN E was also asked about R305's Medihoney treatment ordered for the coccyx on 3/10/26 and started three days later on 3/13/26. WN E stated they remembered the Medihoney treatment order for R305 and stated when they rounded with the Wound Clinician that week, the Wound Clinician gave them the directive to continue the Triad. WN E stated when they received the consult back from the Wound Clinician they reviewed it and saw that they documented for the treatment to change to Medihoney. WN E stated they called the Wound Clinician to confirm the course of treatment and the Wound Clinician replied they forgot to let them know that they wanted to change it. WN E stated they changed the order after the phone call to reflect the correct course of treatment. WN E stated they would look into the other concerns and follow back up.On 4/6/26 at 3:56 PM, the DON was interviewed and the same concerns noted above was discussed with the DON. The DON was asked if they had any information or documentation to provide regarding the concerns. The DON stated they would look into the concerns and follow back up. The DON was asked what staff should do if they identified abnormal changes to a wound and the DON stated they should call the Physician.On 4/7/26 at 9:49 AM, an interview was conducted with the Wound Clinician (WC) F. WC F was asked about the multiple noted delays of their wound consultations being implemented into the medical records, days after they had consulted with the residents'. WC F stated they have 48 hours to get their note into the residents' medical record. When asked how staff are expected to timely implement the new and/or modified treatments for the residents, WC F stated they provide the staff with a sheet of the recommendations on the day of consultations. WC F was asked the expectations if staff identified abnormal changes to the resident wounds and WC F stated the staff has their phone number and that they would usually call them. When asked if they had any additional information they would like to provide for review, WC F stated they would like to be honest- WC F stated they were unsure on why they had not implemented a low air loss mattress for R305 prior to the NP identifying it, however stated the internal medicine physician works alongside them as a team and had implemented it.On 4/7/22 at 4:22 PM, prior to the exit conference the DON was asked if they had any additional information to provide. The DON left and returned with an order placed for R304 for the Triad paste implemented on 5/28/25. The DON stated a facility wide audit had begun regarding the Braden assessments. No further explanation or documentation was provided.

This citation pertains to intake: 2809647.Based on observation, interview and record review the facility failed to conduct a thorough investigation for a staff to resident abuse allegation and failed to protect the alleged victim (resident) while the investigation was conducted for one (R303) of three residents reviewed for abuse. Findings include:A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) on 3/17/26 at 12:46 AM, documented in part . Resident told a staff member that over the weekend they were abused by someone. Immediately the administrator was notified a statement was collected from which the resident identified a staff member that was immediately suspended pending investigation. Nursing Supervisor conducted a skin assessment on residence no concerns were noted. Increased supervision was instituted for the resident's assuring safety throughout the night. Resident stated they feel safe at center, and no psychosocial conditions noted.A review of the investigation summary submitted to the SA on 3/24/26 at 8:59 PM, documented in part . On 3/16/2025 at around 10 pm (R303 name) stated that on the midnight shift- around 11pm that a CNA (Certified Nursing Assistant) came into his room with 2 pillows hitting swinging them at him. He stated that the CNA also threw water at him. Administrator and <sic> collected a statement from the residents. CENA (Certified Nursing Assistant- CNA A name) was suspended till a full investigation was completed . All residents who were assigned to (CNA A name) on 3rd shift on 3/15/2026 were interviewed. No one reported any issues regarding care and or CENA behavior. No issues identified. On 3/20/26 at around 1 pm Administrator (name) and nurse manager (name) LPN (Licensed Practical Nurse) interviewed (R303 name). The resident was resting in bed. He was alert and able to answer questions. Based on investigation facility unsubstantiated mistreatment/abuse.A review of R303's medical record revealed they were admitted to the facility on [DATE], with diagnoses that included mild cognitive impairment, disorientation and required staff assistance for all Activities of Daily Living (ADLs).On 4/6/26 at 10:11 AM, an observation was made of R303 lying on their back in bed receiving care from an aide. Once care was completed an interview was conducted with R303. R303 denied any mistreatment or any staff to have ever hit them. When specifically asked about the incident, R303 denied that anything like that had ever occurred. The resident stated that they were currently in England and in the middle of a war. When asked, R303 stated they felt safe where they were because . I have big bullets and I will hit back and they know that.On 4/6/26 at 10:26 AM, a request was made to the Administrator and Director of Nursing (DON) to provide the complete investigation for the incident with R303 and CNA A and the time sheets for CNA A for the month of March 2026.A review of the investigation provided revealed the following:A statement completed by CNA C documented, . On Monday March 16, 2026 at approximately 7pm, I gave (R303's room mate name and room number) a bed bath. And at that time, he began recalling events he heard going on next door, that happened over the weekend. (R303's room mate name) explained to me that he heard a CNA beating up on his neighbor. Upon hearing this I asked him to describe who he was referring to. He said that he heard (R303 name) yelling for help, but no help came. After finishing his bed bath, I reported what I was told to the supervisor. This statement was not dated to reflect when it was obtained.A statement completed by the Administrator documented, . 3/17/2026- Administrator requested that Nursing Management question competent resident on the (unit name) if they recalled any concerns from distressed residents over the past few days. This was based off the statement from (R303 name) regarding that he could hear multiple residents and staff stating while the staff member was attacking him with pillows why are you doing that? . Ma'am why are you doing that to him? . Don't hit him! The administrator had to attend a conference that week and stated he would follow up upon his return. 3/20/2026- (~12:45pm-1:15pm) meeting with (unit manager name- later identified as UM D- and unit name). Spoke with (unit manager name and unit name). The administrator asked her how her morning rounds went. Unit Manager (name) stated that no concern were noted from residents on (unit name) regarding (R303 name) situation during her rounds throughout the week. (Unit manager name) went on to explain that competent residents (four residents listed) did not mention anything regarding them witnessing or hearing a resident calling out in distress over the past few days during her .morning rounds. Unit Manager (name) and Administrator (name) then went to check in on (R303) together. I explained the reason for his visit was to check in on how he has been being treated during his stay at the center. (R303 name) stated '.staff treat him well and she <sic> has no concern/complaints of care'. The administrator and Unit Manager continued to chat with residents that if he had any issues with quality or care or wrongful doing/treatment that he could tell us. (R303 name) acknowledged stating if anything come to mind Ill make sure to tell you or (unit manager name). Signed by the Administrator and dated 3/20/2026.The investigation did not contain resident statements, nor did it contain interviews and/or assessments from the residents that was assigned to CNA A on the shift that the allegation was made.Further review of the documentation provided revealed CNA A worked in the facility on the following dates and times:3/15/26 - 11:16 to 7AM3/16/26- 3:00 PM to 11:20 PM and there is also a punch for 11:21 PM to 7AM3/17/26- 3:00 PM to 11:00 PM3/19/26- 3:00 PM to 7:00 AM3/21/26- 3:16 PM to 10:54 PMShortly after being provided the documentation- the dates and times were reviewed with the Administrator who stated although CNA A timesheet revealed they were on duty during the investigation, they were not. The Administrator explained that the facility modified the timesheet to pay CNA A during the investigation due to the findings to have been unsubstantiated. The Administrator was asked to provide the time correction sheets or documentation from the responsible department to verify the reason, dates & times that the time punches were modified. No additional documentation was provided to confirm the Administrator explanation regarding CNA A timesheet by the end of the survey. A review of the progress notes revealed the following:On 3/16/26 at 6:02 AM, a Nursing note documented in part . Resident is combative this morning. Resident stating that staff was trying to hurt him. Writer tried to de-escalate resident, but resident picked up TV remote and swung on writer. Resident felt more comfortable with other nurse and allowed her to clean him up.On 3/17/26 at 5:19 AM, a Nursing note documented in part . spoke with Medical Director. regarding res (resident) c/o (complaints of) tenderness to right inner aspect of right eye.On 3/17/26 at 12:47 PM, a Nurse Practitioner (NP) note documented in part . seen for evaluation of change in behavior, pt (patient) agitated, confused, accusing staff of harming him. R (right) eye pain; pt c/o (complained of) pain to the R eye, Xray negative.On 3/18/26 at 3:12 PM, a Social Work (SW) note documented in part . Resident stated he has not been sleeping well because he does not feel safe. Resident stated he thought he saw the person last night come into his room. SW did explain to resident that the person is not in the building so he will not see that person. Resident stated that makes me feel better, hopefully my sleep will improve, he stated. SW asked if he would like to speak with the psychologist, resident stated yes. SW will arrange. Resident thanked SW for speaking with him and making him feel a little better.On 3/21/26 at 3:08 PM, a Psychologist note documented in part . There is a history of dementia. When he did not mention the alleged incident, he was asked about it. He said he remembered 'a woman in a white uniform hitting me with a pillow' on the right side of his face. He said he yelled, 'Stop hitting me'- and 'other people also yelled' for her to stop. He said he 'tried to push the wheelchair to stop her', noting, 'There was a crowd that came to my rescue', He said he had not seen the individual since the alleged attack.On 4/7/26 at 12:06 PM, a telephone interview was conducted with CNA A. CNA A stated they were trying to change R303 and the resident attempted to hit them with a remote. CNA A stated they went to get the nurse and remembered another nurse having to step in. CNA A denied any previous incidents or any further incidents to have occurred between them and R303 since that day. CNA A stated they were informed the next day that they were suspended from the Administrator and a Unit Manager. CNA A explained the day after they were suspended they came to the facility to talk to the DON (Director of Nursing). CNA A stated she was provided an education and was told the investigation is over and they could return back to work.On 4/7/26 at 11:30 AM, the Administrator was interviewed and asked what day CNA A was suspended. The Administrator reviewed the time sheet and replied that CNA A was suspended on the 16th. The Administrator stated CNA A came in on Tuesday to meet with the DON. When asked how long CNA A was suspended and what day they returned, the Administrator stated that CNA A returned on 3/21/26. The Administrator again explained how although the time sheet revealed that CNA A was in the building working during the investigation, they were not. The Administrator was again asked to provide documentation to confirm.On 4/7/26 at 12:03 PM, the Administrator was asked about the statement obtained from the reporting CNA that documented what R303's roommate overheard and asked if they took that statement into consideration and interviewed the room mate due to no statement from the roommate found in the investigation provided. The Administrator was also asked again for any statements/assessments obtained from the residents that was assigned to CNA A during the shift of the alleged allegation. The Administrator stated they believed they had something and would follow back up.On 4/7/26 at 12:45 PM, an observation of R303's roommate was made. R303's roommate was observed lying on their back in bed listening to their mobile device. When specifically asked about the alleged incident between their roommate and CNA A, they stated . I can't remember. I kind of forgot. I can't really recall. An interview was conducted further and before leaving the resident room, the roommate was asked one more time about the incident and stated . I really don't remember what I said.On 4/7/26 at 1:35 PM, an interview was conducted with UM D. UM D was asked their involvement in the alleged abuse investigation that involved R303 and CNA A. UM D explained they were notified by a CNA of the incident when they were home. UM D explained they came back to the facility and conducted a head to toe assessment on R303 and left. UM D explained that the Administrator was in the building when they returned to complete the assessment. UM D could not recall the date they returned to the facility. UM D was asked to look at their phone log and identify the date the CNA had called them to inform them of the incident and UM D explained they had just purchased a new phone. UM D stated that while on duty the next day they followed up with R303 and asked him what happened. UM D stated R303 gave them the description of the CNA and they knew immediately who the CNA was based on the description. UM D then went on to say . he (R303) has never made an allegation against staff that I know of before. Combative with care but he had never made an allegation against staff.On 4/7/26 at 3:46 PM, an interview was conducted with the Administrator and DON (with the Regional Clinical Service Director - RCSD B in attendance. All were asked who conducted the investigation for the alleged abuse and the Administrator responded that they completed the investigation. The Administrator was asked why there was no statement obtained from R303's roommate and asked about statements and/or assessments of the other residents' assigned to CNA A on the shift of the alleged incident. The Administrator stated . I actually was about to email you about a couple of statements. The Administrator was asked why the statements were not provided when the initial request for the full investigation was made on 4/6/26 and thereafter with the additional requests. The Administrator stated they thought it was included in the file. When reminded that additional requests was also made earlier in the day (4/7/26) to provide the documentation for review, they had not. The Administrator was then asked when the investigation was completed and stated it was actually completed when the five day was (five day submission to the SA). The Administrator was asked how CNA A was allowed to return to work the next day after being suspended, while the investigation was ongoing and no explanation was provided. The Administrator left the room to provide the additional statements that they had on their computer.During the exit conference of the survey on 4/7/26 at 4:31 PM, two additional statements were provided. One was the Administrator statement, which was reviewed during the survey and noted above and the other was a statement obtained from R303 on 3/16/26 at 10:10 PM through 11:00 PM.A review of a facility policy titled Abuse updated 5/24/23, documented in part . Residents have the right to be free from abuse. mistreatment. The facility supports and protects patients. from harm during an investigation of alleged abuse including retribution and retaliation. If a staff member is the alleged perpetrator, that staff member should be immediately removed from the facility and the schedule pending the outcome of the investigation. Once reported, the center conducts a timely, thorough, and objective investigation of any allegation of abuse.Identifying and interviewing all involved persons, including the alleged victim. witnesses. Conducting observations of the alleged victim interactions and relationships between staff and the alleged victim and/or other residents. Providing complete and thorough documentation of the investigation. After completion of the investigation, the evidence should be analyzed, and the Administrator. will make a determination regarding whether the allegation is substantiated or unsubstantiated.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: 09/09/2025 between 9:00 AM-9:30 AM, during an observation of the kitchen with Certified Dietary Manager (CDM) E, the following items were observed: In the walk-in cooler, there were opened, undated containers of ranch dressing, vinegarette dressing, and thousand island dressing. CDM E confirmed the items should have been dated when opened.According to the 2022 FDA Food Code section 3-501.17: Ready-to-eat, potentially hazardous food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of 7 days. Refrigerated, ready-to- eat, potentially hazardous food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.There was a personal cellular phone on the food preparation counter. When queried, CDM E stated it should not have been there. According to the 2022 FDA Food Code section 3-307.11 Miscellaneous Sources of Contamination, Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. There were 5 spatulas hanging on the utensil rack, with rough edges, and missing pieces around the spatula edges. CDM E stated he would throw them out and order some new ones. According to the 2022 FDA Food code section 4-202.11 Food-Contact Surfaces, (A) Multiuse food-contact surfaces shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; (4) Finished to have smooth welds and joints; On 9/9/25 at 9:00 AM, there was a package of deli ham located on the food preparation counter. On 9/9/25 at 11:40 AM, the package of deli ham was in the same spot on the food counter. The internal temperature of the ham was measured to be 71 degrees Fahrenheit.According to the 2022 FDA Food Code section 3-501.16 Potentially Hazardous Food (Time/Temperature Control for Safety Food), Hot and Cold Holding, 1. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, potentially hazardous food (time/temperature control for safety food) shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5 C (41 F) or less.

Based on interview and record review, the facility failed to ensure quarterly health care conferences were conducted for one (R154) out of one resident reviewed for care conferences. Findings include:The facility policy titled, Care Conferences (Revised -3/10/25) was reviewed and documented, in part: .Policy: It is the policy of the facility to offer Care Conferences to residents and authorized representatives on admission, quarterly, with significant change condition, and any time the resident and/or authorized representative requests a care conference.The Social Service employee, or assigned designee, will invite the resident and authorized representative to a care conference.The authorized representative may request a join the care conference via phone or virtual method if they are unable to attend in person.A review of R154's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: dementia with agitation, psychotic disorder with delusions and chronic kidney disease. A review of the residents Minimum Data Set (MDS) noted they had a Brief Interview for Mental Status (BIMS) of 0/15 (severely cognitively impaired). The resident was noted as FULL CODE and had a court appointed guardian.A copy of a letter dated 3/17/25 authored by Dr. D and addressed to R154's Guardian was reviewed. The letter noted that based on R154's medical decline the Guardian should consider changing R154's FULL CODE status to DNR (do-not-resuscitate). Continued review of R154's clinical record showed no additional notes that indicated the Guardian responded to the letter and/or any follow-up was conducted including a care conference.Continued review of R154's clinical record revealed that the last quarterly health care conference was held on 3/19/25. The conference document noted, in part, the following: .Advanced Directives were identified, clarified, and reviewed with resident legal representative.Do Advance Directives need to be updated? NO.Conference Summary: Guardian declined care conference.Attendance: Social Worker. Activity Director.On 9/10/25 at approximately 12:03 PM, an interview was conducted with Social Worker Director SW B . SW B was queried about R154's and follow-up regarding considering a change in code status and contact with the Guardian. SW B reported they started working at the facility in May 2025 and they would review the residents record to discuss the concern. *It should be noted that documents were provided but none of them referred to social service follow-up and/or scheduled care conferences.On 9/11/25 at approximately 11:18 AM, a phone interview was conducted with Guardian Case Worker C. GCW C was asked if they ever received a letter from the facility that indicated they should consider changing the resident's code status and/or had they been made aware of any care conferences in 2025. During the phone interview GCW C reviewed R154's file and noted that they had never been asked to join a care conference in 2025. Further, they noted that they did not receive a letter in 2025 asking the Guardian to consider changing the residents' code status.On 9/11/25 at approximately 11:26 AM, a follow-up interview was conducted with SW 'B . When asked how often health care conferences should be conducted, they reported quarterly. SW B agreed that a quarterly care conference should have been scheduled for R154.

Based on observation, interview, and record review, the facility failed to ensure tube feeding and water flushes for hydration were administered per physician's orders for one resident (R23) of one resident, resulting in the potential for unmet nutrition and hydration needs. Findings include:On 9/9/25 at 9:59 AM, R23 was observed in their bed asleep. A tube feeding pump on a pole was observed at the bedside. There was no tube feeding formula bottle or water bag for hydration on the pole attached to the pump. On 9/9/25 at 11:40 AM, a second observation of R23 was conducted and the tube feeding pump and pole remained with no tube feeding bottle or water for hydration. On 9/9/25 at 11:57 AM, a review of R23's physician's orders for tube feeding was conducted and revealed an order dated 6/28/25 for Jevity 1.5 tube feeding formula to be delivered at 75 mL (milliliters) per hour for 16 hours and a water flush to be delivered at 85 mL an hour for 16 hours. The order further indicated the start time for the feeding formula and water was 8 PM and the stop time was 12 PM the following day. On 9/10/25 at 12:20 PM, R23 was observed in their bed asleep. An observation of the pump revealed the amount of tube feeding and water delivered per administration was recorded and maintained as a value on the pump. A review of the values of tube feeding formula delivered to R23 for the administration on 9/8/25 to 9/9/25 was 756 mL and the amount of water recorded on the pump was 867 mL. Per the physician's orders, tube feeding delivered at 75 mL an hour for 16 hours indicated R23 should have received 1200 mL of tube feeding and water delivered at 85 mL an hour for 16 hours indicated R23 should have received 1,360 mL of water. On 9/10/25 at 1:40 PM, an interview was conducted with the facility's Director of Nursing. The observations of the tube feeding and water not being delivered to R23 on 9/9/25 at 9:59 AM and the recalled values from the tube feeding pump were shared with them and they said the physician's order should be followed and they would look into why R23 only received 759 mL of the formula and 756 mL of water. A review of a facility provided policy titled, was reviewed and read, .Feeding tubes will be utilized according to physician orders, which typically include: the kind of feeding and it's caloric value, duration, mechanism of administration, and frequency of flush .

Based on interview and record review, the facility failed to ensure lidocaine patches were available to administer for one resident (R6) of one resident reviewed for medication administration. Findings include: On 9/10/25 the medical record for R6 was reviewed and revealed the following: R6 was initially admitted to the facility on [DATE] and had diagnoses including pain in right leg and Chronic pain. A review of R6's comprehensive plan of care revealed the following: Focus-Risk for impaired comfort r/t (related to): Chronic pain, Resident has breakthrough pain, Dx (diagnosis) Hemiparesis 2/2 (secondary to) CVA (Cardiovascular accident) Date Initiated: 06/21/2024 .Interventions-Administer pain medication as ordered. Monitor for effectiveness. Date Initiated: 06/21/2024 . A Physicians order dated 4/24/25 revealed the following: Lidocaine Max St 24 Hours External Patch 4 % (Lidocaine) Apply to R (right) shoulder topically two times a day for Pain. A second Physicians order dated 7/9/24 revealed the following: Lidocaine HCl External Pad (Lidocaine HCl) Apply to bilateral knees topically two times a day for Knee Pain on 12 hours and off 12 hours. A review of R6's MAR (medication administration record) for August and September 2025 revealed the following dates in which R6 was not administered their lidocaine patches: 8/25, 8/26, 8/27, 8/28, 9/2, 9/6 and 9/7. A review of R6's EMAR progress notes for the administration of their lidocaine patches revealed the following: 8/25-on order (bilateral knees and R shoulder), 8/26-not available (bilateral knees and R shoulder), 8/27-on order (bilateral knees and R shoulder), 8/28-Not [NAME] (available) (bilateral knees and R shoulder), 9/2-not [NAME] (bilateral knees and R shoulder), 9/6-On order (bilateral knees), 9/7-NA (not available) (bilateral knees and R shoulder). On 9/11/25 at approximately 10:02 a.m. Nurse Manager A (NM A) was queried regarding R6's lidocaine patches not being available for administration and they indicated that the unit clerk is responsible for ensuring they have enough and that when they are low, they are supposed to be reordered so the facility does not run out. NM A was queried regarding the multiple days of missed administrations for both their bilateral knees and R shoulder and they acknowledged the concern and indicated the lidocaine patches should have been applied. On 9/11/25 a facility document titled Medication Administration was reviewed and revealed the following: To safely and accurately prepare and administer medication according to physician order, professional standards of practice, and resident needs .Administer medication in accordance with frequency prescribed by physician and standards of practice. If an over-the-counter medication is not available, check the medication storage area to replenish the stock and administer the medication. If a pharmacy supplied medication is not available, refer to the pharmacy policy and procedures related to emergency pharmacy delivery and emergency supply kit usage .

Based on interview and record review, the facility failed to ensure Physican ordered laboratory (labs) were obtained for one resident (R81) of one resident reviewed for laboratory diagnostics. Findings include:On 09/09/2025 the medical record for R81 was reviewed and revealed the following: R81 was last admitted to the facility on [DATE] and had diagnoses including Congestive heart failure and End stage renal disease. A Physician's evaluation dated 8/27/25 revealed the following: CC (chief complaint)- Follow up-Patient seen at bedside today, sitting at the side of the bed. Patient reporting bloating and increased plaque chills with gas, patient also is reporting being unable to tell if she is passing gas or stool, unsure of the patient's having fecal incontinence from history. Patient already on simethicone every 8 hours as needed we will schedule it for a few days and follow up patient also reporting having left hand tingling ever since her left arm procedure, possible nerve impingement, patient reports tingling in all 5 fingers we will get B12 folate and TSH (thyroid stimulating hormone) level continue to monitor. A Physician's order for the laboratory diagnostic dated 8/28/25 revealed the following: B12 (vitamin B12), Folate TSH. Further review of R81's medical record did not reveal any results of the B12, Folate TSH Physican order. On 9/111/25 at approximately 10:02 a.m., during a conversation with Nurse Manager A NM A was queried regarding missing lab results of the B12, Folate TSH lab ordered on 8/28/25. They reported the lab requisition was never completed and the lab was never done. NM A reported they would have to address the issue with the Nurse and that it would have to be reordered and completed. On 9/11/25 a facility document titled Laboratory Results revealed the following: The facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law .Labs not drawn as ordered are reported to the attending physician for further direction The staff will process test requisitions and arrange for tests

Based on observation, interview and record review, the facility failed to ensure assistive devices for eating were provided to one resident (R17) of 21 residents reviewed for dining. Findings include: On 9/09/2025 at approximately 11:51 a.m., R17 was observed in their room, laying in their bed. R17 was observed to have cognitive deficits when conducting initial pool interview and was unable to stay focused during the interview. On 9/10/25 at approximately 9:14 a.m., R17 was observed in their room, attempting to eat the breakfast meal. R17 had approximately one bite gone from their meal. At that time, A review of R17's meal ticket revealed R17 was to be provided built-up utensils with their meal tray. R17 was observed to have been provided standard silverware and no built-up utensils. On 9/10/25 at approximately 9:33 a.m., R17 was still observed in their room, attempting to eat the breakfast meal. R17 was still observed not to have been provided the built-up utensils. On 9/10/25 at approximately 9:47 a.m., R17 was still observed in their room, attempting to eat the breakfast meal. R17 was still observed not to have been provided the built-up utensils. On 9/11/25 at approximately 9:27 a.m., R17 was observed to have been provided their breakfast meal tray but it was left at the foot of their bed and out of reach of R17. On 9/11/25 at approximately 9:33 a.m., R17 was observed in their room, attempting to eat the breakfast meal. Another review of R17's meal ticket revealed R17 was still to have been provided built-up utensils with their meal tray. R17 was observed to have been provided standard silverware which they were not using, and no built-up utensils were present on the tray. On 9/11/25 at approximately 9:55 a.m., R17 was still observed in their room, attempting to eat the breakfast meal. R17 was still observed not to have any built-up utensils. At that time, the Nurse Manager A (NM A) was queried regarding the lack of built-up utensils for R17. NM A reviewed R17's meal ticket and reported that R17 should have been provided the built-up utensils and indicated that they would call down to the kitchen for the built-up utensils to be provided to R17. NM A reported the dietary department is responsible for ensuring the utensils are placed on the meal tray. On 9/10/25 the medical record for R17 was reviewed and revealed the following: R17 was initially admitted to the facility on [DATE] and had diagnoses including Protein-Calorie Malnutrition and Dysphagia. A review of R7's MDS (minimum data set) with an ARD (assessment reference date) of 8/22/25 revealed R17 had upper extremity impairment on both sides and needed assistance from facility staff with their activities of daily living. A review of R17's comprehensive plan of care revealed the following: Focus-Resident has an ADL (activities of daily living) self-care performance deficit related to: ADL abilities will fluctuate between therapy staff and nursing staff ROM (range of motion) impairments and contractures. Date Initiated: 11/14/2024 .Interventions-EATING: 1 person assist. Built up utensils with all meals. Date Initiated: 03/04/2025.A dietary nutrition review dated 5/21/25 revealed the following: Nutritional Quarterly-Resident is a [R17 demographics] residing at [name of facility] with primary dx (diagnoses) critical illness myopathy. PMHx (previous medical history) includes debility, seborrheic dermatitis, adult FTT (failure to thrive), bacteremia, heart failure, dysphagia, pulmonary embolism, anemia, moderate pcm (protein-calorie malnutrition), delayed milestone in childhood, and a-fib (atrial fibrillation). Diet order regular, puree texture, thin liquids (requires assistance w meals), unable to safely handle liquids, no new chewing/swallowing concerns, and . Remains on enteral nutrition as well to fully meet caloric and protein needs. TF (tube feeding) regimen as: Isosource 1.5 @ 85ml/hr (milliliters per hour) x 15 hours providing total 1913kcals, 88 g protein, 974ml FW (total 1800ml fluids w/ 55ml h2o flush x 13 hours). RD (Registered Dietician) observed resident at tableside, did not consume much of meal and was unable to efficiently answer dietary questions or preference updates- kept asking if she can go back to bed. RD did observe resident ability to use built up utensil and feed herself, however resident consumed roughly 1 tsp (tablespoon) and then put down. Resident will remain on TF to meet all nutritional needs with addition of prosource 30ml q daily for additional 15g protein, 60kcals to assist with increased needs. No edema noted. Skin buttock contains MASD (moisture associated skin damage) with scattered openings, L (left) flank with maybe nickel size opening per wound care. CBW (current body weight) 156lbs (pounds), 4/7 162.6lbs, 2/3 154.4lbs, 11/19 157.8lbs, weight has remained stable since admission with minor fluctuations. Dx (diagnoses) moderate malnutrition r.t (related to) temporal, clavicular, thigh, muscle wasting, and poor oral intake resulting in need for enteral nutrition to meet needs. Goal improve PO (by mouth) intake as able, TF tolerance, stable labs, open areas to show signs of healing, wt (weight) maintenance. Continue current dietary interventions, monitor PO intake, weights, and labs. Proceed to care plan.On 9/11/25 at approximately 12:52 p.m., during a conversation with Dietary Director F (DD F), DD F was queried regarding the lack of built-up utensils being provided to R17 according to their plan of care/meal ticket and DD F reported that they have a checking process to try to ensure the meal tickets are read and assistive devices for [NAME] are provided. DD F indicated they would have to talk with the dietary aides who did the tray checking to ensure the meal tickets are read correctly. On 9/11/25 a facility document titled Equipment and Assistive Devices was reviewed and revealed the following: The facility maintains and supervises the use of assistive devices and equipment for residents .Certain equipment and devices that assist with resident mobility, safety, and independence are provided for residents. These may include but are not limited to: Specialized eating utensils and adaptive equipment .The interdisciplinary team will work together to provide assistive devices and equipment to the resident. The facility will provide appropriate assistance to ensure that the resident can use the assistive device. This may include education or therapy sessions for training on the use of the device, set up assistance, supervision, or physical assistance as needed .

This citation pertains to intake: 2581302. Based on interview and record reviews the facility failed to accurately assess, timely report a change in condition to the Physician and timely transfer to a higher level of care, for one (R404) of three residents reviewed for a change of condition/timely transfer to the hospital. Findings include:A review of a complaint submitted to the State Agency (SA) documented in part . resident fell out of his bed at 5am. the facility staff did not evaluate resident and stated that the doctor would see him on Monday. Complainant states it took her until 4 or 5pm Saturday to finally get staff to call the EMS (emergency medical services) and have him sent to (hospital name). Complainant states resident was put in the intensive care unit at hospital with a fractured neck and hematoma in the brain. Complainant states at the time of fall, resident was recovering from a seven hour back surgery.A review of the medical record revealed R404 was admitted to the facility with diagnoses that included: critical illness myopathy, intervertebral disc degeneration, spinal stenosis, wedge compression fracture of second lumbar vertebra and unspecified fall. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition and required staff assistance for all activities of daily living. Review of the progress notes documented the following:On 8/2/25 at 6:36 AM, a Incident Note documented . Nurse called to room after CNA (certified nursing assistant) observed resident laying on the floor on the side of the bed near the window. Call light on and still in the bed. Resident wearing CPAP (continuous positive airway pressure) mask disconnected from the tubing, Bed remote hanging at the side of the bed. CNA responded to call light to witness resident on the floor. Stated he was trying to reach for the bed remote after it kept going up, Stated he slipped out of the bed. Nurse in to observe resident laying on the floor, Vitals obtained, ROM (range of motion completed), Hoyer obtained along with 4 staff members to assist resident off floor. Noted to left ear small skin tear 0.5cm (centimeters) x 0.5cm) with surrounding redness. To left forehead noted redness from abrasion. Resident stated he had some pain to the ear. No increase pain to the rest of his body. Neuro checks initiated. Bed to lowest level. (Doctor name) and wife notified. This note was documented by Licensed Practical Nurse (LPN) A. A Nursing note created on 8/3/25 at 12:54 AM and back dated to 8/2/25 at 7:42 AM, documented . resident was sent out to the hospital per family request. Resident vitals were within resident normal limits. Resident A&O x3 (alert and oriented times three) resident was sitting in his wheelchair watching tv when his wife came in stating they wanted CT scans (computed axial tomography scan) and MRI (Magnetic Resonance Imaging) done on resident. Np (Nurse practitioner) aware, resident had no change of condition throughout the shift, then he stated he was having difficulty turning his head left to right writer assessed the resident no abnormal findings at the time of assessment, wife demanded resident to be sent out. Resident was picked up 8/2/2025 @ (at) 7:30 via transportation (transportation name) to (hospital name) accompany <sic> by wife. This note was documented by LPN B. A review of the hospital record revealed the following:A review of a Emergency Medicine consult date of service 8/2/25 at 5:11 PM, documented in part . thoracic and lumbar fracture s/p (status post) T9-L3 posterior laminectomy and fusion (back surgery) on 06/27/2025 who presents to the Emergency Center today with fall at 5 am, left ear bruising and head injury. Patient has <sic> at (nursing home facility name) since the surgery. Patient does not ambulate. Was found on the side of the bed this morning, nursing facility did not want to bring him in. Patient then started developing left ear bruising. Wife came to visit him, made them (facility staff) called EMS. Patient remembers entire incident, did not lose consciousness. Resp (respirations) 34. Interventions: Cervical collar in place. Cervical back: Spinous process tenderness present. Incision and Drainage. Type: Hematoma. Head. L (left) external ear. Local infiltration. Incision types: Single straight. Drainage: Bloody. Wound left open. Vaseline packing, bulky dressing, and coban (self-adherent wrap with latex). Called by radiology as. suggesting possible small subdural hematoma no other foci of intracranial hemorrhage. Also found to have Evidence of minimally displaced acute multidirectional predominantly oblique fracture through the mid to inferior portion of the odontoid process extending into the lateral mass with questionable involvement of the posterior cortex. will get repeat head CT in the AM (morning). Ortho (Orthopedic) evaluated the patient, patient placed in Aspen collar. Trauma surgery consulted who evaluated the patient. Awaiting recommendations. Chief Complaint: FALL. Working Differential Diagnosis: Odontoid fracture (fracture of the neck), subdural hematoma (a type of bleeding near the brain), hematoma of left auricular region (collection of blood to outer left ear, resulting in swelling, pain, bruising and puffy appearance). Awaiting trauma surgery admission.A review of a Trauma Surgery History and Physical Evaluation Note dated 8/2/25 at 10:08 PM, documented in part. Chief Complaint: Trauma, fall from bed. on Coumadin (blood thinner medication). Trauma Surgery being consulted for trauma evaluation. CT head demonstrated a small left SDH (subdural hematoma) and CT c-spine demonstrated an odontoid fracture. Admit to SICU (surgical intensive care unit). Q2H (every two hours) neuro (neurological) checks. MRI c-spine to further assess injury. NPO (nothing by mouth) for now.A review of a Emergency Medicine consult dated 8/3/25 at 12:08 AM, documented in part . presents with a fall out of bed. He is on warfarin (blood thinner) for antiphospholipid syndrome (a condition in which the immune system mistakenly creates antibodies that attack tissues in the body) and history of pulmonary embolism (blood clot that blocks and stops blood flow to an artery in the lung). Workup found an odontoid process fracture and a small subdural hematoma. Auricular hematoma has been incised and drained, and dressed appropriately. Trauma surgery has been consulted and pending admission.A review of a facility incident report dated 8/2/25 at 5:00 AM, completed by LPN A documented in part . Vitals obtained, ROM completed. Hoyer obtained along with 4 staff members to assist resident off floor. Noted to left ear small skin tear. with surrounding redness. To left forehead noted redness from abrasion. Resident stated he had some pain to the ear. No increase pain to the rest of his body. Injury Type- Abrasion. Top of Scalp. Skin Tear. Left ear. Level of Pain. 4. Injuries Report Post Incident. Injury Type- Other (Describe). Injury Location - Back of head (no description was documented of the injury type to the back of the head).A review of a facility policy titled Fall Management Guidelines dated 12/13/2023, documented in part . If a resident has just fallen or is observed on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities prior to moving the resident. Evaluate for sign and symptoms of pain. If there is evidence of injury, provide appropriate first aide and/or obtain medical treatment immediately. If after the evaluation it is deemed safe, use the full mechanical lift to assist the resident off the floor.On 8/6/25 at 9:14 AM, an interview was conducted with the complainant. The complainant stated in part . I blame that they (facility staff) didn't send him (R404) to the hospital timely. I had to fight for him to go. When I got there (at the facility) he couldn't move his neck, he was complaining of neck pain, his ear was twice the size and bruised all black and blue and it was painful for him. I talked to the nurse several times and I kept telling her that I wanted to talk to the doctor and she said well I paged him. I said I want him to go to the hospital. The complainant went on to say that the resident was transferred to the hospital hours later. The complainant stated they were really concerned considering R404 had a seven hour back surgery prior to admission to the facility. On 8/6/24 at 10:40 AM, LPN B was interviewed and asked about their note that was backdated to 8/2/25 at 7:42 AM, regarding R404 to have been transferred to the hospital per family's request. LPN B was asked if R404 was transferred out at 7:30 AM or PM (evening) and LPN B confirmed it was PM. LPN B was asked why there was such a delay in transferring the resident to the hospital. LPN B stated the resident did not have a change of condition on their shift and once the wife of R404 stated they wanted the resident sent to the hospital, they sent the resident to the hospital. LPN B' was asked to clarify how the resident did not have a change of condition on their shift, but it was immediately identified upon R404's wife arrival to the facility that R404 could not move their head and had a bruised and swollen left ear (this was also identified in the note documented by LPN B on 8/2/25). LPN B acknowledge they had identified that the resident could not move their head but was not sure of the time they had identified the change. LPN B stated they had notified the Physician on call and was awaiting a reply. LPN B stated they believe the wife was present all day at the facility and even accompanied the resident to the hospital. LPN B was asked about the statements made by R404's wife regarding to have asked LPN B initially when they got to the facility to send the resident out to the hospital due to R404 not being able to move their head and to have a swollen and black/blue left ear and to have requested multiple times throughout the day for the resident to be transferred to the hospital before they were actually transferred out. LPN B stated they had contacted the doctor earlier in the day to inform them of R404's wife request, however hours had passed before they received a reply. LPN B was asked to give an estimate of how many hours had passed while waiting for a reply from the Physician and LPN B stated an estimate of four hours. LPN B stated while they were on their break, another nurse had received an order for a scan to be done. LPN B stated they went to R404's room to inform the family that a scan will be ordered and R404's wife was adamant that the resident be sent to the hospital. LPN B stated they informed the Nursing supervisor of the wife request and began the transfer to the hospital. LPN B stated they had two residents that day that were having concerns and needed to be transferred to the hospital at the same time which made things a bit overwhelming for them. A review of a facility policy titled Change in Condition Notification dated 8/9/23, documented in part . The nurse will notify the resident's physician/practitioner. when there is. A significant change in the resident's physical. such as deterioration which includes life-threatening conditions or clinical complications. A need to transfer.On 8/7/25 at 3:32 PM, a follow-up phone call was conducted with the complainant. The complainant stated they arrived at the facility at around 11 AM on 8/2/25. The complainant stated at that time R404 was unable to move their neck and their ear was observed to be swollen and bruised. The complainant stated at that time they informed the nurse that they wanted R404 sent to the hospital. The complainant stated the nurse replied they would call the doctor to see if they wanted radiology done. The complainant stated they told the nurse they did not believe that would be adequate enough. The complainant confirmed they informed the nurse several times throughout the day that they wanted R404 transferred to the hospital, however it was not until the evening time that the resident was transferred out. The complainant stated they were unsure why it took hours to send the resident out when they had previously requested the resident to be transferred to the hospital multiple times.It was confirmed through multiple interviews conducted with the weekend nursing supervisors RN C and LPN D and confirmed by the complainant that a RN, Nurse Practitioner, Physician nor Physician Assistant had not come to assess the resident after their fall and before the transfer to the hospital. This indicated the concern of an accurate assessment of the resident to have been completed by a qualified personnel after the fall.On 8/6/25 at 12:49 PM, the Director of Nursing (DON) was interviewed and asked about the facility's RN weekend coverage. The DON stated that RN C worked the dayshift on 8/2/25. At this time the DON left the conference room to obtain RN C. At 12:54 PM, RN C (with the DON in attendance) was asked if they had assessed R404 on 8/2/25 and RN C stated they did not. RN C stated as they were getting ready to leave their shift on 8/2/25, they were approached by LPN B who stated the family of R404 wanted the resident sent to the hospital. RN C stated LPN B said the doctor was informed and said that the transfer to the hospital was not needed. RN C stated they instructed LPN B to document in their note that the resident was being transferred to the hospital per the family's request. RN C confirmed they were not aware of the fall or any concerns with R404 prior to LPN B approaching them at the end of their shift. The interview was concluded with RN C. At 1:07 PM, LPN D the weekend supervisor that worked 8/1/25 to 8/2/25 midnight shift was interviewed via telephone (with the DON in attendance). LPN D stated they were not informed of R404 to have had a fall on the morning of 8/2/25. LPN D stated they did not see the resident on 8/2/25. The interview was concluded with LPN D. At 1:03 PM, the interview with the DON resumed. The DON was asked how they were made aware of the fall with R404. The DON stated they were reviewing the electronic medical system from home and saw the documentation regarding R404's fall. The concern regarding the accurate assessment of R404 was discussed and the timely transfer to a higher level of care as requested by R404's family. The DON replied they believed the LPN's assessed the resident correctly. The DON stated it was their understanding that the resident did not exhibit a change of condition, however the family was requesting R404 to be sent to the hospital and the nurse sent the resident out. The DON was asked if they were aware that R404's family identified that the resident could not move their head, was complaining of pain and had a swollen/black/blue left ear when they initially observed the resident that morning. The DON was asked if they were aware that R404's family had requested the resident to be transferred to the hospital at that time. The DON stated they were not aware of the change in condition and was not aware that R404's family had requested the resident to be transferred to the hospital when they arrived at the facility. At 1:15 PM, Physician E (the Physician assigned to R404) was interviewed via telephone with the DON present. The Physician was asked about the fall with R404. Physician E stated they were informed by staff that the resident slid out of bed and there was no injury or pain. Physician E stated staff later called to inform them of the resident having ear and neck pain and the resident was being sent out to the hospital. The incident regarding the injury and pain noted on the incident report after the fall was discussed with Physician E and Physician E replied No, they didn't tell me about injury or pain. The concern of an accurate assessment, informing the physician of a change of condition and timely transfer to the hospital was again discussed with the DON. On 8/6/25 at 4:00 PM, a telephone interview was conducted with LPN A (the nurse assigned to R404 at the time of the fall on 8/2/25). LPN A was asked about the fall with R404 on 8/2/25. LPN A explained the fall incident as documented in their note on 8/2/25. LPN A stated two other CNA's joined them and the CNA in the room, a total of four staff members that . had to turn him (R404) back and forth to put the hoyer pad under him. LPN A' stated they couldn't do much ROM with the resident because the resident condition is normally stuck in one position. LPN A stated the resident is stiff in all areas and doesn't really move. LPN A stated they completed a full body check. LPN A stated the resident complained of . a little pain on his forehead. LPN A stated . He had a little abrasion on forehead and small skin tear to his ear. LPN A stated they called and informed Physician E . about the ear and forehead and that the wife was concerned that he might have re-fractured something on his back. LPN A stated Physician E stated they would see the resident on Monday and to continue to monitor and complete neuro checks. LPN A stated they called R404's wife and informed them of the Physician response and the wife told LPN A that they would be at the facility later. When asked about the documented injury to the back of the head noted on the incident report without a description, LPN A stated they did not remember identifying an injury to the back of the head. When clarified if they had R404 conduct ROM with their head and neck, LPN A state they had R404 . move his head as much as he could do. No further information or documentation was provided by the end of the survey.

This citation pertains to Intake Number(s): MI00150988. Based on interview and record review, the facility failed to thoroughly evaluate and timely address a foot injury for one (R802) of one resident reviewed for a change in condition, resulting in a delay in diagnosing and treating a moderately comminuted avulsion fracture (bone broken in multiple places) to the resident's heel (calcaneus), increased pain, and the inability to fully participate in physical rehabilitation. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that the resident sustained an injury to her foot in the facility. On 4/8/25, an unannounced onsite investigation was conducted. A review of R802's clinical record revealed R802 was admitted into the facility on [DATE] and discharged on [DATE] with diagnoses that included: orthostatic hypotension and syncope and collapse. A review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R802 had intact cognition, received scheduled pain medication, no as needed (PRN) pain medication, and did not experience any pain during the assessment period. A review of a Physical Therapy (PT) Treatment Encounter Note dated 10/21/24 revealed R802 complained of pain in the right foot after being assisted with transferring into bed which was new onset. According to the note, the nurse was notified and ice was applied. A review of a Occupational Therapy (OT) Treatment Encounter Note dated 10/21/24 revealed, Upon returning patient to bed, patient sudden <sic> yelled out and grabbed her right ankle, stating that it suddenly started hurting. Not <sic> bruising identified .(Licensed Practical Nurse - LPN 'E') informed .Patient did not trip or kick any object and also did not appear to roll or twist her ankle during transfer. Unknown what exactly caused pain . A review of a Nursing - Progress Note dated 10/21/24 at 12:00 PM, written by Licensed Practical Nurse (LPN) 'E' documented the following, Resident was working with therapy and when she stood up her foot buckled. Res (resident) right ankle is swelling res stated her pain is at a 9 (out of 10 with 10 being the worst level of pain). spoke with NP (Nurse Practitioner) she ordered a STAT (right away) xray. A review of a Radiology Results Report dated 10/21/25 revealed R802 had an X-ray of the right ankle and there was no fracture or significant abnormality identified at that time. A review of a Nursing - Progress Note dated 10/22/24 at 2:33 PM, revealed, R802 .complains of pain, ice pack given. NP spoke with resident regarding care, pt (Physical Therapy) and ot (Occupational Therapy) to continue. A review of a Nursing - Progress Note dated 10/23/24 at 12:55 PM, written by LPN 'E', revealed, Resident (R802) is complaining of pain to the right foot spoke with NP she is aware. NP ordered 1 time Dose for Norco (opiate pain medication) .she ordered .Hydroxyzine .anxiety . A review of a PT Treatment Encounter Note dated 10/23/24 revealed R802 declined PT on that date. A review of an OT Treatment Encounter Note dated 10/23/24 revealed, .Pt (patient) c/o (complained of) ankle pain and states she doesn't think she sure <sic> do therapy today. Therapist educated pt on the need for consistent participation in therapy to reach goals . A review of a progress note written by Physical Medicine and Rehabilitation (PM&R) Physician (Physician 'G') on 10/23/24 at 4:30 PM revealed, R802 .had no complaints today. She feels well. She continues to have some difficulties with blood pressure during therapy .Inspection of the .BLE (bilateral lower extremities) revealed no acute swelling .tenderness .gait not tested .Pain: Reasonably controlled. Continue gabapentin (a pain medication used to treat neuropathy - nerve pain) which she takes at home for some neuropathy . There was no mention in Physician 'G's note regarding R802's potential ankle injury and that R802's right foot was evaluated specifically for that reason as R802 had complained of pain that day and declined PT and OT due to the pain. A review of an OT Treatment Encounter Note dated 10/24/24 revealed R802 refused to do any standing today. C/O right ankle pain. A review of a PT Treatment Encounter Note dated 10/25/24 revealed, .Pt with NEW RT ANKLE swelling, X rays negative for any fractures, swelling present . A review of an OT Treatment Encounter Note dated 10/25/24 revealed, .pt only able to take one-step this day as she is reporting Max ankle pain. Nurse and PMR Dr (doctor) aware of pt's c/o's .Pts fear of ankle pain impeding optimal performance. 'I know the doctor said the x-rays were fine, but still. On 10/26/24 at 1:03 AM, it was documented in a Nursing - Progress Note that R802 .has edema to the rle (right lower extremity), cool to touch, pain to the heel, np notified new orders for rle venous arterial us (ultrasound). A review of an OT Treatment Encounter Note dated 10/26/24 revealed, .Pt states she hurt her ankle stating that her leg collapsed when she was standing. 'It just collapsed suddenly'. Her leg is wrapped in ace wrap and she states it is painful. Xrays taken and negative . It should be noted that upon further review of R802's complete clinical record, as of 10/26/24, five days after R802 first complained of pain to the right ankle/foot, there was no documentation that R802's right foot was evaluated by a medical provider after complaints of pain, swelling, and inability to participate in therapy, other than Physician 'G's note which did not address the potential injury and/or pain experienced that day. A review of an OT Treatment Encounter Note dated 10/27/24 revealed R802 declined OT on that day. On 10/27/24 at 1:09 PM, six days after R802 first complained of pain to the right ankle/foot, R802's attending physician, Physician 'H', documented, .CHIEF COMPLAINT: Right ankle injury .The patient stated that she inured her right ankle, moving inside of her room from the wheelchair to the bed. The patient had x-ray done secondary to significant amount of discomfort. It did not show the fracture, X-ray shows no significant abnormalities including soft tissue being intact. Arterial Doppler was also done reveals to abnormalities. At this point, the patient is complaining that she is unable to put pressure on the ankle. It is swollen with significant bloody bruising involving the inner side of the right ankle going down to the sole .Positive for inability to ambulate, significant pain in the right ankle, swelling and tenderness .Examination of the right ankle appears to be swollen in the outer area with significant amount of bruising and tenderness .ASSESSMENT AND PLAN: .Injury to the right ankle, no fracture of the bones. The patient definitely has some injury of the soft tissue involving swelling and bruising. At this point, I strongly encouraged the patient to be no weightbearing .I do not believe the patient should walk on these extremities .The patient is no weightbearing status on the right lower extremity until evaluated by podiatrist . A review of a PT Treatment Encounter Note dated 10/27/24 revealed, Pt declined gait training today due to new R ankle swelling (it should be noted that R802 first injured her ankle on 10/21/24); stating 'they don't want me walking or standing on it'. Writer unable to find documentation on (electronic medical record) .Declined gait training today due to R ankle swelling . On 10/28/24 at 7:30 PM, PM&R Physician 'G' documented, .Since last evaluation, she does complain of right ankle pain (It should be noted that R802 although she did not exhibit pain during the last evaluation by Physician 'G' on 10/23/24, she did exhibit pain during therapy and according to the nursing progress note at which time pain medication was administered). She stated this started when she stood up but does not remember any overt trauma. She had been placed NWB (non weightbearing) by the primary team. She had an x-ray, which did not show any acute process. She is pending a podiatry evaluation .Inspection of the .BLE revealed no acute swelling .tenderness .The patient does have ecchymosis (bruising) with increased swelling over the lateral right ankle. The patient does have tenderness to palpitation over the fibula (leg bone) as well as the fifth metatarsal (foot bone) .IMPRESSION/PLAN: .Right ankle pain: Anticipate that this is related to an ankle inversion injury (sprain) .Will obtain a CT (computed tomography) scan of the ankle and foot to rule out small fracture. The patient is currently NWB with pending podiatry evaluation. This will likely be a barrier to the patient's rehab . Further review of R802's progress notes revealed R802 was transferred to the hospital for issues with orthostatic blood pressure on 10/29/24. A review of a DR (Digital Radiography - X-ray) of the right ankle dated 10/21/24 revealed, There is a small ossific density which projects in the region of the superior calcaneus (heel bone). This is indeterminate, but could relate to an avulsion type injury. Recommend further dedicated radiographs of the calcaneus. A review of a DR of the right foot dated 11/1/24 revealed, .Minimally displaced likely avulsion-type fracture of the posterosuperior calcaneus (heel bone) at the Achilles tendon (tendon on the back of the foot) insertion, correlating with torsion (torsion) included suspicious findings on the left <sic> ankle series one day earlier . A review of R802's hospital records revealed an Orthopedic Foot and Ankle Surgery Consult Note dated 11/1/24 that read, .Reason for consultation/Indication: Right heel pain .reports having twisted her ankle 1 week ago which has been painful and difficult to bear weight on .She reports her ankle pain is worse with weightbearing, improved with rest .Assessment/Plan: .closed avulsion type fracture of the R (right) calcaneus (heel bone) after a twisting injury 1 week ago .Placed into a well padded bulky posterior mold splint .please no pressure is <sic> on the heel at any time .Maintain the RLE elevated .CT of the R hindfoot ordered for further evaluation .NWB RLE . A review of a CT of R802's right lower extremity dated 11/2/24 revealed, .Moderately comminuted avulsion fracture at the posterior superior calcaneus at the attachment of the Achilles tendon with numerous avulsed and displaced bony fragments . On 4/8/25 at 1:38 PM, a telephone interview was attempted with LPN 'E' to inquire about how R802's foot was assessed, which NP was contacted, and what information was given to the NP, as the progress notes did not address level of pain, a visual assessment of R802's right foot, or documentation that R802 had trouble with therapy due to the ankle pain. LPN 'E' was not available for interview prior to the end of the survey. On 4/8/25 at 2:11 PM, an interview was conducted with the Director of Nursing (DON). When queried about whether R802's right foot should have been physically evaluated by a medical provider after continued pain, swelling, and the inability to participate in PT and OT, despite a negative X-ray, the DON reported the nurse notified the NP and therefore they did what they were supposed to do. At that time, the nursing notes related to R802's right ankle were reviewed with the DON and the DON was asked about the lack of documented assessment of R802's foot. The DON reported when the nurse called the NP (it was unknown which NP was contacted either time) the NP would ask more questions even if it was not documented. The DON reported a physical evaluation of R802's foot/ankle probably should have been done, but she would review the clinical record and follow up. On 4/8/25 at 3:08 PM, the DON followed up and reported it was documented on 10/22/24 that the NP talked to R802 and on 10/23/24 R802 was seen by PM&R Physician 'G'. When queried about where it was documented that Physician 'G' documented an evaluation specifically of R802's injured ankle, the DON reported Physician 'G' documented R802's pain was reasonably controlled. However, it should be noted that the pain assessment was related to R802's chronic neuropathy and did not address the new and acute pain R802 had been experiencing, even if she did not experience it at that time (while at rest). On 4/8/24 at 3:40 PM, a telephone interview was conducted with Physician 'G'. When queried about whether he evaluated R802's right ankle/foot on 10/23/24 specifically to address the potential injury and new onset pain that began on 10/21/24, Physician 'G' reported he did not recall R802 and said if he documented there was no pain, swelling or tenderness then that was going on at that time. Physician 'G' stated, Pain can come and go, if medicated, even with a small fracture. Physician 'G' clarified that he did not recall who R802 was or if he was notified by the therapy department of R802's pain and declination of therapy due to the pain.

This citation pertains to intake #MI00150776. Based on interview and record review, the facility failed to provide timely incontinence care for one (R801) of two residents reviewed for bowel and bladder. Findings include: Review of a complaint filed with the State Agency included allegations that they were not provided with timely incontinence care and were left wet and soiled for approximately 11 hours. On 4/8/25 at 9:30 AM, R801 was observed in bed, asleep. Upon entry, the resident woke up and participated in an interview about their care. R801 reported concerns that they were left over eight hours before they got changed or repositioned. R801 further reported that unless they put their call light on, the staff on midnights don't come in to check or reposition them, they wait for the resident to put the call light on. R801 reported if they aren't changed on midnight shift, then they have to wait until after breakfast. The resident was asked if they had reported these concerns to anyone at the facility and they indicated they did, but concerns remained. Review of the clinical record revealed R801 was initially admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: unilateral primary osteoarthritis, unspecified injury at unspecified level of cervical spinal cord, morbid obesity, scoliosis, bipolar disorder, and paraplegia. According to the Minimum Data Set (MDS) assessment dated [DATE], R801 had a low Brief Interview for Mental Status (BIMS) score of 00/15 (which indicated severe cognitive impairment, however this was due to the resident not responding verbally to questions asked per the social service quarterly assessment on 2/20/25 - during the interview with this surveyor, they were alert and oriented to person, place and time and recalled staying up late last night to watch a championship game of the March Madness basketball). The resident was dependent for toileting, did not have a bowel and bladder program and was always incontinent of bowel and bladder. Review of the care plan for ALTERATION IN ELIMINATION r/t (related to): incontinent bowel and bladder debility and generalized weakness RESIDENT MAY OFTEN REFUSE HYGIENE/INCONTINENCE CARE date initiated 5/19/21. Interventions included: Incontinent care per facility policy. Keep resident clean and dry. Date initiated 7/15/24. Review of the social work quarterly assessment dated [DATE] included, .Social Work (SW)completed a cognitive screening and current BIMS score is 0/15, resident did not respond verbally to questions, she stared and waved goodbye. SW asked if she wanted to participate in her quarterly assessment, resident waved goodbye again to SW .Previous BIMS score was 15/15 . On 4/8/25 at 10:50 AM, the Director of Nursing (DON) provided a large binder of R801's concern forms and follow-up. Review of these concerns included one dated 2/27/25 initiated by the resident to the DON which read, in part: .CENA involved was educated & disciplined .On 2/28/25 attempt to discuss follow up with [R801]. Pt (patient) is not a good mood. Request writer to leave and don't come back . Included with the facility concern form was the original email sent by R801 to the DON on 2/27/25 at 6:45 AM which read, in part: .On [DATE], I turned on the call light, at 9:45 AM, to ask for my brief to be changed & have my breakfast tray picked up & removed because I was finished with my breakfast. I DIDN'T get a responds <sic> to the call light until 10:15 AM, an <sic> half hour later. The receptionist from the Hickory Unit nurse's station was dressed in an aide's uniform. She responded to the call light. She removed my breakfast tray & said she'd tell the aides I needed to have my brief changed. I turned the call light on AGAIN at a quarter to noon (11:45AM) because I STILL HAVEN'T got my brief changed. The receptionist from the Hickory Unit nurse's station AGAIN answered/responded to the call light. I told her I'm STILL waiting to get my brief changed. I've been waiting almost 2 HOURS to have it changed. She said if the aides don't change my brief she'll come back & change it. The aides DIDN'T change my brief. She didn't come back to change my brief, either. The lunch tray came .I told the aide who brought by lunch tray to me that I had been waiting almost 3 HOURS to get my brief changed. All she said was wow. She made NO effort or attempt to change my brief. For the 3RD TIME today, I AGAIN turned on the call light. This time NOBODY responded to the call light until the shift changed with evening shift (3PM to 11PM) starting. Thank GOD & heaven! My evening shift aide & the Hickory Unit nurse's station receptionist dressed in an aide's uniform, FINALLY, changed by brief & my urine soaked bed linen. After waiting 5 HOURS to have my brief changed my bed linen was urine soaked. The last time I had by brief changed was 4AM earlier this morning. So I was in my brief for a total of 11 HOURS (4AM to 3PM) before it was changed. WHAT A DAMN DISGRACE!! . The assignment sheets from 2/26/25 identified Certified Nursing Assistant (CNA 'A') had been assigned to R801. The DON's interview with nursing staff from 2/26/25 revealed the room assignments had changed and CNA 'A' had been informed that R801's room was under their assignment around 9:00 AM on 2/26/25. The DON's interview with the Unit Clerk 'D' (who was also a CNA) denied being told by R801 they needed to be changes or that the call light was not answered for a long time (which conflicted with R801's recollection of events). Review of an employee counseling and corrective action record dated 3/4/25 documented, in part: .2nd Written Warning .CENA didn't provide care to [R801]on 2/26/25 7A-3P. Education given . the form was noted as refused to sign. The educational in-service by the DON to CNA 'A' read, OBJECTIVE/OUTLINE: CENAs reeducated on importance to check assignment at the beginning of the shift and freq (frequently). throughout the shift .TEACHING METHOD/EQUIPMENT: lecture . A text message to all nurses included, ATTENTION ALL NURSES: When you make changes to the CNA assignment after start of shift you MUST let them know of the changes and update the assignment sheet, Thank you . On 4/8/25 at 12:53 PM, a phone interview was conducted with CNA 'A'. When asked about R801 and what they could recall from 2/26/25, CNA 'A' reported that specific day they were not assigned to R801 and didn't know they swapped the assignment until the end of their shift (approximately 3:00 PM). CNA 'A' further reported they were familiar with R801 and when they are assigned to the resident they make them the first one to get done, and reported the resident tolerated them. When asked how they document when incontinence or toileting care is completed, CNA 'A' reported they document in [electronic system] and will do that at the end of the shift. That's when they told me about R801, they didn't tell me earlier. On 4/8/25 at 2:10 PM, an interview was conducted with the DON. When asked when should staff be expected to check for incontinence care, or toileting needs, the DON reported the standard of care is every two hours. The DON was informed of the discrepancies between what R801 reported and what the facility's documentation reflected and the DON reported on that day, there was no documentation of refusals. When asked if they were able to provide a call-light report for that specific day, the DON reported they didn't think so, but would see as they periodically monitored call lights using an actual hard form (not electronic). (There was no additional documentation or follow-up regarding the call-lights provided by the end of the survey.) The DON was requested to provide the ADL documentation for the resident's bladder and bowel (B&B) elimination from 2/26/25 as this information was not available to the surveyor in the electronic medical record (EMR). On 4/8/25 at 3:38 PM, the DON provided the ADL documentation which revealed the B&B - Bladder Elimination and Bowel Elimination for the Day shift (7:00 AM - 3:00 PM) were incomplete (blank). The DON was informed of the concern that incontinence care was not provided to R801 on 2/26/25. According to the facility's policy titled, Incontinence Care - Urinary and Fecal dated 4/22/2024: .Residents who are incontinent of bowel and/or bladder will be provided incontinent care assistance as needed based on resident request and/or check and change, or as per resident preference or need .

This citation pertains to intake #MI00150187. Based on interview and record review the facility failed to ensure a consent for psychotropic medications were obtained from a legally authorized resident representative for one resident (R303) of three residents reviewed for rights of legally authorized representatives. Findings include: On [DATE], a concern submitted to the State Agency was reviewed with alleged R303 was provided psychotropic medications without the consent of their legally authorized representative (Durable Power of Attorney for healthcare-DPOA-H). On [DATE] the medical record for R303 was reviewed and revealed the following: R303 was initially admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, Fall from bed and Cerebral Infarction and had expired on [DATE]. A review of R303's MDS (minimum data set) with an ARD (assessment reference date) of [DATE] revealed R303 needed assistance from facility staff with their activities of daily living. R303's BIMS score (brief interview of mental status) was 12 indicating moderately impaired cognition. A Physician Certification of Capacity dated [DATE] that was signed by two Physicians revealed R303 was deemed Incompetent to participate in medical treatment, care and custody decision-making. The reason that the resident is unable to participate is Dementia and Visual Hallucinations . A Durable Power of Attorney for Healthcare (DPOA-H) form signed by R303 on [DATE] was reviewed and revealed that R303's wife was their appointed DPOA-H. A review of R303's Medication Orders revealed R303 was ordered Sertraline on multiple dates including the following: (Anti-depressant) Zoloft Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth in the morning for depression-Start date: [DATE] . Sertraline HCl Tablet 50 MG Give 1 tablet by mouth one time a day for Depression-Start date [DATE] . Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for depression-Start date [DATE] . Sertraline HCl Tablet 50 MG Give 1 tablet by mouth one time a day for Depression-Start date [DATE] . Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for Depression Give in addition to 50mg to equal 75mg Daily-Start date [DATE] . Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for Depression-Start date [DATE] . Sertraline HCl Oral Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for ANTIDEPRESSANTS, CHEMICALS-Start date [DATE] . (Anti-Anxiety)LORazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet sublingually every 6 hours for anxiety crush tablet-Start date [DATE] . A review of R303's UDA (User defined assessment) psychotropic consent and education forms was conducted and revealed the following: [DATE] was struck out XXX[DATE]-Consent and education provided to R303 [Note-deemed incapacitated on [DATE]] without the DPOA-H. [DATE]-Education/Consent field was blank. [DATE]-DPOA-H [declined consent for Sertraline.] Further review of R303's psychotropic medication consent forms did not reveal R303's legally authorized representative- DPOA-H had provided consent for either the Sertraline or the Lorazepam. On [DATE] at approximately 1:04 p.m., Social Worker C (SW C) was queried regarding the psychotropic medication consent forms for R303. SW C indicated that residents have to consent for their psychotropic medications. SW C was queried regarding R303's DPOA-H of not consenting for R303 to be provided Zoloft/Sertraline and they indicated that they were aware of R303's DOPA-H not consenting to the medication. At that time, a request for the psychotropic consent forms that R303's DPOA-H had provided consent for their psychotropic medications was requested. On [DATE] at approximately 9:42 a.m., during a follow-up conversation with SW C, SW C indicated they did not have any documentation that R303's DPOA-H had provided consent for their psychotropic medications. SW C was queried as to why and they indicated nobody had brought it to their attention that it needed to be done. On [DATE] a facility document titled Policy and Procedures-Psychotropic Medication Use was reviewed and revealed the following: It is the policy of the facility to only prescribe psychotropic medications when it is necessary to treat a specific diagnosed condition and the medication is deemed as beneficial to the resident. The facility will identify when a resident is prescribed a psychotropic medication and will obtain informed consent from the resident or authorized representative for each psychotropic medication ordered Informed Consent-For any resident taking a psychotropic medication, the Social Service employee or designee will obtain informed consent from the resident and/or authorized representative using the Psychotropic Medication Consent UDA in [electronic medical record] The Social Service employee, or designee, will review the medication prescribed, dosage, side effects, and risks versus benefits of the medication, which are outlined on the psychotropic informed consent evaluation. The Social Service employee, or designee, will discuss any Black Box Warnings associated with the psychotropic prescribed to the resident or authorized presentative <sic>so that they are aware of the potential risks. After review, the resident and/or authorized representative will either consent or refuse the psychotropic medication. The consent or refusal of the psychotropic medication may be obtained in person or verbally via a telephone conversation. If the resident and/or authorized representative refuses to consent to the psychotropic medication, the physician/medical practitioner will be notified so that the medication can be discontinued On [DATE] the facility Administrator provided a copy of R303's UDA form dated [DATE] that indicated R303's DPOA-H had declined consent for sertraline. No other documentation was provided by the end of the survey that indicated R303's DPOA-H had provided consent for R303's psychotropic medications including the multiple dose increases of sertraline or the lorazepam.

This citation pertains to intake #MI00150047 Based on interview, and record review, the facility failed to follow pest control procedures for one resident (R305) of three residents reviewed for pest control. Findings include: On 2/19/25 a concern submitted to the State Agency was reviewed which alleged staff were not utilizing effective procedures to maintain pest control resulting in an infection of bed bugs. On 2/19/25 at 10:03 a.m., during a conservation with Maintenance Director A (MD A), MD A was queried regarding allegation of a bed bug infestation in the facility. MD A reported they did have multiple rooms in where bugs were found and that the facility pest control provider had been out multiple times to inspect and treat the rooms. MD A indicated that the rooms with alleged infestation were 414 and 409. A request for documentation of the bed bug procedures and treatments were requested. On 2/19/25 a review of the facility's investigation into the bed bug infestation revealed the following: Bed Bug Investigation 2/6/2025 . On 2/5/25 sister of resident, [Name of resident] in (room) 414L visited resident. At that time, she brought in resident's clothing and belongings that were from her old apartment before admission to Evergreen. Bed bugs were noted on resident [Name of resident] in 414L after her sister [name of sister] had visited her. Before sister left, she hugged resident's roommate [R305]. Bed bug policy and procedures initiated. Both residents were showered. Resident's rooms were moved and orientated to their new bedrooms. Families notified. [Name of roommate] moved to 416 and [R305] moved to 409. All linen and clothing from bedroom [ROOM NUMBER] bagged and sent to laundry. Room cleaned, UV'd (ultra violet light) and exterminator contacted. Items that were unable to be thoroughly cleaned or washed were inspected by the exterminator and UV'd. Both resident's wheelchairs were also inspected and UV'd. On 2/6/25, bed bugs were noted in [R305's] hair. Resident voiced that CENA (Certified Nursing Assistant) showered her yesterday and put her old clothes back on her. Facial edema and lip swelling noted. Per UM (Unit Manager) EpiPen was administered. Facial edema occurred by an unknown reason. Provider notified. No new orders at this time. Bed bug policy and procedure started over. Resident showered and provided a gown. All clothing and linens were sent to laundry. Resident's room was cleaned and UV'd. CNA B was educated and disciplined regarding bed bug policies and procedures. On 2/19/25 at approximately 12:48 p.m., CNA B was queried regarding being disciplined as result of R305 having bed bugs in their hair on 2/6/25 after being showered on 2/5/25. CNA B reported that they were unaware that putting on the same clothes that R305 was in previous to the shower was wrong and that they thought they were fresh clothes. CNA B reported they were disciplined and educated on the bed bug procedures after the incident. On 2/19/25 at approximately 1:50 p.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the bed bug investigation and CNA B placing the potentially infested clothing back on R305 after being showered. The DON indicated that they re-educated CNA B on the correct procedures when bed bugs are found on a resident and that all the education was completed as of 2/6/25 and they have not had any more bed bug occurrences. A review of CNA B's re-education on the facility bed bug procedures was reviewed and revealed the following: Employee Counseling and Corrective Action Record Date: 2/6/25 .CENA assist resident with shower secondary to suspected bed bugs. After completing shower, CENA assisted patient with same clothes patient was wearing before shower An education in-service attendance record for CNA B dated 2/6/25 revealed the following: Topic-Bed Bug Policy and Procedures .Objective/Outline-Resident to be fully showered with hair washed and new/clean outfit to be put on resident after shower . On 2/19/25 the medical record for R305 was reviewed and revealed the following: R305 was initially admitted to the facility on [DATE] and had diagnoses including Bipolar disorder and Post traumatic stress disorder. A review of R305's MDS (minimum data set) with an ARD (assessment reference date) of 2/9/25 revealed R305 needed assistance from facility staff with their activities of daily living. R305's BIMS score (brief interview for mental status) was 15 indicating intact cognition. A Physician progress note dated 2/6/25 revealed the following: .Pt (patient) alert and conversive upset as had to evacuate room d/t (due to) bedbugs. Reports bed bugs found in hair and few small bites observed on inner thighs. Pt was thoroughly showered. All belongings cleaned, clothes washed . On 2/20/25 A review of the facility policy pertaining to bed bugs was reviewed and revealed the following: Policy-Bed Bug .Policy Overview: The purpose of this policy is to provide guidelines for the identification and treatment of bed bugs .The resident(s) should be thoroughly bathed and changed into a fresh gown. The resident(s) should be moved to a different room using a new wheelchair, walker, cane, etc. per their plan of care and given fresh clean linens and personal care products During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included staff specific education, implementation of the current policy and follow through after interventions (showers, linen change, room treatments). The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to Intake Number MI00147674. Based on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one (R803) of four residents reviewed for abuse, resulting in R804 pushing R803 out of their wheelchair. Findings include: A review of a Facility Reported Incident (FRI) submitted to the State Agency (SA) revealed an allegation that R804 pushed R803's wheelchair and R803 fell . On 12/10/24 at 12:40 PM, an interview was conducted with R803. R803 reported he used to be in another room and has had many roommates. R803 was difficult to understand, but said something about not trying to bother anyone. When queried about whether there had been any physical altercations with other residents, R803 reported there was, but did not give additional details and reported his memory was not good. On 12/10/24 at approximately 12:50 PM, R804 was observed seated at the table in the dining room for lunch. A review of R803's clinical record revealed R803 was admitted into the facility on [DATE] and readmitted on [DATE] with a diagnoses of Alzheimer's Disease with hallucinations. A review of a Minimum Data Set (MDS) assessment revealed R803 had moderately impaired cognition and no behaviors. A review of R803's progress notes revealed the following: A Nursing-Progress Note dated 10/15/24 and written by Licensed Practical Nurse (LPN) 'B', noted, Writer was alerted to (R804's room) after hearing screaming. Upon entering room, (R804) was standing near doorway irate and yelling towards (R803). (R804) stated he pushed (R803) and suggested (R803) was trying to take items. (R803) was on the L (left) side of (R804's) bed, on the floor sitting upright directly parallel to his wheelchair behind him. (R803) stated he was pushed when questioned by writer. (R803) is currently housed in (another room number). Occurrence happened in (R804's room number), where (R803) was previously housed. (R803) states slender black male rolled him into (R804's room number) and he thought it was his room. He was looking through the drawers when (R804) entered became upset and pushed him onto the floor from his w/c (wheelchair) . A Social Work progress note dated 10/21/24 noted, .Resident stated he was taken to a room by mistake. The occupant of room became angry, shook my wheelchair and I fell out per resident. Resident stated he was spouting profanities at him. Resident also stated he feels he is being stalked by this resident because he keeps walking back and forth all day, I feel he's menacing per resident. Resident also stated the man yelled I don't like people touching my stuff. Per resident, when I see him coming, I look the other way . A Physician Note dated 11/4/24 noted an altercation with R803's roommate and the roommate hit his left hand on 9/4/24 and the altercation on 10/15/24 when R803 was found in his old room .pushed on the floor and kicked in his back by other resident after going through his things . A review of R804's clinical record revealed R804 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included: Metabolic encephalopathy. A review of a MDS assessment dated [DATE] revealed R804 had severely impaired cognition. A review of R804's progress notes revealed the following: A Nursing-Progress Note dated 9/5/24 noted, (R804) pushed roommate (determined to be R803) due to roommate touching his belongings .(R804) encouraged to notify staff for further concerns without touching roommate . A Nursing -Progress Note dated 9/30/24 noted, Resident was visibly upset this morning and refused all medication. I tried to talk to the resident, and he cursed at me .Resident began to pace quickly/aggressively up and down the hall .I saw (R803) in the hallway sitting in his wheelchair. (R804) was pacing angrily and pushed the wheelchair of (R803) and telling him to get out of his way and accusing him of trying to trip him. I did not witness (R803) try and trip (R804) . On 10/4/24, R804 asked staff if he could get a weapon to protect himself from a guy. On 10/7/24, R804 was sent to the hospital. There was no documentation in R804's record regarding the incident that occurred with R803 on 10/15/24. A Social Work progress note dated 10/21/24 noted, .Resident remembered that a person was in his room going through his stuff which upset him. Per resident, I grabbed his w/c to take him out of my room and he fell on to the bed not the floor. Per resident, I did use profanity. SW (Social work) explained resident was taken by mistake to his room and that's why he was there . On 12/10/24 at 12:28 PM, an interview was conducted with LPN 'B' regarding the incident between R803 and R804 on 10/15/24. LPN 'B' reported they returned to the unit from break, redirected a female resident away from R804's doorway and went to the medication cart. LPN 'B' reported R804 had the curtain closed and therefore they were unaware R803 was in R804's room at that time. When LPN 'B' was at the medication cart, they heard R804 yelling so they ran back to the room and R803 was on the floor near his wheelchair and next to R804's bed. Upon entrance to R804's room, LPN 'B' reported R804 was walking toward the door and yelling. R804 reported he pushed R803. When queried about how R803 got into R804's room, LPN 'B' reported there were only rumors that another staff member brought R803 into R804's room. LPN 'B' confirmed R803 previously resided in R804's room as his roommate and stated, (R804) is just aggressive, in general. A review of an investigation conducted by the facility revealed the following: A handwritten note by the Assistant Director of Nursing (ADON)/Inservice Director, Registered Nurse (RN) 'A'. that read, On 10/22/24, (RN 'A') had conversation with (Dietary Staff 'C') from kitchen. (Dietary Staff 'C') reported that on 10/15/24 he did assist (R803) to (R804's room) . A summary of the facility's investigation that documented, Per interview with (R804's roommate), shortly before 5 pm 'young skinny male' assisted (R803) to (R804's) side of the room. On 12/10/24 at 1:30 PM, a phone interview was attempted with Dietary Staff 'C' who was no longer employed at the facility. Dietary Staff 'C' was not available for interview prior to the end of the survey. On 12/10/24 at 1:32 PM, an interview was conducted with RN 'A'. When queried about the education provided to Dietary Staff 'C', RN 'A' reported initially Dietary Staff 'C' denied that he brought R803 into R804's room, but RN 'A' talked to him again to try to figure out what happened. RN 'A' explained Dietary Staff 'C' was able to point out the resident (R803) but did not know his name and told RN 'A', R803 was in the doorway of R804's room, R803's wheelchair wheels were locked up. Dietary Staff 'C' was trying to be helpful, unlocked the wheels and R803 proceeded into R804's room, but Dietary Staff 'C' did not know that was not R803's room. RN 'A' provided education to ask the nursing staff when not sure of a resident's room. A review of a facility policy titled, Abuse, updated on 5/24/23, revealed, in part, the following, Residents have the right to be free from abuse .

This citation pertains to Intake # MI000148791 Based on interview and record review the facility failed to report allegations of neglect to the Administrator/Abuse Coordinator and to the State Agency (SA) for one (R806) out of four residents reviewed for Abuse/Neglect. Findings include: A complaint was filed with the SA that alleged that on 12/5/24, R806 was observed covered in dry feces over an extended part of their body. The complainant noted that the allegation had been reported to Nurse F and the Director of Nursing (DON) on 12/5/24. The complainant noted that both the Nurse F and the DON indicated that incontinence care was not needed as the resident was dying and it was okay to leave them covered with hardened feces. The Complainant further reported that Unit Manager (UM) D, a family member of R806 was never informed on the incident until after the resident was discharged . A review of R806's clinical record revealed the resident was initially admitted to the facility on [DATE] with diagnoses that included: spontaneous bacterial peritonitis, cirrhosis of the liver and malnutrition. The resident was discharged from the facility to home on 12/6/24. Review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 14/15 (cognitively intact cognition). Continued review of R806's clinical record revealed: Care Plan: Focus: Risk for Pressure Injury .Incontinent of bowel and bladder Interventions: prevent skin care post incontinence care daily/prn . *There was no documentation in the resident care plan that documented they refused incontinence care. On 12/10/24 at approximately 1:23 PM, an interview was conducted with Unit Manager (UM) D. UM D was queried as to the allegation that R806 was left in dried feces and staff members told CNA (certified nursing assistant) 'E not to worry about it as the resident was dying. UM D reported that they heard that had happened on Saturday (12/7/24) and had a discussion with the DON. UM D noted that R806 had discharge home on 12/6/24 with Hospice and had passed away at home. On 12/10/24 at approximately 1:30 PM, an interview was conducted with Nurse F. Nurse F identified themselves as a Registered Nurse (RN) and had been employed by the facility for a year. When asked if they recalled CNA E reporting that that R806 was left covered in feces, Nurse F noted that they were not familiar with R806. Further, they had never been assigned to work with the resident. They noted they had never had a conversation with CNA E, never responded that the resident should be left alone as they were dying and further never had a conversation with the DON. On 12/10/24 at approximately 2:00 PM, an interview was conducted with the DON. The DON was queried as to the facility's protocol when allegations of abuse/neglect are observed by a CNA. The DON noted that all allegations of abuse/neglect should be reported to their supervisor and/or to her as the DON and/or the Administrator. When asked if they were made aware of any neglect concerns pertaining to R806, the DON noted that they believe someone had mentioned an incident where the resident was left soiled, however they were not aware of anyone stating that the resident should not be cared for as they were dying. The DON was asked if they remembered who reported the concern and the date and time. The DON could not recall the name of the person who reported the concern. The DON was asked if they discussed any concerns pertaining to R806 with UM 'D. The DON reported that they did not. The DON did note that towards the end of their stay at the facility, R806 refused care and was combative at times when being changed. The DON was asked to provide any documentation that noted the resident refused to be cleaned following a bowel movement. *It should be noted that no documentation was provided prior to the end of the Survey. Further, no documentation reviewed in R806's clinical record noted the resident's refusal of incontinent care. On 12/10/24 at approximately, 2:10 PM, an interview was conducted with the Administrator/Abuse coordinator. The Administrator was asked if they had received any indication that R806 had been lying in dried feces and that nursing staff indicated that the resident did not need to be changed as they were dying. The Administrator reported that they did not receive any allegations of abuse by any staff on 12/5/24. The Administrator reported that today they received notice from the DON that the resident may have been left in feces but refused care. On 12/10/24 at approximately 2:50 PM, the DON reported that they believe the staff person who noted the resident was left sold was most likely CNA E. Again, they were not able to recall the date/time they reported the allegation. The DON noted that they had written up the CNA on two occasions and believed they were upset and might have alleged that R806 was neglected. *It should be noted that that prior to the interview, Human Resource (HR) staff provided staff personnel records for four employees, including CNA E, there was no indication in CNA E's personnel record that they had received any disciplinary actions. HR G was able to confirm that all disciplinary actions should be in the staff's record. On 12/10/24 at approximately 4:15 PM, the DON presented a typed document, not dated that documented, in part: Investigation report re: R806 .On 12/5/24 at around 4:30 PM CENA (*No name was noted) reported to writer that R806 was found in bed covered in dry feces .Per interview with CENA (hereinafter CNA H) who was assigned to R806 7 AM to 3 PM At time resident removed his incontinent briefs and at time did not like to be changed. The last round was completed at around 2 PM .resting in bed clean and dry .per interview with Nurse F who was assigned to R806 on 12/5/24, 7 AM to 11 PM; no concerns or issues were reported (*It should be noted that Nurse F when interviewed on 12/20/24 reported that they were not familiar with R806 and was never assigned to the resident or interviewed regarding concerns) .Per interview with UM D .R806 was presented with worsening confusion .at 10 am resident demonstrated aggressive behavior .staff kept the resident safe and wait till resident calm down to continue with care . *It should be noted that during an initial interview with the DON on 12/10/24 at approximately 2:00 PM, there was no mention that the incident as noted above occurred on 12/5/24 and further that any staff were interviewed as to the alleged incident. The facility policy titled, Abuse (5/24/23) was reviewed and documented, in part, the following: .Resident have the right to be free from abuse, neglect .mistreatment .the facility will develop and implement written policies and procedures that include: training new and existing staff on prohibiting, preventing and identifying abuse .The facility will ensure that all allegations involving abuse, neglect .mistreatment .are reported immediately to the Administrator and Reported to the State Agency immediately but not later that two hours after the allegation is made if the allegation involves abuse .Definitions: .Abuse: the willful infliction of injury .Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being .Neglect: Failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress .

Based on interview and record review, the facility failed to ensure unrestricted, 24-hour visitation for residents. This deficient practice had the ability to affect all 143 residents in the facility. Findings include: On 8/6/24 at 10:30 AM, during a resident council meeting with the State Agency, several anonymous residents reported that the facility's visitor hours ended each night at 8:00 PM with the front door being locked at that time, and were announced overhead. Twelve residents were present and each resident reported not knowing that they were allowed to have visitors outside of the hours of 8:00 AM and 8:00 PM. On 8/7/24 at 1:10 PM, an interview was conducted with the Administrator. When queried what the facility's visitor hours were, they responded 8:00 AM to 8:00 PM with the front door locking at 8:00 PM each day, which is announced overhead. When queried if the residents were aware that they had the right to have visitors outside of the 8:00 AM to 8:00 PM timeframe, the Administrator chose not to speak for what the residents were aware of. The Administrator mentioned there may be visitor hours listed in the facilities admission packet. When asked if there was a script that was followed each night when announcing the end of visitor hours, the Administrator deferred to the Business Office Manager (BOM). When the BOM was queried about the overhead announcements, they reported that beginning at 7:45 PM each night, there is a series of announcements made announcing the end of visitor hours and informing residents and visitors that visiting hours end at 8:00 PM and the front door will be locked at that time. A visitor policy was requested from the facility, however the Administrator responded that they did not have a formal visitor policy. Review of the first page of the admission packet provided by the facility revealed, in large bold print and in all capital letters VISITATION 10 AM TO 7:45 PM DAILY. LOBBY DOOR LOCKS AT 8PM.

Based on observation, interview, and record review, the facility failed to maintain the ventilation hood filters in a sanitary manner, failed to ensure the dish machine was sanitizing, and failed to maintain the dish machine in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 8/5/24 at 9:30 AM, the cookline hood ventilation filters were observed with a buildup of grease. Certified Dietary Manager (CDM) O stated kitchen staff were responsible for cleaning the hood vent. According to the 2017 FDA (Food and Drug Administration) Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils.(C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 8/5/24 at 9:40 AM, a plate simulating dishwasher tester was sent through the dish machine to check the sanitizing properties of the facility's high temperature dish machine. The maximum temperature recorded on the plate simulator was noted to be 152 degrees Fahrenheit. At 9:50 AM, the plate simulator was again sent through the dish machine, and the maximum temperature noted on the plate simulator was 153 degrees Fahrenheit. At that same time, the digital temperature display unit on the dish machine noted the final rinse temperature to be 146 degrees Fahrenheit. When queried about what temperature the rinse temperature should be to ensure sanitization, CDM O stated 150-160. On 8/5/24 at 9:45 AM, the Temperature Log for the dish machine was reviewed and noted the following: 8/1 AM 165/147 8/2 AM 175/139 8/2 PM 173/140 8/3 AM 175/139 8/4 AM 122/139 8/4 PM 122/139 When queried about the low temperatures documented on the dish machine temperature log, CDM O stated he was not made aware of the low temperatures for the dish machine. CDM O was unable to provide an explanation as to why staff continued to use the dish machine after logging inadequate temperatures. On 8/5/24 at 10:00 AM, kitchen staff was observed using the dish machine to clean soiled dishware. The plate simulating dishwasher tester was again sent through the machine, and recorded the maximum temperature of 147 degrees Fahrenheit. The final rinse temperature on the machine's digital display unit was noted to be 155 degrees Fahrenheit. At that time, dietary staff noted the dishwasher temperature on the temperature log as 151/155. On 8/5/24 at 11:10 AM, Maintenance Supervisor P was observed working on the dish machine. When queried, Maintenance Supervisor P stated there were forks inside that were blocking the sensor and that the machine needed cleaning inside. At that time, the inside of the dish machine as well as the coils, were observed with a thick, slime buildup. According to the 2017 FDA Food Code section 4-703.11 Hot Water and Chemical, After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: (B) Hot water mechanical operations by being cycled through EQUIPMENT that is set up as specified under SS 4-501.15, 4-501.112, and 4-501.113 and achieving a UTENSIL surface temperature of 71 C (160 F) as measured by an irreversible registering temperature indicator; P According to the 2017 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures, (A) Except as specified in (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90 C (194 F), or less than: Pf (1) For a stationary rack, single temperature machine, 74 C (165 F); Pf or (2) For all other machines, 82 C (180 F). Pf.

Based on observation, interview and record review, the facility failed to provide an environment that promoted and enhanced residents' dignity for multiple residents, including three (R42, R73, and R85) of residents reviewed for dignity. Findings include: According to the facility's policy titled, Dignity dated 9/21/23: .Residents will be treated with dignity and respect at all times .Residents' private space and property are respected at all time .Staff are expected to knock and identify themselves before entering residents' rooms .Demeaning practices and standards of care that compromise dignity are prohibited .Staff are expected to treat cognitively impaired residents with dignity and sensitivity . On 8/5/24 from 9:00 AM to 11:30 AM, multiple observations included nursing staff entering the rooms of residents on Anna's Place (a secured unit) without knocking, announcing themselves prior to entering the room, or waiting of acknowledgment from the residents to enter. Additional dignity concerns were observed during the lunch meal on 8/5/24 which included: At 12:56 PM, Nurse 'K' was observed standing while providing feeding assistance to R85 who was seated in a gerichair recliner in the dining room. There were several empty chairs nearby that were available to use. At approximately 1:00 PM, the family member of R42 was observed standing while at the end of the table and feeding the R42. This family member was then observed to state to R73 (who was directly across from R42 at the end of the table), You look like you haven't had a crumb of food in years, right?. During this time, the family member was observed to touch their clothing, hair, and table multiple times. This family member was then observed to begin to feed both R73 and R42 at the same time. There was no use of hand sanitizer or washing of hands by this family member in between assisting the two residents with their lunch meal. Additionally, although nursing staff were present, no one was observed to intervene or address this family member's actions. On 8/7/24 at 8:45 AM, an interview was conducted with Nurse Manager (NM 'N'). When asked about the observations during the lunch meal on 8/5/24, NM 'N' reported they had been made aware and also observed the same in regard to Nurse 'K' standing while feeding. They were also informed of the multiple observations of nursing staff entering the rooms without knocking, acknowledging prior to entering and they reported staff should absolutely be knocking and announcing before entering the rooms. R42 Review of the clinical record revealed R42 was admitted into the facility on [DATE], readmitted on [DATE], signed onto hospice on 11/21/23 with diagnoses that included: Alzheimer's disease with late onset, adult failure to thrive, unspecified severe protein-calorie malnutrition, and anorexia. According to the Minimum Data Set(MDS) assessment dated [DATE], R42 had severe cognitive impairment. Review of the resident's plan of care included, .Announce self when entering room and explain all procedures .Assistance needed with feeding, may fluctuate day to day .EATING: 1 person assist as needed . R73 Review of the clinical record revealed R73 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: cerebral palsy, bipolar disorder, metabolic encephalopathy, unspecified severe protein-calorie malnutrition, and unspecified intellectual disabilities. According to the facility's MDS assessment dated [DATE], R73 had severe cognitive impairment. Review of the resident's plan of care included, .EATING: 1 person assist .Encourage resident to join small dining for meals . R85 Review of the clinical record revealed R85 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Alzheimer's disease, dementia with other behavioral disturbance, legal blindness, and adult failure to thrive. According to the MDS assessment dated [DATE] documented R85 had severe cognitive impairment. Review of the resident's plan of care included, .assist w (with)/feeding as indicated .EATING: 1 person assist .

This citation pertains to intake: MI00142846. Based on interview and record review the facility failed to ensure staff timely identified a worsening of condition and communicated a change of condition with the nursing staff and physician staff for one (R801) of three residents reviewed for a change of condition. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of the facility to have failed to assess a change of condition with R801 in a timely manner. Review of the medical record revealed R801 was admitted to the facility on [DATE] with diagnoses that included: malignant neoplasm of cervix, abscess of vulva and acute kidney failure. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition and required staff assistance for Activities of Daily Living (ADLs). Review of a Physician Team - Discharge Note dated 11/17/23 at 1:33 PM, documented in part . Notified by staff that was <sic> found to have low Spo.(oxygen level) 77% (normal is 90-100%) on room air. She was placed on NR (non-rebreather) at 15L (liters) and Spo2 87%. HR (heart rate) 124, RR (respirations) 8-14. Orders for breathing treatments. No improvement with oxygenation and stat labs and CXR (chest x-ray) ordered. IVF (intravenous fluids) started as well. BP (blood pressure) retaken 104/55. Given lack of improvement and acute change in condition, decision made to call 911 and she was transferred to hospital for further eval. (evaluation) discussed with nursing management as well as DON (director of nursing). Review of the medical record revealed a 94/44 BP documented on 11/15/23 at 11:11 AM and again at 11:32 AM. Review of the November 2024 Medication Administration Record (MAR) documented despite the 94/44 BP, staff administered multiple hypertensive (high blood pressure) medications such as amlodipine besylate 10 mg (milligram), lisinopril 40 mg and metoprolol tartrate 25 mg. There was no documentation of the nursing staff to have notified the physician of the low blood pressure. On 11/15/23 at 3:19 PM, a Physician Team - Progress Note documented the following, . Notified by pts (patients) daughter hat she has not been eating well and has lost weight . Review of a Physical Therapy note dated 11/15/23, documented in part . Pt (patient) has difficulty remaining on task, req (required) freq (frequent) vc (verbal cues) for re direction Freq breaks taken . Pt exhibiting increased confusion on this date; telling PTA (physical therapist assistant) about the fire last night, and how she was so scared I wouldn't be able to get to my walker. Pt reported standing outside. Pt hyper verbal with increased confusion req constant re direction for task initiation and to remain on task . This note was documented by Physical Therapist Assistant (PTA) A. Review of the medical record revealed there was no documentation of the therapy staff to have communicated the change in condition from the resident's baseline to the nursing staff or the physician. The resident started to have a decreased appetite and a change in mental status that was not collaboratively identified by the facility staff and relayed to the physician team, resulting in R801 to have been transferred to the hospital for the worsening of their change of condition two days later. Review of a facility policy titled Change of Condition (Issue Date: 12/13/23) documented in part . An acute change in condition is a clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional status . Acute changes of condition can occur abruptly, over several hours, or over several days . Notification to the licensed nurse regarding a change of the resident's condition may come from the resident themselves, a visitor, or facility staff . Any facility staff that notices a change in the resident's condition should notify the licensed nurse for further evaluation . Review of the hospital records, Emergency Medicine note dated 11/17/23 at 12:20 PM, documented in part . Admitting Diagnosis Severe sepsis . chief complaint of altered mental status . For the past 2 days, she has been steadily declining. She is less interactive and not eating as much as normal . Tachycardia present . Labial wound was purulent, with a very foul smell . She is lethargic and confused . R801 was then started on IV antibiotics by the emergency room medical team. Review of the medical record revealed no documentation of the facility staff to have identified a purulent and foul smelling labial wound prior to the hospitalization . On 3/12/24 at 11:17 AM, PTA A was interviewed and asked about the change of condition identified with R801 on 11/15/23, PTA A replied they wanted to review their notes for that resident and follow back up. Shortly after, PTA A returned and confirmed R801 did have a change of condition from their baseline. PTA A stated R801 had increased confusion. PTA A was asked who they reported the change of condition to, and PTA A stated they could not remember who they reported it to and did not document it, however they stated they always report change of conditions to the nursing staff. On 3/12/24 at 1:01 PM, the DON was interviewed and asked about the low bp and change of mental status not collaboratively communicated and identified by the facility staff and communicated to the medical team to timely identify a change of condition and worsening of, the DON stated they would look into it and follow back up. On 3/13/24 at 8:55 AM, a follow up interview was conducted with the DON. The DON stated they talked to PTA A and educated them on communicating a change of condition to the nursing staff. The DON stated they were unable to identify the nurse that PTA A stated they reported R801's change of condition to on 11/15/23. The DON stated they were reeducating all of their departments. No further explanation or documentation was provided by the end of the survey.

This citation pertains to Intake(s): MI0014286, MI00143149, MI00142861 & MI00143213. Based on observation, interview, and record review the facility failed to ensure pressure wounds were identified (R801), assessed and monitored by physicians/wound clinicians consistently if at all (R's 801 & 804) , implement effective treatment for identified wounds timely (R803), implement preventive interventions (R802) for four (R's 801, 802, 803 & 804) of four residents reviewed for wounds, resulting in R801 to have developed an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) coccyx/sacrum wound, R802 to have developed a Deep Tissue Injury (DTI- Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue), R803 to have developed a Stage III (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present) coccyx wound and R804 to have developed and unstageable left heel wound. Findings include: R801 R801 was admitted to the facility on [DATE] with diagnoses that included: malignant neoplasm of cervix, abscess of vulva and acute kidney failure. A Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition and required staff assistance for Activities of Daily Living (ADLs). Review of a nursing Admission evaluation dated 10/27/23 at 7:22 PM, documented in part . Clinical Evaluation Integumentary (Skin) . Does the resident have any skin abnormalities? No . Review of a Braden assessment (at tool used to identify a resident's risk for pressure ulcer development) dated 10/27/23 at 4:45 PM, documented a score of 15, which indicated At Risk. Review of a Skin - Total Body Evaluation dated 11/13/23 at 10:35 PM, documented in part . wound in <sic> the coccyx. Treatment completed bed bath given . Review of the November 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no implemented treatment for the R801's identified coccyx wound. Review of the medical record revealed no assessments of the physician notification/follow up and monitoring of the identified coccyx wound. Review of a Skin - Total Body Evaluation dated 11/16/23, documented in part . coccyx wound noted . Review of the medical record revealed R801 was transferred to the hospital the next day on 11/17/23 for a change of condition. Review of the hospital records revealed the following: A photograph of the wound taken on 11/17/23 at 11:26 PM, revealed a large unstageable wound that covered the left and right aspects of the sacrum area. A Surgical Wound Care Consult Note dated 11/18/23 at 10:23 AM, documented in part . Reason for consult: To evaluate the patient's sacral wound . The patient was found on nursing admission skin assessment to have a sacral wound . Sacrum (Open unstageable sacral pressure injury) . Measurements: 11 cm (centimeters) x 14 cm. Unable to determine the entire wound depth . Base: The centermost aspect of the wound with yellow/tan necrotic base. The outermost aspect of the wound with an open, moist, pale pink and yellow slough mixed base. The wound base has areas of both partial and full thickness tissue loss, with scattered areas of pink hypopigmented scarring present along the outer edges . Minimal serosanguinous drainage . wound is slightly malodorous . On 3/12/24 at 10:48 AM, the Director of Nursing (DON) was interviewed and asked about the skin assessments completed on 11/13/23 and 11/16/23 that identified the coccyx wound, with no follow up documented, no assessments of the sacral wound, no physician notification of the wound, no treatments implemented, or care plans implemented, and the DON stated they had a soft file on R801. The DON explained once the resident was admitted to the hospital the family called to question the DON about the sacral wound that they were not informed of. The DON stated after they investigated the situation. Review of an Investigation report provided by the DON documented the following in part, . Resident was sent to the hospital on 11/17/23. At the hospital resident noticed to have coccyx wound . CONCLUSION: Resident is alert and able to make her needs known. Was favoring laying on her back in order to elevate(sic) pain and pressure from adenocarcinoma of the vulva. During stay at our facility resident developed wound on coccyx which was unavoidable due to resident medical condition. On 3/12/24 at 1:01 PM, the DON was reinterviewed and asked about their soft file and their conclusion of R801 sacral/coccyx wound to have been unavoidable. The DON was asked how they can conclude that it was unavoidable if the facility never implemented treatment to the area or had the wound monitored and assessed by a physician and the DON acknowledged the concern. The DON stated they had identified problems with the facility's wounds and had educated staff on the correct protocols and policies of the facility for skin impairments. No further explanation or documentation was provided by the end of the survey. R802 Review of the medical record revealed R802 was admitted to the facility on [DATE] with diagnoses that included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, quadriplegia, gastrostomy status and heart failure. Review of a Physician Statement of Capacity for Medical Treatment and Decisions revealed R802 lacked the capacity to make decisions regarding their medical affairs. Review of a nursing admitted d 1/19/24 at 10:31 PM, documented in part . Clinical Evaluation Integumentary (Skin) . Does the resident have any skin abnormalities? No . Review of a Braden assessment dated [DATE] at 10:28 PM, documented a score of 9.0, indicating Very High Risk. Review of the medical record revealed the resident was transferred to the hospital on 2/3/24 for a change of condition. Review of the hospital records identified a DTI (deep tissue injury) to the right ear . Review of the medical record revealed no identification of the facility staff to have identified the DTI to R802's right ear. Review of the census revealed R802 was readmitted to the facility on [DATE]. Review of the physician orders documented the following: Helmet must be on when out of bed, every shift for Craniotomy (brain surgery) . order date 2/12/24. Review of the progress notes revealed the following: On 2/23/24 at 12:55 PM, a Nursing note documented in part . Opening to right ear. Resident wear helmet due to medical condition. Helmet is ill fitting and slide up and down when on. Family is aware of ill fitting helmet . asked PCP (primary care physician) for a proper fitting helmet and never was given one . Review of the care plans revealed no preventive intervention in place to prevent the helmet opening to have developed. Review of a Wound Rounds Note dated 2/27/24 at 4:51 PM, documented in part . ear wounds . noted to have right ear wound. Pt (patient) wears a protective helmet that is malfitting <sic>; slides across ears . As a result, she has developed a wound on her right ear . Right ear abrasion, 0.2 cm deep, scant drng (drainage), no cellulitis, base granular, Recommend Tx (treatment) apply foam dressing 3x/week. Review of the wound photo taken by the facility staff on 2/27/24 revealed an open wound to the right ear and the wound bed could not be visualized by the photo. On 3/13/24 at 1:28 PM, the DON was interviewed and asked how the facility staff failed to identify the development of the right ear wound, despite the hospital to have identified it during their hospitalization on [DATE] and why the facility did not but preventive interventions in place for the monitoring of the helmet against the residents skin and the DON responded the facility staff did not know that R802 was going to develop the right ear wound and as soon as they found out they addressed it. No further explanation or documentation was provided before the end of the survey. R803 Review of the medical record revealed R803 was admitted to the facility on [DATE], with diagnoses that included: acute kidney failure and diastolic heart failure. Review of a nursing admission assessment dated [DATE] , documented in part . Coccyx - redness . Review of a February 2024 MAR and TAR documented the following order implemented . PeriGuard external ointment . Apply to Sacrococcyx & Groin topically every shift for incontinence . this order was implemented on 2/15/23. Review of a Nursing progress note dated 3/1/24 at 7:04 AM, documented in part .Resident coccyx area has openings with small amount of blood noted. Coccyx area cleansed and cream applied. Ordered a wound consult. Logged for dr (doctor) . Although worsening of the wound was identified on 3/1/24, the facility nurse continued the Periguard treatment and logged the assessment in the physician's book for them to review the next time the physicians came to the facility. Review of a care plan titled Risk for Pressure Injury Formation . dated 2/16/24, documented the following intervention . weekly nursing skin evaluations with showers. Notify PCP (primary care physician) and wound care nurse of any skin changes . implemented 2/16/24. Review of the medical record revealed R803 was examined by a physician on 3/3/24, however no documentation of an assessment of the coccyx area was documented. Review of the record revealed no documentation of a physician follow up regarding the wound identified on R803's coccyx area. Further review of the medical record revealed no care plan implemented for the coccyx wound. An additional review of the medical record revealed on 3/11/24, the facility uploaded a wound consultation dated 3/5/24, that documented the following in part, . Geriatrics Wound Consult . consult regarding coccyx . total area 8.7 x 6.0. The left side is open with yellow necrotic slough, the right side is open and dark granular tissue scant serosanguineous drainage no clinical evidence of infection . Pressure ulcer of sacral region, unstageable . Review of the medical record revealed the resident was transferred out to an appointment and admitted to the hospital on 3/6/24. Review of the hospital records revealed the buttock wounds were identified upon admission and revealed a stage III buttock wound. On 3/12/24 at 10:31 AM, Wound Care Nurse (WCN) E was interviewed and asked the facility's protocol when a skin impairment is identified and WCN E replied they would assess the residents' skin impairment and implement the treatment they feel is sufficient for the skin impairment and document it in the doctor's log book so the skin impairment could be assessed. WCN E was asked to confirm that they would assess the area, implement what treatment they felt the resident should have with out getting an order directly from the physician? Or informing the physician of the skin impairment assessment? WCN E was asked to confirm that they are putting orders in the system for skin impairments without the physician's approval and WCN E declined to answer. On 3/12/24 at 2:23 PM, the DON was interviewed and asked why the nurse did not immediately notify the physician on 3/1/24 of the worsening of the coccyx wound instead of logging it in the physician book for the physician to review next time they came to the facility and the DON stated the nurse that identified the worsening of the wound on 3/1/24 was educated on the proper facility protocols when identifying worsening of a wound. On 3/13/24 at 9:19 AM, the DON and WCN E requested to talk to the surveyor to clarify WCN E statement regarding the implementation of treatment to a skin impairment without notifying the physician and writing it in the log book for the physician to review the next time they visited the facility. WCN E stated they go by the recommendations of the facility's policy that documented recommended treatments for skin impairments, both the DON and WCN E were asked if they were concerned that staff are implementing treatment from a policy recommendation, and not notifying the physician of the treatment that is being implemented under the physician's name and failing to timely report the skin impairment to the physician and the DON stated they understood the concern and will start education with their staff. No further explanation or documentation was provided by the end of the survey. R804 Review of the medical record revealed R804 was admitted to the facility on [DATE] with diagnoses that included: palliative care, hemiplegia and hemiparesis following infarction affecting left non-dominant side and required staff assistance for all ADLs. Review of an Admission nursing evaluation dated 12/23/23 at 11:37 PM, documented in part . Clinical Evaluation Integumentary (Skin) . Left lower leg (front) Scar . Right lower leg (front) Scratches . Back of head redness . Right ear dark mold . Review of an admission Braden dated 12/24/23 at 12:15 AM, documented a score of 13, which indicated Moderate Risk. Review of a Nursing progress note dated 1/9/24 at 11:17 AM, documented in part . Writer informed by staff with new noted skin issues, fluid filled blister to left heel . Review of a Wound Rounds consultation dated 1/16/24 at 4:44 PM, documented in part . seeing pt (patient) re (regarding) . heel wounds . Left heel unstageable ulcer, desiccating blood blister, ruptured with central eschar, 2.5 x 1.3 . On 3/13/24 at 3:50 PM, R804 was observed sleeping on their back in bed with family at bedside. R804's daughter explained the resident was on hospice and was currently declining and transitioning. Review of the medical record revealed no documentation of the left heel wound to have been monitored, assessed, or evaluated by the wound clinician since 1/16/24. On 3/13/24 at 2:27 PM, the DON was interviewed and asked why R804's left heel wound had not been monitored or assessed by the wound clinician since 1/16/24 and the DON stated they would look into it and follow back up. On 3/14/23 at 9:31 AM, the DON returned and stated the nursing staff had been educated on wounds and could provide QAPI (Quality Assurance Performance Improvement) documentation of R804's wound to have been monitored. Review of the QAPI documentation provided revealed documentation of measurements of R804's left heel on 1/16/24, 1/24/24, 1/31/24, 2/6/24, 2/13/24, 2/20/24, 2/27/24, and 3/1/24. No additional physician wound assessments were provided. No further documentation was provided by the end of the survey.

This citation pertains to Intake #MI00134725 Based on observation, interview and record review the facility failed to timely review abnormal lab results for one (R58) out of four residents reviewed for Urinary Tract Infection (UTI) resulting in a delay in treatment for a UTI and hospitilization. Findings include: A complaint was filed with the State Agency (SA) that alleged R58 had a UTI (urinary tract infection) that was left untreated resulting in R58 being sent to the hospital on 1/29/23 after they were observed with a change in mental status. On 6/27/23 at approximately 10:45 AM, R58 was observed lying in bed. The resident was alert but not able to answer most questions asked including a history of UTI(s) or hospitalization . The resident expressed that they were in pain but were not able to activate their call light with their hand. A nurse was asked to come assist the resident. A review of R58's clinical record noted the resident was initially admitted to the facility on [DATE] with diagnoses that included, in part: heart disease, brain and bone cancer and depressive disorder. A review of the resident Minimum Data Set (MDS) noted the resident was significantly cognitively impaired and required extensive one to two person assist for most activities of daily living (ADL) and was incontinent of both bladder and bowl. Continued review of R58's clinical record revealed, in part, the following: 1/21/23: Nursing Note: .wife told writer she noticed resident has pain on groin when urinating. Logged the complains<sic> in MD (medical doctor) book . 1/23/23: Physician Team: (R58) is seen today for general medical visit . family report that he has groin pain with urination. On my arrival he is groaning in pain as CENA (certified nursing assistant) is washing him up. He admits to pain with using the bathroom .will order a UA (urinalysis) to r/o (rule out) infection . 1/24/23: Spoke with (MD HH) to review Urinalysis . 1/25/23: Physician Team: .R58 is seen today for .f/u (follow up) on pain and urinary complaints .UA obtained to r/o (rule out) infection, and it appears contaminated . 1/27/23: Laboratory Results: 1/27/23 (9:57 PM) Culture, Urine .Reviewed (1/29/23 at 8:26 AM) .Collection Date .1/24/23 .Reported date: 1/27/23 .Ord. Provider: Dr. HH Results for R58 . Culture, Urine . Escherichia Coli .>100,000 .Source: Urine, Clean Catch. 1/27/23: Nursing Progress Note: Labs placed in MD book for review. 1/27/23: Nursing Progress Note: While giving resident afternoon pain pill, resident was reluctant to take water . 1/29/23: Nursing Progress Note: .checked with Dr. HH to clarify she was aware of urine culture results No new orders received. Dr. HH said she would review notes . 1/29/23: Physician Team: Results of urine culture reveals a single, pan-sensitive E. Coli He is afebrile, allergic to penicillin, has chronic kidney disease .Use of IM (intramuscular) gentamicin (an aminoglycoside used to treat serious bacterial infections) .as a single dose could be used if he develops more symptoms. I will evaluate him in the morning. *It should be noted that IM gentamicin was not provided to the resident. 1/29/23: Nursing Progress Note: .Assign CENA notified writer resident did not eat breakfast .family came in around lunch and have concerns of residents .mental state. Log for physician to contact family . 1/29/23 (6:07 PM): Nursing Progress Note: .Pt. (patient) observed with stroke like symptoms .Pt sent to (name redacted Hospital) . A facility Concern Form along with an attached e-mail was reviewed and it documented, in part: .Date received: 2/7/23 .Documentation of Concern .per hospital record family expressed quality of care .(R58) positive for UTI .e-mail .Patient was reportedly positive for UTI on 1/24 as tested by facility, however the UTI was left untreated .patient was hospitalized ,d+[DATE]. Patient was discovered by family member to be unresponsive in his room, contracted and lying in bed . Hospital records dated 1/29/23 were reviewed and documented, in part: (R58) presents with complaint(s) of Altered mental status .stopped eating 2 days ago .spoke with patient's sister .she notes last week (R58) was complaining of burning with urination. A UA (urinalysis) and UC (urine culture) were completed on 1/24/23 with E-Coli (bacteria that originates in the intestine and migrated to the bladder causing UTIs) . She notes (R58) did not get ABX (antibiotics) at the facility. She notes he subsequently started eating and drinking less .Reported fever at facility .Temp 100.2.admitted to our hospital secondary to worsening levels of alertness, reduced oral intake .sepsis, complicated UTI .The patient was identified to have a UTI with E. coli .Infectious Disease Consultation .Date of Admission 1/29/23 .Date of Consultation .1/30/23 .urine cultures form 1/24/23 had recovery of E. coli .Empiric antibiotic therapy consisting of Vancomycin and Cefepime has been initiated . On 6/28/23 at approximately 5:22 PM and 6/29/23 at approximately 9:19 AM, attempts were made to contact Dr. HH via phone. While a return call was attempted by Dr. HH no phone interview was conducted before the end of the Survey. *It was noted by the facility that Dr. HH was no longer providing physician services at the facility. On 6/29/23 at approximately 9:43 AM an interview and record review were conducted with Medical Director (MD) K. MD K again reported that Dr. HH no longer provided services at the facility. MD K was asked as to the facility policy/protocol for reporting lab results to resident's physicians. MD K noted that abnormal lab results should be reported immediately to a resident's treating physician. When asked if R58's lab results (Friday: 1/27/23) should have been reviewed on the date reported as they noted the resident was positive for E Coli, MD K reported they should have. MD K stated that sometimes the results end up in the logbook, however the physicians also need to be contacted especially when results arrive on the weekend. When asked if a quicker response to the positive E. Coli results (1/27/23) may have prevented R58 change in condition and hospital stay, MD K noted that an earlier antibiotic treatment might have been helpful. On 6/29/23 at approximately 3:23 PM, an interview was conducted with the Director of Nursing (DON). The DON was queried as to the protocol/policy pertaining to lab results. The DON reported that the facility is to timely report the results of abnormal lab results so as not to delay any necessary treatment. The facility policy for labs results was reviewed and documented, in part, as follows: Policy: It is the policy of this facility to promptly notify the attending physician or physician extender of laboratory values .Explanation and Compliance Requirements: The facility must promptly notify the attending physician of lab results. Delayed notification may contribute to delay in changing the course of treatment or care plan. The lab will determine parameters for Panic/Abnormal or Normal lab results .Abnormal notifications: a. Notify physician or physician extender with lab result and resident current condition. b. Add Review to document notification of result(s) and condition (date, time, name of individual reported to, new orders if applicable) .Physician or physician extender will sign off on .Abnormal lab result .5. If there is not response from the physician or physician extender within 2 hours of notification of Panic/Abnormal lab, contact the Director of Nursing or his/her designee for further instructions.

This citation pertains to Intake #MI00135548 Based on interview and record review the facility failed to initiate necessary treatments for one (R155) of seven resident's reviewed for pressure ulcers, resulting in the worsening of a pressure wound to the spine. Findings include: A complaint was filed with the State Agency (SA) that alleged R155 did not receive proper wound treatment for their pressure sores. The complainant reported that the resident was discharge from the facility on or about 2/16/23 and ended up in the hospital on 2/21/23 with unstageable wounds. A review of R155's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: non-displaced fracture of the right femur A review of the resident's Minimum Data Set (MDS) noted the resident had a Brief Interview for Mental Status (BIMS) score of 15/15 (cognitively intact) and required extensive one to two person assist for most Activities of Daily Living (ADLs). Continued review of R155's clinical record documented, in part: 1/17/23: Wound Rounds Note (authored by Wound Nurse Practitioner (NP) Z : I was referred by (name redacted) physician to consult re: back, hip, coccyx wounds .at the time of admission noted to have aforementioned wounds. Tx (treatment) and advanced pressure downloading interventions were implemented .T-Spine DTPI (deep tissue pressure injury), dark nonblanching, no drng (draining), no cellulitis, significant bony processes .Recommend Tx: foam dressing (an ultra-soft foam that protects and cushions wounds) 3 x/week . 1/24/23: Skin and Wound Evaluation: Type: .Pressure .Stage DTI .Location: Spine .Area: 1.8 cm, length 3.1, width 1.0 cm .Wound Bed .100% wound covered .Goal of Care: healable .Dressing appearance: missing. 1/31/23: Wound Rounds Note (authored by NP Z): .Pt. very resistant to turning/repositioning .T-spine previous DTPI now open stg 2 ulcer, .open area granular surrounding tissue fading darkness, slow blanching, scant drng, .recommend Tx: foam dressing 3x/week . 1/31/23: Skin and Wound Evaluation: Type .Pressure .Stage 2 .Location: spine .Wound measurements .Area: 1.8 cm .length 3.2cm .width .9 cm . 2/7/23: Wound Round Note (authored by NP Z ): .T-spine stg 3 ulcer .open area darkened with dark nonviable tissue, surrounding tissue darkened, minimal drng .recommend Tx: Apply M. (Medi honey gel) cover with foam dressing 3x week . *It should be noted that following a review of R155's treatment orders for the spine showed no documentation that an order for Medi honey gel cover with foam dressing 3x per week was implemented as noted in NP Z's note above. A review of R155's Medication/Treatment Administration (MAR/TAR) record for February 2023 was conducted. The TAR indicated the following: cleanse spine with wound care and apply Medi honey gel and cover with foam gauze change 3 times a week. Every day shift every Tues, Thu, Sat for wound care. Start date 2/9/2023 .D/C date 2/8/2023. There was no indication that this treatment was provided to the resident. 2/14/23 Wound Care Note: (authored by NP 'Z): .T-spine ulcer unstageable. Covered with dark necrotic eschar (dead tissue) .Recommend: Apply M. Honey cover with dry dressing daily and prn. 2/14/23 Skin and Wound Evaluation: .Type .Pressure .Stage: Unstageable .location: spine .Area: 10.6 cm .Length 13.8 cm .width 1.7 cm . On 6/29/23 at approximately 2:33 PM, a phone interview and record review were conducted with Wound NP Z. NP Z reported that they do not work exclusively for the facility but are in the building generally on Tuesdays to work with residents referred by the facility staff. NPZ was asked about R155 and their recommendation dated 2/7/23 for R155 to receive Medihoney, NP Z stated that to their knowledge the treatment recommendation should have been followed. NP Z was noted that they were not able to review R155's MAR/TAR. NP Z was asked if failure to provide the recommended treatment possibly led to the decline in the resident's pressure ulcer on their spine from a stage II to unstageable. NP Z noted again that R155 should have received the recommended Medihoney treatment. NP Z noted that after reading their notes, that R155 often refused to be turned. When asked where that information came from, NP Z stated that it might have been something I observed myself and/or reported to me by staff. When asked if the R155 ever declined treatment, NP Z stated that they did not. *It should be noted that there were no nurses' notes indicating the resident's refusal to be turned. On 6/29/23 at approximately 2:51 PM, an interview and record review were conducted with the Director of Nursing (DON). The DON was queried as the facility's protocol for ensuring resident's receive necessary treatments for wounds. The DON reported that NP Z works at the facility generally on Tuesdays along with Wound Nurse P. After rounds, NP Z will give verbal orders and it should be uploaded to the electronic record. When asked about R155, the DON reviewed the resident's record and stated that the recommendation was not placed correctly into R155's record and thus was not given. When asked if the treatment should have been provided to prevent a decline , the DON stated Yes. The facility policy titled, Skin and Wound Policy (revised 1/22) was reviewed and documented, in part: Policy: it is our policy to perform a full body skin assessment .as part of our systematic approach to pressure injury prevention and management. It is also our policy to follow the treatment plans for any wound/skin concerns as ordered by physicians .wound treatments will be provided in accordance with physician orders, including cleansing method, type of dressing and frequency of dressing change .

This Citation pertains to Intake #MI00132138 Based on interview and record review the facility failed to consistently monitor, obtain monthly weights and implement interventions to prevent a significant weight loss for one (R803) of two residents reviewed for nutrition/hydration, resulting in R803 sustaining a significant weight loss (25.3) pounds (lbs.) in two months, change in mental status and hospitalization . Findings include: A Complaint was filed with the State Agency (SA) that alleged R803 was not eating and was found emaciated on or about 11/12/23, was transferred to the hospital and diagnosed with severe dehydration. A review of (name redacted) Hospital records documented, in part: R803 was admitted to the emergency department with dehydration on 11/12/22 .Physician consult dated 11/13/22 .R803 presents to hospital on 11/12 with decreased mentation and poor oral intake .sister visited her yesterday and was alarmed at her decrease in mental status .Impression: .the patients delirium is attributed to dehydration .Weight is 115 lbs. Patient's Hospital Course .was admitted for hypernatremia dehydration, improved with IVF(intravenous fluid) .severe protein calorie malnutrition, had peg tube placed. 11/12/22 .Need for artificial feeding is needed .patient remains at risk of malnutrition due to weight loss, inadequate energy intakes and increased nutrient needs .Gastroenterology consult .reason for consultation: PEG (percutaneous endoscopic gastrostomy) tube placement Interventions .insert enteral feeding tube .peg placed 11/25, tf (tube feeding) started . A review of R803's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included: vascular dementia, chronic pain and history of stroke. A review of the Minimum Data Set (MDS) indicated the resident was severely cognitively impaired and required extensive one person assist for eating. Continued review of the R803's clinical record documented, in part, the following: Weight Summary: three weights were taken in June 2022 with an end weight on 6/16/22 of 156.8 lbs. Five weights were taken in July 2022 with an end weight on 7/26/22 of 144.0 lbs. Three weights were taken in August 2022 with an end weight on 8/18/22 of 140.2 lbs. Only one weight was taken in September 2022 dated 9/1/22 with a weight of 139.8 lbs. No weights were obtained in the Month of October 2022. One weight was obtained in November (11/9/22) with a weight of 114.5 lbs. indicating a 25.3 lbs. weight loss/18.2%. R803's Care Plan: Focus: Resident is at nutritional risk with risk for . weight loss. Chronic illness, variable oral intake, Need for altered diet, with risk of dehydration (date initiated 6/7/22) .Goal: Resident will have no significant wt. loss (6/7/22) .Interventions/Tasks .Monitor and record weight per policy (6/7/22) .Monitor for signs of malnutrition (pale skin, dull eyes, swollen lips, swollen gums, magenta tongue, poor skin tugur .physical evidence of muscle and fat loss (6/7/22) .Pt requires 1:1 assist with meals (6/7/22) .Supplements as ordered . *It should be noted that no interventions were place in the resident's care plan after 6/7/22. Further, there was no indication in R803's care plan that indicated they refused to eat. Kardex review: one person assists for feeding. Nutritional/Dietary Note (7/19/22): .Current weight is 144lbs as re-weight with first weigh last week of 144.4 lbs. x30 days 155.8 lbs. reflecting 7.1% loss in one month which is significant . *It should be noted that no interventions and/or supplements were ordered. Nutritional/Dietary Note (7/25/22): Nutritional follow-up; resident seen today at lunch .Resident eating independently .Oral intake is variable. There were no further Nutritional notes found in the resident's clinical record until 11/10/22: .Weight loss follow up: Weights: 114.5 lbs. as of this month, refused 30 days ago .Continue on diet as ordered .Refuses to eat .weight loss of 25 lbs. in 60 days . On 2/1/23 at approximately 1:55 PM an interview and record review were conducted with Registered Dietician (RD) H. RD H was queried as to the facility policy pertaining to obtaining resident weights. RD H reported that upon entry weights are obtained every week for four weeks and once per month thereafter unless a resident was having nutritional concerns. When queried as to why the resident was not weighed in October 2022, RD H reported that the resident had refused. RD H was asked to provide documentation that indicated the resident refused to be weighed in October 2023. When queried as to whether staff communicated concerns as to the resident's refusal to eat and/or observations that the resident was losing weight, RD H reported that she was not aware of the weight loss until 11/10/22. When asked what interventions they might have recommended if they had been notified earlier as to the resident's refusal to eat and/or weight loss, RD H reported that they would have suggested interventions such as Hospice, tube feeding, food stimulant medication and/or enhanced food options. *It should be noted that no documentation pertaining to October 2022 weights was provided by the end of the survey. On 2/1/23 at approximately 3:41 PM an interview was conducted with the Director of Nursing (DON). When asked as to the facility policy pertaining to resident weights, the DON indicated that weights should be obtained weekly upon admission for four weeks and then monthly unless nutritional concerns are noted. When asked about R803's 25 lb. weight loss in two months, the DON indicated that the resident should have been weighed at least monthly and if weight loss and/or refusal to eat was noted additional interventions should have been implemented. The facility policy titled, Nutritional Management Policy (approved 10.22) was reviewed and documented, in part: .Policy: the facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in context of his or her overall condition .Compliance Guidelines: a. Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy .c. Developing and consistently implementing pertinent approaches .d. Monitoring the effectiveness of interventions and revising them as necessary .4. Care plan implementation: The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care .b. The resident will be monitored for complications associated with interventions. c. The care plan will be updated as needed, such as when the resident's condition changes .d. The physician will be notified of 1. Significant changes in weight, intake or nutritional status .6. Informed consent: .The comprehensive care plan should describe any interventions offered but declined by the resident or the resident's representative .

This citation has two deficient practice statements (DPS). DPS #1 This citation pertains to Intake Number(s): MI00132706, MI00131102, and MI00129114. Based on interview and record review, the facility failed to implement treatment in a timely manner, administer treatment consistently according to physicians orders, and identify the worsening condition of an arterial ulcer for one (R804) of two residents reviewed for non-pressure skin impairments, resulting in a maggot infestation of the wound located on R804's left great toe. Findings include: Review of a complaint submitted to the State Agency revealed it was alleged R804's left foot wound had maggots in it and the dressing had not been changed in a while. Review of a second complaint submitted to the State Agency revealed it was alleged maggots were found in R804's wound. An unannounced, onsite investigation was completed from 1/31/23 through 2/2/23. Review of R804's clinical record revealed R804 was admitted into the facility on [DATE] and discharged on [DATE] with diagnoses that included: peripheral vascular disease, gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), congestive heart failure (CHF), type 2 diabetes mellitus, and anemia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R804 had moderately impaired cognition, no behaviors, required extensive assistance for bed mobility, had two unhealed stage 2 pressure ulcers (partial thickness skin loss with exposed dermis) that were present on admission, four venous and arterial ulcers (ulcers caused by damaged veins and arteries due to lack of blood flow), and a surgical wound. Review of a run sheet completed by the local fire department revealed they responded to R804 at the facility on 9/5/22 and documented, .weak and hypotensive (low blood pressure) .covered in feces .On assessment, clusters of maggots found on .foot wrapped .due to peripheral vascular disease and gangrene . Review of R804's hospital records revealed the following: An ED (emergency department) Provider Note dated 9/5/22 at 9:33 AM, noted, .dry gangrene (gangrene associated with arterial obstruction) on both BL (bilateral) LE (lower extremities) .presenting to the ED with AMS (altered mental status). Patient lives at nursing facility and was last visited by his friend and daughter on Saturday. Patient at the time was well per daughter. Over the past 2 days nursing staff noted the patient to become more altered. He was attempting to have a bowel movement and had been constipated over the weekend and nursing staff gave him a bowel regimen. He was found today in feces .BL LE gangrene with maggots .ED Course/Medical Decision Making: .Upon arrival to the ED patient was noted to be hypotensive blood pressure 82/53 otherwise saturating 98% on room air. Temp was noted to be 99.2. On exam, patient is altered but awake, responds to painful stimuli. Notable bilateral lower extremity dry gangrene with maggots . An ED Nurse Note dated 9/5/22 at 9:45 AM noted, Patient has dressings applied to multiple sites on lower extremities dated last changed 9/2. Multiple maggots moving in between left foot toes once dressing taken off and wound exposed . Further review of R804's clinical record from the facility revealed the following: Review of a Skin & Wound - Total Body Skin Evaluation dated 8/11/22 revealed, Stitches to left inner thigh and calf. IV to left upper arm. Port to left side of neck with 3 lumen. Bruises to abdomen, hands, and arms. Scratch to left inner arm. Healing abrasion to left knee. Open area to left buttocks 3x6 cm Review of a Nursing - Progress Note dated 8/11/22 revealed, Skin assessment in place. Resident has catheter 16 FR (french). IV (intravenous) to left upper arm. Port to left side of neck with 3 lumen. Stitches to left inner calf and thigh. Scratches to left upper arm. Healing abrasion to left knee-tissue pink intact. Bruises to abdomen,arms. Gangrene to bilateral great toes. Open areas to left buttocks 3x6 cm (centimeters). Open area to right buttocks 3x7 cm. Open area to left outer ankle 3x7 cm. Open area to left outer calf 4x5 cm. Blister noted by calf stitches. Review of Physician's orders for R804 revealed the following orders dated 8/11/22: 1. Cleanse outer ankle with NS (normal saline) then apply dry dressing Q (every) daily, every day shift 2. Cleanse outer left calf with normal saline then apply dry dressing Q daily every day shift 3. Consult Wound Care: Gangrene bilat (bilateral) feet. Multiple wounds There were no orders to address the surgical wound to the left inner calf or the gangrene to bilateral great toes. Review of a Wound Rounds Note dated 8/16/22 (five days after R804 was admitted into the facility) revealed the following documentation: Wound Consult .I was referred ro consult re: (regarding) numerous wounds .At time of admission noted to have multiple wounds . .Left lateral leg surgical incision line proximal half CDI (clean, dry, intact) approximated with sutures. Distal half dehiscence, base covered with loosening nonviable tissue . Recommend Tx (treatment): M.Honey (medihoney) cover with dry dressing 3x/week . .Left medial (inner) leg vascular wound, minimal drng (drainage) .base covered with destabilizing eschar (dead or devitalized tissue) Recommend Tx (treatment): M Honey cover with dry dressing 3x/week . . Left lateral ankle vascular wound .base granular rim surrounding tight necrotic tissue .Recommend Tx: M.Honey cover with dry dressing 3x/week . .Left great toe to 1st MTH (metatarsal head - bone in the foot behind the big toe) arterial wound .base covered with stable eschar .Recommend Tx: wipe with betadine (an antiseptic solution to aide in prevention of infection) cover with dry dressing 3x/week . .Right great toe to 1st MTH arterial wound .base covered with stable eschar .Recommend Tx: wipe with betadine cover with dry dressing 3x/week . Further review of R804's Physicians Orders revealed the following orders dated 8/17/22: 1. Wound Care Order Site: Left Great Toe .cleanse wound cleanser .Wiper with betadine wipes .Wrap in kerlix (rolled gauze dressing) if indicated every day shift every Tue (Tuesday), Thu (Thursday), Sat (Saturday) for wound care 2. Wound Care Order Site: Right Great Toe .cleanse wound cleanser .Wiper with betadine wipes .Wrap in kerlix (rolled gauze dressing) if indicated every day shift every Tue (Tuesday), Thu (Thursday), Sat (Saturday) for wound care 3. Wound Care Order Site: Left medial leg .cleanse .pat dry .apply medihoney .cover with ABD (abdominal pad) .wrap in kerlix .every Tue, Thu, Sat for wound care . 4. Wound Care Order Site: Left lateral ankle .cleanse .Pat dry .Apply medihoney .Cover with ABD (5x9 gauze) .wrap in kerlix .every day shift every Tue, Thu, Sat for wound care . Review of the physician's orders revealed the treatment for R804's left lateral leg surgical incision was not changed to Medihoney according to the wound consult note on 8/16/22. The order remained in place to cleanse with normal saline and apply dry dressing with a start date of 8/12/22. It should be noted that there were no treatment interventions put into place for the vascular/arterial wounds to R804's left medial leg and bilateral great toes until five days after they were admitted into the facility. Review of R804's Treatment Administration Records (TAR) for August and September 2022 revealed multiple missed treatments, as evidenced by no nurse's signature to indicate the treatment was completed. The following treatments were missed: Treatment to the left great toe was not done on 8/20/22, 8/25/22, and 9/3/22. Because the treatment to this site was ordered on Tuesday, Thursday, and Saturday, there were gaps of four to five days between treatments due to the days missed. The last treatment prior to R804 being transferred to the hospital was on 9/1/22. When R804 was assessed by EMS (emergency medical services) and in the ED, maggots were found in that wound. Treatment to the left lateral ankle was not done on 8/20/22, 8/25/22, and 9/3/22. Because the treatment to this site was ordered on Tuesday, Thursday, and Saturday, there were gaps of four to five days between treatments due to the days missed. Treatment to the left medial leg was not done on 8/20/22, 8/25/22, and 9/3/22. Because the treatment to this site was ordered on Tuesday, Thursday, and Saturday, there were gaps of four five days between treatments due to the days missed. Treatment to the right great toe was not done on 8/20/22, 8/25/22, and 9/3/22. Because the treatment to this site was ordered on Tuesday, Thursday, and Saturday, there were gaps of four five days between treatments due to the days missed. Treatment to the outer left calf was not done on 8/12/22, 8/17/22, 8/19/22, 8/20/22, 8/21/22, 8/22/22, 8/26/22, 9/3/22, and 9/4/22. On 2/2/23 at 9:05 AM, an interview was conducted with the Director of Nursing (DON). When queried about the facility's skin management protocols, the DON reported upon admission, the floor nurse did the initial skin assessment and documented any skin issues on the Total Body Assessment. The DON explained, the floor nurse was not supposed to stage or diagnose the wound, but to document the description of the wound. The DON further explained, if a skin impairment was identified, the unit manager was notified and they would assess the resident's skin the next day and determine if they needed to be evaluated by the wound care practitioner. If the resident was determined to need a wound consult, the wound practitioner evaluated the resident the next time they were in the facility on Tuesdays. At that time, R804's clinical record was reviewed with the DON. When queried about why there were no treatments implemented upon admission for the arterial wounds to R804's right and left great toes and medial left leg, the DON reported the nurse may have thought it did not need a treatment. The DON further explained that due to the amount of wounds R804 was admitted with, the nurse should have called the attending physician to discuss any needed treatments until the wound practitioner could come see the resident. When queried about the missing treatments on R804's TARs, the DON reported the treatments should have been done according to the physician's orders. The DON reported they received a grievance regarding the maggots found in R804's wound, investigated it, they did not substantiate anything. At that time, the DON provided the facility's investigation and the grievance form. Review of a Grievance Documentation, Investigation & Follow-Up form dated 9/9/22. The following was documented, Nurse liaison reported concern from (hospital) that resident had maggots in his left lower extremity and gangrene .Investigation: .Nurses that provided wound care to (R804) on Saturday 9/3 and Sunday 9/4 report no findings of maggots to bilateral feet and feet were noted to be clean and dry eschar . It should be noted that R804's TAR indicated no wound care treatment was provided on 9/3/22 or 9/4/22 and the last time it was signed off as completed was on 9/1/22. Review of a facility policy titled, Skin & Wound Policy revised 2/2022, revealed, in part, the following: .All wounds will have treatment orders from the physician team .Wound treatments will be provided in accordance with physician orders .In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse .Treatments will be documented on the Treatment Administration Record . 34275 DPS #2 This citation pertains to Intake Number(s): MI00131467. Based on interview and record review, the facility failed to address changes in condition in a timely manner and thoroughly evaluate the root cause of a change in condition for one (R807) of six residents reviewed for changes in condition, resulting in a delay in sending R807 to the hospital where it was determined the resident had a stroke. Findings include: R807 A Complaint was filed with the State Agency (SA) that alleged R807 had a stroke on 7/17/22 on or about 5-6 AM. The facility was asked to send the resident to the hospital but was told they needed to get approval from the Administrator. The resident was sent to (name redacted) hospital on 7/17/22 at 8:30 AM and passed away in the hospital on 7/24/22. The Complaint was interviewed on the phone and indicated that Nurse J informed them that the resident had already had a stroke when they got to work at 7:00 AM and the supervisor (name not known) told them not to send the resident to the hospital. A review of (name redacted) hospital records documented, in part: .ED (emergency department) notes (9:14 AM) .Pt to EMS for extremity weakness .upon arrival pt. has fixed gaze preference to R side. L side weakness .unable to squeeze on L side .Stroke Team: 7/17/22: Time arrived: 8:50 AM: .slight drift noted on the L side .does not have dentures in and not sure of slight facial .daughter stated that resident does not want aggressive measures .I informed her that patient is having another major stroke with symptoms of fixed gaze/Aphasia .Hospital Course: .presented to Hospital on 7/17/2022 from facility with a chief complaint of possible stroke. Patient suffered a CVA and was deemed a 21(severe stroke) on the NIH (National Institutes of Health) stroke scale .After 48 hours patient had no improvement I neurological recovery, a decision was made to have the patient be made comfort care .passed away peacefully on 7/24 . A review of R807's clinical record revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Gastrointestinal hemorrhage, hypertensive heart and chronic kidney failure, personal history of transient ischemic attack (TIA) and dementia. A review of the resident's Minimum Data Set (MDS) indicated the resident was severely cognitively impaired and required extensive one to two person assist for most Activities of Daily Living. Continued review of R807's clinical record documented, in part: 7/17/22 -Progress Note (7:40am): Resident able to use call light .upon entering room at 6:30 am resident was staring and not alert Resident non-verbal Notified 11-7 am supervisor who assessed resident also Notified. Dr. B who requests for resident to be sent out 911. 11-7 am supervisor notified DON (name redacted) and said there (sic) not sending resident out. 7-3 am supervisor aware and 7-3 nurse aware .7-3 am supervisor aware and will update Dr. B. (Authored by Nurse I). 7/17/22- Progress Note (8:29 am): Resident received stroke like symptoms. Nurse writer spoke to Nurse Supervisor and DON, and they agreed to send resident to (name redacted) hospital. Nurse writer spoke to Resident daughter (name redacted), and she is aware of what is going on .'. (Authored by Nurse J). An attempt to contact Nurse J via phone was made on 2/1/23 at approximately 2:50 PM. A voice mail message was left, and no return call was made before the end of the survey. It should be noted that Nurse J is no longer employed by the facility. On 2/2/23 at approximately 9:51 AM a phone interview was conducted with Nurse I. Nurse I reported that they had been employed by the facility for over [AGE] years and generally worked the night shift (11 PM to 7 AM). Nurse I was queried about the R807 and the note that was authored on 7/17/22. Nurse I recalled that they noticed the resident was showing signs of mental status change and they contacted Dr. B who indicated based on their observation that the resident should be sent to the hospital via 911. Nurse I reported they told Nurse Supervisor K that the resident was showing significant mental status changes and Dr B wanted the resident sent to the hospital. Nurse I stated that Nurse K called the DON and was told not to send the resident out to the hospital. Nurse I stated they endorsed the information on to Nurse J and then left the facility. On 2/2/23 at approximately 1:46 PM an interview and record review were conducted with the DON. When asked about R807 and why there was a delay in sending R807 after Nurse I spoke to Dr. B, the DON indicated that they recalled speaking with Nurse Supervisor K who noted that the resident was stable and sending the resident out was not urgent. On 2/2/23 at approximately 4:15 PM a phone interview was conducted with Nurse K. Nurse K reported that they had worked at the facility for approximately two years as a House Supervisor on the afternoon and mid-night shifts but was no longer employed by the facility. When queried as to the incident involving R807 on 7/17/23, Nurse K reported that Nurse I did report that the resident was exhibiting some changes but was not able to recall what they were. Nurse K stated that they recalled the resident had a history of starring into space and noted that when they went to see the resident, they took some vitals that were fine, remembered the resident was reaching for their TV remote and did not believe there was anything wrong with the resident. They then informed the DON, and the resident was not sent out. When asked if they had completed an assessment or documented their observation, Nurse K responded that they did not. When informed that the resident was sent to the hospital that day at approximately 8:30 AM, they noted that they had left the building by that time. On 2/3/23 at approximately 4: 15 PM, a phone interview was conducted with Dr. B. Dr. B was queried as to R807 and their recommendation to send the resident to the hospital after being notified of a change in mental status by Nurse I. Dr. B reported that they did not have the resident's records in front of them but stated that if they indicated a resident should be sent out to the hospital the facility should have sent the resident out. When asked if the facility policy indicated the DON needed to confirm the resident needed to be sent out following their recommendation, Dr. B noted that was not the policy. A review of the facility policy titled, Change in Condition (8/8/2022) revealed, in part: .Resident who exhibit signs and symptoms of change in condition shall be evaluated by the nurse immediately upon identification .3. A progress note, or .Assessment should be documented .detailing the assessment and all interventions performed .

This citation pertains to Intake Numbers: MI 823 and MI 831 Based on interview and record review, the facility failed to promptly identify, thoroughly assess, implement timely interventions to areas of altered skin integrity, and prevent avoidable pressure ulcers for two (R708 and R709) of five residents reviewed for pressure ulcers, resulting in the development of multiple unstageable (Full-thickness skin and tissue loss . obscured by slough or eschar) pressure ulcers and deep tissue pressure injuries (DTPI - Intact skin with localized area of persistent non-blanchable . discoloration due to damage of underlying soft tissue) Findings include: R708 A complaint was filed with the State Agency that alleged in part, .(R708) was left wet on 01/13/22 from 10 am until 4 am the next morning. Her pants hadn't been taken off .She has two bedsores on her bottom . Review of the closed record revealed R708 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Minimum Data Set (MDS) assessment dated [DATE], R708 was cognitively intact and required the assistance of staff for all activities of daily living (ADL's). The MDS assessment also indicated R708 had no pressure ulcers when admitted into the facility. Review of R708's ADL care plan initiated 12/14/21 revealed interventions that included: .BED MOBILITY: 2 person assist .TOILET USE: 2 person assist .TRANSFER: 2 Person assist HOYER LIFT FOR SAFETY . Review of R708's Certified Nursing Assistant (CNA) tasks for January 2022 revealed on 1/13/22 there was no documentation of ADL care provided to R708, including ADL - Toilet Use, B&B (bowel & bladder) - Bladder Elimination and B&B - Bowel Elimination. Review of the most recent Braden Scale for Predicting Pressure Sore Risk dated 1/3/22 revealed R708 scored 14.0 indicating Moderate Risk for pressure ulcers. Review of R708's January 2022 Treatment Administration Record (TAR) revealed an order that read, Skin Assessment upon admission and weekly . The box on the TAR was checked on 1/3/22, indicating the assessment was completed. The box on 1/10/22 was left blank, indicating the assessment was not completed. Review of R708's Skin Observation Tool assessments revealed: On 1/4/22, .Notes: no skin issues noted at this time. right hip surgical incision healing well . On 1/17/22, .Site: Other (specify) .Open area with necrotic (dead) skin surrounding wound noted . No area of the body was indicated as to where the open area was located. Review of R708's progress notes revealed: A Nursing - Skin/Wound Note dated 1/14/22 at 1:47 PM read in part, .two open areas: one on the right and one on the left inner buttocks. Right inner buttock open area = 5.5 x 2.0 cm (centimeters). Wound bed bright pink, with centralized slough (non-viable . tissue . may be adherent to the base . or present in clumps throughout the wound bed) and well approximated margins. Left inner buttock opening = 6.0 x 4.0 cm with 40% eschar (dead or devitalized tissue). Slough noted on inner most aspect of wound .Will continue to follow plan of care. A Wound Rounds Note dated 1/18/22 at 4:43 PM read in part, .Left heel DTPI 2.5 x 2.5, dark nonblanching [sic] area, no drng (draining), no [CONDITION(S)] . Coccyx/buttocks unstageable ulcer, 9.6 x 10.5 x utd (unable to determine), scant drng, no [CONDITION(S)] .base tight dark necrotic tissue . Review of R708's Actual Pressure Ulcer care plan, initiated 1/17/22, three days after pressure wounds were documented on 1/14/22, revealed interventions that included, .Low Air Loss mattress .Provide surface support and pressure redistribution, position changes, and off loading daily . On 3/8/22 at 4:01 PM, Nurse Practitioner (NP) Y, who was the wound care consultant, was interviewed and asked about R708's wounds. NP Y explained she saw R708 on 1/18/22 and R708 had pretty significant wounds at that time. NP Y was asked if sitting or lying in a soiled brief for long periods could exacerbate pressure ulcers. NP Y agreed that it contribute to the worsening of pressure ulcers. On 3/9/22 at 3:57 PM, the Director of Nursing (DON) was interviewed and asked how often a skin observation should be completed. The DON explained upon admission a skin assessment and a Braden should be done, after that, a skin assessment should be done weekly, and a Braden as needed. When informed R708's pressure ulcers were first documented, four days after a missed skin observation assessment, as having slough and eschar, the DON had no explanation. The DON was asked when interventions should be put into place. The DON explained interventions should be put in place upon any breakdown. The DON was also informed the complaint alleged R708 had not had her brief changed on 1/13/22 and there was no CNA documentation on that day. The DON was asked if the lack of ADL care could contribute to the formation/worsening of pressure ulcers. The DON did not reply. R709 A complaint was filed with the State Agency that alleged in part, .Dec. 10, 2021, family member observed open abrasion (pressure wound) on buttocks and right ankle . Review of the closed record revealed R709 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MDS assessment dated [DATE], R709 was severely cognitively impaired and required the extensive to total assistance of staff for all ADL's. The MDS assessment also indicated R709 had no pressure ulcers when admitted into the facility. Review of R709's progress notes revealed no documentation of wounds. Review of R709's risk for pressure ulcer care plan initiated 11/10/21 revealed interventions that included, .Monitor skin daily during care for redness, excoriation, or breakdown .Preventive skin care post incontinence care daily/prn (as needed) . Review of the most recent Braden score dated 11/24/21 revealed R709's score was 13, indicating moderate risk for pressure ulcers. Review of R709's Skin Observation Tool assessments revealed two assessments dated 12/8/21 by Licensed Practical Nurse (LPN) CC: On 12/8/21 at 7:12 PM, .Comments: Scar to head healing. Buttocks intact. No open areas. On 12/8/21 at 8:31 PM, .Comments: Small open scab to right outer ankle. On 3/9/22 at 12:52 PM, LPN CC was interviewed by phone and asked why there were two skin assessments for R709 on 12/8/21. LPN CC explained she had completed the first assessment after doing a skin assessment, but then went back and did another skin assessment and noticed a scab on R709's ankle, so she completed another tool. LPN CC was asked if she notified anyone or implemented any interventions. LPN CC explained she could not remember if she had logged it into the doctor's book but did not do anything else as it was just a small scab. When asked if she knew if the scab had gotten better or worse, LPN CC explained it had probably stayed the same. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the clinical record revealed R709 was transferred to the hospital after sustaining a fall on 12/13/21. Review of R708's eInteract Transfer Form dated 12/13/21 at 10:07 PM by LPN DD revealed the section to document Skin/Wound Care: 1. Pressure Ulcers/Injuries (stage, location, appearance, treatments): was left blank, indicating R709 had no pressure ulcers/injuries. Review of R709's medical records from [Name Redacted - Local Hospital] revealed: On 12/13/21 at 2:40 PM, ED (Emergency Department) Provider Notes documented in part, .Skin: .Lesion present .pressure ulcer in the inner aspect of the right gluteal fold . On 12/13/21 at 3:24 PM, a consult with wound management was ordered. On 12/14/21 at 2:46 PM, a wound care note documented: Right groin extending into Right buttock Full thickness skin loss Unable to determine depth of injury secondary to eschar obscuring base .3 by 12 (Linear); Right lateral malleolus Unable to determine depth of injury secondary to eschar obscuring base .3.7 by 2.5; Right lateral 5th toe (digit) Unable to determine depth of injury .1.2 by 0.6; Right lateral foot .0.5 by 0.6; Right heel Unable to determine depth of injury .0.8 by 0.5; Assessment: .Open unstageable pressure injury of Right groin extending into Right buttock; Open unstageable pressure injury of Right lateral ankle; Deep tissue injury of Right heel, Right lateral foot and Right 5th toe . On 3/9/22 at 3:03 PM, LPN DD was interviewed by phone and asked about R709's skin and transfer to the hospital on 12/13/21. LPN DD explained she had not known of any issues with R709's skin until R709's Family Member told her they wanted R709 to go to the hospital because of the breakdown on R709's bottom and the fall. LPN DD explained that was the first she had heard of any breakdown of R709's skin. When asked if she had seen R709's bottom or seen any skin issues on the right ankle, LPN DD explained she had not. On 3/9/22 at 3:14 PM, Registered Nurse (RN) F, who served as Unit Manager for R709's unit, was interviewed and asked if he knew anything about R709 having any skin breakdown. RN F explained he had never heard anything about R709 having any skin issues. On 3/9/22 at 3:57 PM, the DON was interviewed and asked if a nurse found a scab on a bony prominence like an ankle, what should they do. The DON explained the nurse should document approximate size and characteristics of the scab, notify the treatment nurse, unit manager and doctor. When asked about the lack of documentation about the scab on R709's ankle, the DON had no answer. The DON was informed upon admission to the hospital, it was documented R709 had multiple pressure ulcers/injuries. The DON explained she had no knowledge of that and would look into it. Review of a facility policy titled, Skin & Wound Policy dated 2/1/22 read in part, .A full body, or head to toe, skin and oral cavity assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter .All wounds will have treatment orders from the physician team .In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders .The effectiveness of treatments will be monitored through ongoing assessment of the wound .

This citation pertains to intake #'s MI 670, MI 783, and MI 816. Based on observation, interview, and record review, the facility failed to ensure consistent and accurately performed weekly skin assessments, completion of physician ordered wound care treatments, and turning and repositioning of residents needing encouragement and assistance for bed mobility for one resident (R805), of four residents reviewed for pressure ulcers, resulting in the development of an unstageable pressure ulcer (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) and the potential for the development of new pressure ulcers or worsening of existing pressure ulcers. R805 On 5/18/21 at 12:20 PM, R805 was observed in their wheelchair in the Hickory Unit common area. At that time, an interview with R805 was attempted, regarding whether they had any wounds and R805 said they did not know. A review of R805's clinical record was conducted on 5/18/21 at approximately 12:40 PM and revealed an admitted [DATE] and a re-admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a 5-day Minimum Data Set (MDS) assessment, dated 2/23/21 revealed R805 had severely impaired cognition, was non-ambulatory, and required extensive assistance from two staff members for transferring and bed mobility. Review of the MDS Section M.-Skin Conditions revealed R805 did not re-admit with any pressure ulcers but was at risk for the development of pressure ulcers. It was also noted in Section M. of the MDS that in response to the question C. Turning/repositioning program, No had been documented. R805's CAA's (Care Area Assessments) section of the MDS dated [DATE] were reviewed and documented, Resident was admitted to our facility with decreased mobility. No pressure ulcers present. Resident is occasionally incontinent of B&B (bowel and bladder) functions and needs assistance with bed mobility . A review of R805's re-admission Braden Score (a score that calculates the risk for the development of pressure ulcers) dated 2/23/21 indicated R805 was a Moderate Risk for the development of pressure ulcers. R805's Continued review of R805's clinical record revealed an order dated 2/23/21 that read, Skin Assessment upon admission and weekly .WEEKLY PLEASE OPEN SKIN ASSESSMENT UNDER ASSESSMENTS TAB . A review of R805's weekly skin assessments in the Assessment Tab of the electronic medical record was conducted and revealed the following: A skin assessment dated [DATE] that did not document any skin impairments and a skin assessment dated [DATE] that did not document any skin impairments. It was noted the next weekly skin assessment present in the record for R805 was dated 3/29/21, 27 days after the previous assessment. The assessment dated [DATE] read, .Coccyx, open yellow tissue moist, Surround red skin non blanching <sic> . A review of a Wound Rounds Note dated 3/29/21 was reviewed and read, .Seen on wound rounds re <sic> open area to coccyx .Developed an unstageable ulcer to coccyx. Base covered almost entirely with yellow slough. Margins intact. Scant drainage. 5.2 x 3 x utd (unable to determine) cm (centimeters) . Review of nursing progress notes was conducted and did not document R805 had been assisted with turning and repositioning prior to the development of the unstageable pressure ulcer on their coccyx. A review of R805's Certified Nursing Assistant (CNA) Kardex (care guide) was reviewed and indicated R805 needed assistance to turn and reposition. A review of the CNA task list and shift task documentation was conducted; but did not have a task that indicated the CNAs were assisting or encouraging R805 to turn and reposition. On 5/18/21 at 2:55 PM, an interview was conducted with the facility's Director of Nursing (DON) regarding R805's unstageable pressure ulcer on their coccyx. The DON explained that R805's pressure ulcer was unavoidable due to their refusals. At that time, the DON was asked if staff should have been documenting R805's refusals and indicated they should. The DON was then asked if they were aware that no Weekly Skin Assessments had been performed between 3/2/21 and 3/29/21 (the day it was identified R805 had a pressure ulcer on their coccyx) and they indicated they were not aware, but the assessments should have been done weekly. Finally, the DON was queried about documentation for turning and repositioning and said the staff do not document it. The DON explained that it was a Standard of Nursing Practice and indicated that if a resident's skin is in good shape it showed that the residents had been turned. On 5/18/21 at 3:45 PM, an interview with the facility's Wound Care Coordinator, Nurse 'C' was conducted and indicated they were also unaware that R805 had no documented skin assessments between 3/2/21 and 3/29/21. On 5/18/21 at 2:42 PM, an interview was conducted with the Director of Nursing (DON). When asked about the facility's process for assessing and documenting wounds, the DON reported there was an assessment completed upon admission and weekly skin assessments under the assessment tab in the computer. A review of a facility provided document titled, Skin-Pressure Ulcer Guidelines with an issue date of 8/13/20 was conducted, and read, .PURPOSE: To promote the prevention of pressure ulcer development; promote the healing of pressure ulcers that are present .and prevent development of additional pressure ulcers. Procedure .9. Weekly skin and oral cavity assessments will be completed on each patient regardless of Braden Scale score of skin condition .

This citation pertains to Intake #MI 364. Based on interview and record review, the facility failed to accurately and thoroughly assess skin integrity upon admission, initiate pressure ulcer interventions and/or treatments for one (R#806) of three residents reviewed for pressure ulcers, resulting in the development and/or worsening of pressure ulcers and the likelihood of a decline in overall health status. Findings include: A complaint was filed with the State Agency that alleged R#806 skin integrity was neglected at the facility and as such R#806 was found to have a large unstageable wound to the buttock/coccyx area. The Complainant was contacted via phone on [DATE] at approximately 9:00 AM. The Complainant reported that R#806 left (name redacted) hospital on [DATE] and discharged to the facility for rehabilitation. The Complainant noted that the resident had a small superficial wound on the coccyx area that was being treated with consistent two hour turning. R#806 was readmitted to the same (name redacted) hospital on [DATE] and it was noted by hospital nursing staff that the resident had an unstageable wound that was approximately 20 cm (centimeters) x 10 cm and other wounds on different areas of the body. The Complainant reported that they spoke with Physician N at the hospital and was told by the physician that the only reason the resident would have such a large unstageable wound would be due to neglectful treatment by the facility. A review of R#806's clinical record documented that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record noted that on [DATE], R#806 left the facility for a blood transfusion and did not return to the facility. A review of the resident's Minimum Data Set (MDS) indicated that the resident was moderately impaired and required extensive two person assist for most activities of daily living (ADL), including bed mobility. The skin condition section of the MDS completed [DATE] (four days after the resident left the facility) indicated the resident was at risk for pressure sores and had an unstageable pressure ulcer (wound bed covered by slough and/or eschar dead skin) and two unstageable deep tissue injuries. An initial skin assessment completed by Nurse K on [DATE], the date R806 was admitted , documented in part the following: Section 5: Skin Assessment .Site (sacrum) Description: open area attached edges red center no foul odor no warmth [DIAGNOSES REDACTED] (redness) Other (specify) bil (bilateral) heels dry flaky toenails darken thick . A Braden Scale (an assessment used for predicting pressure sore risk) dated [DATE] indicated the resident was at risk for pressure sores. No hospital records documented that the resident had an open wound prior to entering the facility on [DATE]. A review of physician orders [REDACTED]. 1. [MEDICATION NAME] Ointment XXX,[DATE].6% - Apply to buttocks/coccyx ([DATE]). Per the MAR/TAR this treatment identified as a PRN (as needed) was never administered to R#806 from [DATE] through [DATE]. 2. Buttocks/sacrum cleanse w/soap and water, Apply TRIAD PASTE, cover with loose ABD every morning and at bedtime ([DATE]). Per the MAR/TAR this order was not documented, and no treatment was administered from [DATE]-[DATE]. 3. BL (bilateral) Heels cleanse . skin prep, cover with ABD (wound dressing) and wrap from toe with [MEDICATION NAME]. (order date [DATE]). This order was never administered as the resident did not return to the facility. No prior orders for the resident's heels were noted in the clinical record. The care plan for R#806 documented, in part, the following: Focus: The resident has an alteration in musculoskeletal status r/t (related to) pain on coccyx wound (date initiated [DATE]) .Interventions/Tasks: Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Give [MEDICATION NAME] as ordered .plan activities during optimal times when pain .is abated .Focus: the resident has potential/actual impairment to skin integrity of the coccyx r/t suspected deep tissue injury (date initiated [DATE]) .Interventions: Avoid scratching and keep hands and body parts from excessive moisture .keep fingernails short .good nutrition and hydration . Float heels from bed to reduce pressure . completed by Nurse K. A progress note dated [DATE] and authored by NP L documented, in part, the following, Wound Consult . I was referred by (name redacted) physician to consult re: heel and coccyx wounds .at time of admission he was found to have heel and buttock wounds. Tx (treatment) and pressure downloading interventions were implemented .Skin: coccyx/Left buttock/perianal unstageable ulcer tot (body surface) area 19.5 x 14, minimal drainage, no [MEDICAL CONDITION], based distal end granular more necrotic .recommend Tx TRAID BID (twice per day). Right heel DTI wound 3x3 . recommend. Tx: wipe with skin prep cover with Dry dressing change 3x/week, Left heel DTI wound 3x4.2 .Dry dressing change 3x/week. Heel-lift pressure offloading boots, low air loss mattress . A review of R#806's (name redacted) Hospital records documented, in part, the following: . Admit Note .Creation Time [DATE] Reason for admit .altered mental status .pt. slow to respond and weak .pt with brief on with loose stool, removed and cleansed, large open wound present, social work consulted due to wounds .Wounds to buttocks/sacrum/coccyx/scrotum .Condition of skin: large open bleeding wounds to buttocks/coccyx/sacrum-scant bleeding, also appear to be areas around the open wounds that are skin tears, unable to measure size of wound as pt moaning loudly/yelling out when turning with 3 person assist, .RN (registered nurse) to take pictures to upload to chart .wound care consulted, pressure injury precautions implemented, turning wedge ordered, heel lift boots ordered, [MEDICATION NAME] applied to heels .specialized bed . Continued Hospital notes documented: Plastic Surgery Wound Care Consult Note .Attending Physician: Physician N .Consultant (name redacted) .Reason for Consultation: wound care-sacral wound .Date of Admission: [DATE] .Chief Complaint: The patient was admitted with mental status changes . Dr. (name redacted) is consulted regarding a sacral wound .History of Present Illness .The patient was recently discharged following an extended stay related to a fall and has been residing in a sub-acute rehab facility .The history of the wounds is not known .The patient is not previously known to our service .Continence: Incontinent of stool .Wound: The sacral and bilateral buttocks demonstrate an area approximately 20 x 10 cm of moist, black eschar without obvious odor. Drainage is difficult to determine, as the patient is incontinent of golden-brown liquid stool . Assessment: .Open unstageable pressure injury of sacral area with eschar, Open unstageable pressure injury of right buttock eschar, Open unstageable pressure injury of left buttock with eschar .Suspected deep tissue injury of right posterior thigh, Suspected deep tissue injury of right posterior thigh, Suspected deep tissue injury of right lateral malleolus, Suspected deep tissue injury of right heel, Suspected deep tissue injury of left lateral foot, Suspected deep tissue injury of left lateral malleolus .Fecal incontinence, Immobility . On [DATE] at approximately 1:30 PM, an interview was conducted with Nurse K regarding R#806. Nurse K was queried as to the initial skin assessment that was completed on [DATE]. Nurse K reported that when doing an initial skin assessment, they were trained not to stage and/or measure a resident's wounds. Nurse K reported that generally they would inform the facility physician and/or wound nurse of a resident's wound. When queried as to R#806's wound that they documented as Sacral: open area attached edges red center no foul odor no warmth [DIAGNOSES REDACTED] (redness), Nurse K indicated that she could not remember and/or describe the size of the wound, if the wound extended to the buttocks or if they remembered anything extraordinary as to the wound. Nurse K was also queried as to any possible wounds/pressure sores on the resident's bilateral heels. Nurse K was not able to recall. On [DATE] at approximately 12:22 PM, an interview and record review was conducted with the Director of Nursing (DON). The DON reported that the wound specialist had recently resigned from their position. The DON was queried as to R#806's wound(s) upon admission to the facility. The DON reviewed R#806's hospital records, including referral form and the H&P (history and physical) prior to the admission to the facility on [DATE] and was not able to find any documentation that indicated the resident had a wound prior to leaving the hospital. The DON was asked what was expected of a Nurse who recognizes a wound upon admission. The DON reported that the Nurse should not stage a wound but could provide measurements and request a physician/wound consult and obtain treatment orders. The DON indicated that photographs of resident's wounds are not taken. The DON was asked to review the resident's TAR/MARs to determine if any wound treatments were administered during their stay at the facility. The DON was not able to provide any documentation that R#806 received any treatments as per physician orders, including TRIAD paste and/or [MEDICATION NAME] Ointment. It should be noted that [MEDICATION NAME] Ointment was documented as a PRN (as needed) order but was never administered. When queried as to whether R#806 had an order and/or was care planned for an air loss mattress that would have relieved pressure on the sacrum. The DON reported that sometimes an order is and/or placed into the resident's care plan. No documentation as to whether there was an air loss mattress used during the resident's stay at the facility was noted in the resident's record. When queried as to whether there would be any documentation that R#806 was turned and repositioned at least every two hours, the DON reported that was standard nursing treatment and would not be documented. On [DATE], a phone interview was conducted with (name redacted) Hospital Physician N. Physician N reported that she had treated R#806 both prior to admission to facility and on re-admission to the hospital on [DATE]. Physician N stated that the resident had a small/tiny, unopened area prior to admission to the facility on [DATE]. Physician N indicated that when the resident was readmitted to the hospital on [DATE], R#806's wound was open/large, and they referred the resident for a wound consult. Physician N indicated that the resident was placed on Hospice and expired on or about [DATE] at the Hospital. Physician N indicated the deterioration in R#806's skin was most likely due to failure of the facility to treat the resident. On [DATE] at approximately 3:30 PM, a phone interview was conducted with Nurse Practitioner (NP) L regarding R#806. NP L recalled that the resident had a significantly large wound on the sacral area and reported that was most likely the reason she was called for a consult. NP L also recalled that on [DATE] a treatment order was implemented for the resident and should have been implemented. The facility policy titled Pressure Ulcer/Injury Protocol (undated) documented, in part, the following: Policy: Based on the Comprehensive Assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individuals clinical conditions demonstrates that they were unavoidable .and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing .Procedure: 1. Upon admission all residents shall have a comprehensive skin assessment completed and documented .2 when assessing an ulcer, it is important to do the following: Differentiate the type of ulcer (pressure related versus non-pressure related. Interventions may vary depending on the specific ulcer.

This citation pertains to Intake Number(s): MI 057. Based on interview and record review, the facility failed to assess, treat, and respond in a timely and appropriate manner to a resident with a critically low oxygen saturation level ranging from the low 50's to low 60's over the course of approximately six hours for one (R#611) of four residents reviewed for changes in condition, resulting in an emergent hospital transfer for acute [MEDICAL CONDITION] requiring mechanical ventilation via bi-level positive airway pressure ([MEDICAL CONDITION] - a treatment that uses mild air pressure to keep your airways open without intubation). Findings include: A complaint was submitted to the State Agency on 8/17/20 that alleged the following: (R#611) resides at (facility name redacted). (R#611) is in the COVID-19 (Coronavirus Disease - 2019) wing of the nursing home due to being exposed to COVID. Today, (R#611) had low oxygen saturation in the 50s. (R#611) was on a nasal cannula at 3 Liters per minute. There was no staff caring for (R#611) during this time. EMS (Emergency Medical Services) was contacted and immediately noticed (R#611) was not receiving enough oxygen. EMS put (R#611) on 15 Liters per minute of oxygen. (R#611's) oxygen level improved prior to her being transferred to (hospital name redacted). It is unknown how long (R#611) was in the room alone with her low oxygen level. There is a concern with the lack of care (R#611) did not receive. A review of R#611's clinical record was conducted and revealed the following: R#611 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R#611 was discharged from the facility to the hospital on [DATE]. A Minimum Data Set (MDS) assessment dated [DATE] documented R#611 had intact cognition and required oxygen therapy while in the facility. A review of R#611's progress notes revealed a Physician Team - Progress Note dated 8/15/20 at 7:07 AM written by Nurse Practitioner (NP) R that documented, (R#611) is seen urgently this morning in f/u (follow up) respiratory distress. She is lying in bed, states it is very hard for her to breathe. She cannot answer other questions d/t (due to) DIB (difficulty in breathing) .: Vitals: T (temperature): 96.9, BP (blood pressure): 140/77, HR (heart rate): 87bpm (beats per minute), RR (respiratory rate): 22brpm (breaths per minute), SpO2 (blood oxygen saturation level, normal is 95-100): 50% 5L (liters) NC (nasal cannula) GEN: Frail, elderly lady lying in bed with labored breathing .RESP (respiratory): breathing even, labored, chest equal/symmetrical, lungs congested, extending neck outward to get more air .Psych: anxious about difficulty breathing .Imp/Plan 1. Respiratory distress/[MEDICAL CONDITION] (decreased oxygen level): Patient struggling to breath- O2 (oxygen) still at 50% on 5LNC. She continues to extend her neck out to get more air. Will send to (hospital name redacted) for evaluation. Nursing to call 911 as this is an emergent transfer. Patient has + COVID-19, [MEDICAL CONDITION], and [MEDICAL CONDITION] . On 8/19/20 at 11:26 AM, NP R was interviewed. When queried about what occurred with R#611 the morning of 8/15/20 and how they were notified to see the resident, NP R reported Physician U contacted them saying they were paged to R#611's room. NP R reported they were in the building so they walked over to R#611's room to see the resident. NP R further reported the nurses said they paged the physician because R#611's oxygen saturation was at 50 percent on five liters of oxygen. NP R reported when they assessed R#611, they were not doing well and I told them (the nurses) to call 911. NP R reported they would have expected the nurses had already called 911 based on their assessment of the resident. When queried about who stayed with the resident after 911 was called, NP R reported (Nurse S) and (Nurse T) stayed with the resident. On 8/19/20 at 1:40 PM, Nurse S was interviewed via the telephone. Nurse S reported they worked the night shift from 7:00 PM beginning 8/14/20 until 7:00 AM on 8/15/20 assigned to the Redwood Unit (a unit designated for residents who tested positive for COVID-19). Nurse S reported residents' vitals were monitored at least one time each shift and were documented in the electronic medical record. When queried about what occurred with R#611 during the night shift on 8/14/20, Nurse S reported there were two nurses assigned to the Redwood Unit, Nurse S and Nurse T. Nurse S reported they entered the room of R#611 with Nurse T to administer wound care and to change the resident's brief. At that time, R#611 reported they felt like they did not have their oxygen on. Nurse S reported R#611's oxygen was running at 3 liters per minute, their vital signs were checked at that time and R#611's oxygen saturation was just below 64 percent. At that time, Nurse S reported they increased R#611's oxygen to 4 liters per minute to see how they responded. Nurse S explained they completed R#611's care with Nurse T, reassessed the resident and their oxygen saturation was still low, had crackles in their breathing, but she was talking so Nurse S increased the oxygen to 5 liters per minute, lifted up the resident's feet, and allowed them to rest. Nurse S was further interviewed. When queried about any increased monitoring of R#611's oxygen saturation after they received low readings and increased the oxygen, Nurse S reported the resident was checked on about four times. Nurse S further reported that R#611 was due to be changed again at approximately 6:00AM and R#611's oxygen saturation continued to drop. Nurse S stated, That's when I told the other nurse she (R#611) is not getting better and we should think about sending her out. When queried about what was done at that time, Nurse S reported they paged Physician U and started pulling paperwork to send the resident out. Nurse S stated, (Physician U) always calls us back, but she didn't call us this time and called the nurse practitioner who was in the building. She (the NP) asked what was going on and went to see the patient. Nurse S reported after NP R assessed R#611 they said the resident had to go to the hospital and to call 911. Nurse S reported they called 911 at that time and it was approximately 6:20 or 6:30 AM. When queried about who stayed with the resident after 911 was called, Nurse S reported NP R was in the room and Nurse S and Nurse T were trying to get the paperwork ready for EMS. They were unsure when NP R left the resident's room. When queried about the interaction with the EMS members when they arrived to the facility, Nurse S reported EMS was concerned there was nobody with the resident in the room. Nurse S stated, I explained that the resident was not deteriorating and was stable and talking. Nurse S explained Nurse T then followed the EMS team to R#611's room, then Nurse T came back to ask Nurse S about an oxygen mask. When Nurse S spoke with EMS, EMS asked Nurse S if the facility had a non-rebreather mask. Nurse S stated, According to the respiratory policy, up to 5 liters (of oxygen) is best by nasal cannula and if more was needed then switch to a mask. Nurse S then explained EMS took R#611 to the hospital and Nurse T documented in R#611's clinical record. On 8/19/20 at 2:56 PM, NP R was interviewed a second time. When queried about when a non-rebreather mask should be considered for oxygen delivery, NP R stated, If they start desating (decreased oxygen saturation), you should consider using one. NP R reported they probably should have switched to a non-rebreather mask for R#611 based on the assessment. When queried about whether or not they were aware R#611 had oxygen saturation levels in the low 60's earlier in the night, NP R reported they were not made aware and the physician should have been called right away and the resident should have been sent out to the hospital. On 8/20/20 at 7:30 AM, Nurse T was interviewed via the telephone. Nurse T reported they worked the night shift on 8/14/20 from 7:00 PM until 7:00 AM on 8/15/20 on the Redwood Unit. Nurse T reported there were two nurses assigned to the unit, Nurse S, who passed the medications during the shift, and Nurse T who took care of the resident care. When queried about what occurred with R#611 that night, Nurse T reported they checked the resident's vitals at the start of the shift and their oxygen saturation was between 90 and 91 percent, the resident did not experience any shortness of breath, had the oxygen infusing via nasal cannula that was properly positioned on the resident, and the resident did not have any complaints. Nurse T further explained that a few hours later, they, along with Nurse S put R#611 into bed from the wheelchair, performed a dressing change, and changed the resident's brief. Nurse T reported Nurse S then gave R#611 medications and they let the resident rest in bed. Nurse T reported there was nothing abnormal with the resident at that time. Nurse T further explained when they went into R#611's room around 6:00 AM to change the resident during rounds, the resident's nasal cannula was not in their nostrils so they assisted the resident to put it back in properly and left the room. Nurse T reported, Nurse S then entered R#611's room to pass medications and came out and said, We need to send her to the hospital. When queried about why R#611 required a hospital transfer, Nurse T stated the resident had shortness of breath and low oxygen saturation. Nurse T was queried about R#611's presentation between the beginning of the shift at 7:00 PM, during the dressing change a few hours after that, and 6:00 AM. Nurse T reported R#611 was stable throughout the shift until 6:00AM at the last medication pass. When queried about what happened next, Nurse T reported they let NP R know and they went in to see the resident and told the nurses to call 911. Nurse T was queried about who stayed with the resident after 911 was called. Nurse T reported NP R left the room and when EMS arrived there was nobody in the room with the resident. Nurse T stated, I handed them (EMS) the paperwork and walked with them to the resident's room. When queried about the interaction with the EMS staff, Nurse T reported EMS questioned her about whether or not the facility had a non-rebreather. Nurse T stated, I told them there was one in the crash cart and they started questioning the other nurse and asking why they were not using a non-rebreather. Nurse T reported they later asked the respiratory therapist what should have been done and they reported a non-rebreather could have been used. Nurse T could not remember R#611's oxygen saturation level at the time of the 911 call, but reported it was very low and could not remember what setting the oxygen concentrator was set to and stated, (Nurse S) told me he turned it up. Nurse T was further interviewed about where vital signs and assessments of R#611 were documented. Nurse T reported they took vitals on the shift and the first set taken at the beginning of the shift would be in the vital signs section in the electronic medical record. Nurse T further explained that subsequent checks of R#611's oxygen saturation were performed, but was not sure where they were documented. It was reported by Nurse T that they were required to check residents' vitals on the COVID-19 unit once per shift, unless there was something abnormal, then they would check them periodically. When queried about who would have documented the events that occurred with R#611 on 8/14/20 and 8/15/20, Nurse T stated, I did not. I was assuming (Nurse S) did it. All I did was hand EMS the paperwork and call the son. On 8/20/20 at 8:51 AM, the facility's Director of Nursing (DON) was interviewed. When queried about vital signs monitoring for residents who resided on the COVID-19 positive unit, the DON reported the staff assigned to that unit worked 12 hour shifts and were required to take a full set of vitals once every 12 hour shift and more frequently if the resident was in any distress. The DON reported the vital signs were documented in the Weights and Vitals section of the electronic medical record. The DON was queried about what oxygen saturation level would trigger the nurse to contact the physician or send a resident to the emergency room . The DON reported it depended on the resident's baseline, but anything lower than 88 percent would require an intervention. When queried about when a non-rebreather mask would be used to deliver oxygen, the DON stated, If their oxygen was very, very low in the 50's you would put it on depending on what was going on with the resident. The DON reported the nurses would use their best clinical judgement to determine the best delivery method for oxygen. The DON was further interviewed and queried about their knowledge of what occurred with R#611 during the night shift on 8/14/20. The DON reported they were aware R#611 was in acute respiratory distress and was sent to the hospital. The DON was not aware there was no nursing documentation prior to the progress note written by NP R and reported the vital signs and assessments of the resident should be documented by the nurse. When queried about what should have been done when Nurse S assessed R#611's oxygen saturation at less than 64 percent, the DON reported they should have increased the oxygen, reassessed the resident, and documented in the clinical record. When queried about when the nurses should have called 911 for R#611, the DON reported they were required to get a physicians order to send a resident out to the hospital, but in an emergent situation they should do what was best for the resident to keep them safe. When queried about whether or not a staff member should remain with the resident in respiratory distress after 911 was called and before EMS arrived, the DON reported someone should remain with the resident. On 8/20/20, a (City name redacted) Fire Department Patient Care Record (EMS run sheet) for R#611 dated 8/15/20 was reviewed and documented the following: .PTA (prior to arrival) Oxygen Flow Rate 3 lpm; unsuccessful .7:08 (AM) Oxygen Flow Rate 15 lpm; Patient Response: Unchanged; Successful .dispatched to a (sex redacted) pt (patient) with low oxygen saturation. Arrived to find the .pt lying in bed. RN (Registered Nurse) on scene states that the NP came out of the room and stated that her spO2 is low. The RN reported an SpO2 in the 50s. Upon assessment, the pt is alert but speaks in 1 or 2 work <sic> sentences with labored breathing. There was no care provider in the room with the patient. The pt was found to be on a NC at 3 LPM. Paramedics were unable to obtain a pulse ox reading. The pt was placed on oxygen via NRB (non-rebreather) at 15 lpm. The pt was transferred to the stretcher .Following the increase oxygen delivery, the pts SpO2 had increased, but the pt was still labored around 20 resps/min. The pts lung sound were diminished in the lower lobes bilaterally . The EMS run sheet documented dispatch received the call from the facility at 6:56 AM on 8/15/20 and arrived on the scene at 7:05 AM. It was documented R#611 was transported with lights and sirens to the local emergency room . A review of hospital records for R#611 was conducted and revealed the following: An ED (emergency department) Provider Note dated 8/15/20 documented R#611 presented with shortness of breath and according to the resident was increasing for the past four days. It was documented that R#611 had tachypnea (fast shallow breathing) and respiratory distress present with Wheezing and rales (abnormal sounds in the lungs) present. The ED note further documented, .Concern for COVID exacerbation and possible superinfection (an infection occurring on top of an earlier infection). Initially together, placed on 15 L nonrebreather with moderate improvement in work of breathing .Patient presents plan with admission to ICU (intensive care unit) for continued care .Disposition: Admission .Final Impression: Covid Pneumonia . A Internal Medicine Consult Note dated 8/19/20 documented, .Impression: Acute resp (respiratory) failure requiring [MEDICAL CONDITION] .Pt continues care in icu and on [MEDICAL CONDITION] . A Care Management note dated 8/19/20 documented, Patient on ventilator on [MEDICAL CONDITION] settings .Mental status not improving . Further review of R#611's clinical record revealed there was no documentation by Nurse S and Nurse T from the night shift on 8/14/20 and 8/15/20. The last documented blood pressure and temperature was 8/12/20 at 10:03 AM, the last documented pulse and respiratory rate was 8/13/20 at 5:17 PM, and the last documented oxygen saturation level (prior to NP R's documentation of 50%) was 8/14/20 at 11:14 AM. Physicians Order revealed active orders (as of 8/14/20 and 8/15/20) for COVID-19 screen - Are there any of the following symptoms present? .cough .new shortness of breath . and COVID-19 screen: Monitor VS (vital signs) every shift . The Medication Administration Record [REDACTED]. However, the abnormal oxygen saturation reported during their interview was not documented anywhere in the clinical record. The clinical record also included an order for [REDACTED]. A facility provided document titled, Change in a Resident's Condition or Status (dated 10/19) was reviewed and documented, .Our facility shall promptly notify the resident, his or her Attending Physician .of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): .significant change in the resident's physical/emotional/mental condition .need to transfer the resident to a hospital/treatment center .specific instruction to notify the Physician of changes in the resident's condition .A 'significant change' of condition is a major decline or improvement in the resident's status that: .Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions .Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider .The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . A facility provided document titled, Oxygen Administration Policy & Procedure (revised 9/17/19) was reviewed and it documented, .Oxygen shall only be administered by physician order, except in an emergency. In an emergency situation, oxygen can be administered without physician's orders [REDACTED].Pulse oximetry levels are to be obtained every shift and prn basis for signs/symptoms of shortness of breath . A policy regarding assessment and monitoring of residents with confirmed COVID-19 was requested. A policy was provided by the facility. However, it did not include assessment and monitoring of residents with COVID-19. A review of Centers for Disease Control and Prevention (CDC) guidance dated 4/2020 titled, Responding to Coronavirus (COVID-19) in Nursing Homes documented, .Response to Newly Identified [DIAGNOSES REDACTED]-CoV-2-infected HCP or Residents .Resident with new-onset suspected or confirmed COVID-19 .Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infections .

This citation pertains to Intake Number: 7 Based on interview and record review, the facility failed to ensure the safety of one sampled resident (R500) of two residents reviewed for falls, resulting in the resident falling and sustaining fractures to their hip, femur, and knee. Findings include: On 7/22/20 at 9:00 AM, an Incident/Accident report (IA) was reviewed regarding an incident involving R500 and indicated the following, Date of Incident: 3/16/2020 Time of Incident: 3:10 PM .location of Incident: Resident's room. (6). Statement by (staff .) Certified Nursing Assistant (CNA) A who observed: 'I was cleaning the patient up for the day. I told the patient to turn over they ended up falling on the floor.' 5.effects of Accident/Incident .pain to left knee post fall. On 7/22/20 at 9:15 AM, progress notes located in R500's Electronic Health Record (EHR) were reviewed and revealed the following, 3/18/20 11:11 AM, Resident had a fall on 3/16/20 at 3:00 PM, and hit left knee. X-ray confirmed fractured left knee. Resident will be sent to (Hospital) for further evaluation .3/24/20 10:07 PM, Resident arrived at facility at approximately 8:00 PM .Resident presents with hip and femur fx (fracture). On 7/22/20 at 9:30 AM, a review of R500's Kardex (Summary of Patient's Care Plan) revealed that R500 required two person physical assistance for bed mobility and two person physical assistance for incontinence brief change and/or bed pan use. On 7/22/20 at 11:15 AM, R500 was met in their room for an interview. R500 was queried about the incident which occurred involving them on 3/16/20. R500 stated, I fell and fractured my hip. A girl was cleaning me up and I was on my side and rolled off the bed onto the floor. On 7/22/20 at 12:55 PM, CNA A was contacted by phone and queried about the incident involving R500. CNA A stated, No one would help R500, they were wet, I helped them, and they ended up slipping on me and falling on the floor. CNA A was queried on what level of assistance was required when assisting the resident with incontinence care. CNA A stated, I think she was a two person assist, but no one would help me. I feel terrible that R500 fell , I ended up getting fired. On 7/22/20 at 1:20 PM, a review of a document involving CNA A titled Employment Profile indicated the following, Status .Termination Date 03/17/2020 Termination Reason Misconduct. On 7/22/20 at 2:15 PM, the Director of Nursing (DON) was interviewed and queried about the incident involving R500 and the reason for CNA A being terminated. The DON stated, CNA A was terminated because they did not follow the requirement for two person assistance when providing incontinence care for R500. On 7/22/20 at 2:25 PM, R500's EHR revealed that R500 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. R500's most recent Minimum Data Set Assessment ((MDS) dated [DATE] indicated that the resident had an intact cognition and required extensive two person assistance for activities of daily living (ADLs).

This citation pertains to Intake Number: MI 746 Based on interview and record review the facility failed to accurately assess, consistently assist R#704 with turning and repositioning interventions and notify the physician for worsening of a buttock pressure wound for one (R#704) of three residents reviewed for wounds, resulting in the worsening of the buttock wound, delayed initial wound care consultation evaluation, a formal complaint to the State Agency and R#704 requiring hospitalization for further treatment and care of the buttock wound. Findings include: On 8/26/19 at 11:40 AM, a complaint submitted to the State Agency documented in part, . I feel he was neglected due to his size. He was bariatric. They were supposed to turn him every 2 hours. They did not do it . I kept asking how it (buttock ulcer) was at the NH (nursing home), they kept saying it was the same . When I saw his wound, I screamed and ran out of the building. It was horrible . It was a hole and was down to the bone . He was so dehydrated . Why didn't the facility send him to the hospital . On 9/5/19 at 9:57 AM, R#704 hospital records were obtained and reviewed. R#704 hospital records documented in part, . 4/15/19 at 13:10 (1:10 PM) present to the ED today with complaints of worsening of sacral decubitus ulcer . pain reported to be 10/10 in the area of the sacral decubitus ulcer. Patient has a large stage IV sacral decubitus ulcer which appears to extend to the vertebral bone . The wound has been packed with gauze which appears old . The ulcer measures approximately 20 x 15 cm and is approximately 8 cm deep . I did have a extensive conversation . at the bedside relating to his large ulcer and the need for surgical debridement . I am concerned about the possibility of infection . Electrolyte panel also reveals a BUN (Blood Urea Nitrogen) of 45, which suggest dehydration . He will be admitted to the hospital at this time for further management of this advanced sacral decubitus ulcer, including surgical consultation . Final Impression(s)/Diagnoses: [REDACTED]. Acute dehydration, requiring IV fluid hydration . On 9/4/19 and 9/5/19 an unannounced onsite investigation was conducted at the facility. R#704 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) of 3 (Indicating severely impaired cognition). R#704 required a two-person physical assistance from staff for transfer, dressing, hygiene and toilet use. R#704's clinical record was reviewed and revealed the following: On 3/13/19 the Admission nurse for R#704 documented R#704's wounds as: A) (Lower left leg) 0.5 width, 2.5 length, 0.1 depth, no odor, 2 drainage and stage II. B) (Lower right leg) 0.5 width, 2.0 length, 0.1 depth, no odor, 2 drainage and stage II. C) (Left buttock) 3.0 width, 3.0 length, 0.1 depth, no odor, 2 drainage and stage III, No significant drainage. Has Allevyn dressing. D) (Right buttock) 3.0 width, 3.0 length, 0.1 depth, no odor, 2 drainage and stage III, No significant drainage, Has Allevyn dressing. An Admission Clarification (by nursing staff) dated 3/13/19 documented R#704's wounds as: A) (Lower left leg) 1 width, 2.5 length, 0.1 depth, (odor and drainage are blank), stage II. B) (Lower right leg) 1 width, 2.5 length, 0.1 depth, (odor and drainage are blank), stage II. C) (Left buttock) 3 width, 3 length, 2 depth, (odor and drainage are blank), stage UTD (unstageable), L (left) buttock pink area with irregular borders and dark eschar. D) (Right buttock) 3 width, 3 length, 1 depth, (odor and drainage are blank), stage UTD (unstageable), R (right) buttock dark with irregular borders with dark eschar tissue, no drainage. On 3/14/19 at 8:14 PM, a Wound Consult with (Doctor's name redacted) is initiated related to: calf and buttocks/coccyx wounds (one day after admission). On 3/15/19 at 3:29 PM, a Low Air-Loss Mattress order is initiated (two days after admission). On 3/15/19 at 1:44 PM, a History and Physical completed by (medical doctor name redacted) documented in part, . Musculoskeletal: states he has a sore bottom- unable to adjust himself in bed . On 3/14/19 at 8:18 PM, a Physician Assistant note documented in part, . integument- 12x11cm+ open area at buttocks/coccyx with undeterminable depth; base is bright pink with eschar . large buttocks/coccyx wound- appears to have tunneling; triad is currently ordered to area; will change to wet to dry, followed by [MEDICATION NAME] and Vaseline gauze to area; consult wound care; he is at high risk for further breakdown, given size and gross debility; add nutritional supplement . On 3/20/19 R#704's Treatment Record documented (by nursing staff) R#704's buttock wounds as: C) (Left buttock) 3.0 width, 3.0 length, 0.1 depth, no odor, 2 drainage, stage II, Alleyn dressing to [MI] (left) buttock. D) (Right buttock) 3.0 width, 3.0 length, 0.1 depth, no odor, 2 drainage, stage II, No drainage noted, aleyn <sic> dressing on. On 3/27/19 R#704's Treatment Record documented (by nursing staff) R#704's buttock wounds as: C) Blank (no measurements noted), area with pink border and flap of brownish tissue. D) Blank (no measurements noted), two line are documented (indicating same as above). A Clarification (by nursing staff) noted 3/27/19 documented R#704's buttock wounds as: C) (Left buttock) 3 width, 3 length, 2 depth, (blank for odor and drainage), stage UTD (unstageable), L (left) buttock pink area, dark eschar. D) (Right buttock) 3 width, 3 length, 1 depth, (blank for odor and drainage), stage UTD (unstageable), R (right) buttock dark with irregular borders and dark eschar. On 3/27/19 at 7:17 PM, a Nurse practitioner note documents in part, . Integ: (integument) large open wound to buttocks/coccyx- appears to extend to muscle with hanging slough/eschar present. No drainage or odor . Pressure ulcer (unstageable) to buttocks/coccyx: current treatment with [MEDICATION NAME] to promote autolytic debridement. Wound MD (medical doctor) (name redacted) on consult. Encourage frequent weight shifts. on low air loss mattress. Pain to pressure ulcer: Does not appear infected. Temps are WNL (within normal limits). Check CBC diff (lab work) on 3/29 to monitor stability. Has PRN (as needed) [MEDICATION NAME] available. Will schedule [MEDICATION NAME] TID (three times a day) in addition to PRN (as needed) in effort to promote better pain control, consequently promoting improved performance in therapy . On 3/29/19 an initial wound consultation (two weeks and one day after wound consultation was ordered) documented in part, . Buttock Right, Left Present on admission, Pressure Ulcer Buttocks . Wound Care was consulted for a deep, unstageable PU (pressure ulcer) to his Sacrum/Buttocks that was present on admission . The PU (pressure ulcer) Buttocks on the Right, Left Buttock is Active. It measures 10.8 by 10.5 by 3.1 . Note Pressure ulcer of right and left buttocks, unstageable, At least Stage 3, Through Muscle . Debridement was performed on wound number 1, located at the Right, Left Buttock . Tissue Removed: Fat, Sub-Q Tissue, Slough, Necrotic Tissue, Eschar . The Post Debridement area of the wound Measures 10.8cm by 10.5cm . and 30% of the wound was debrided . The sacral wound was malodorous (smelling very unpleasant) from moist, necrotic eschar. About 1/3 of the eschar was debrided at the bedside. Recommendations: Continue PU (Pressure Ulcer) precautions including LAL (low air loss) Bed and frequent turning, Clean with Dakins and allow to dry, Protect surrounding tissue with [MEDICATION NAME] or Triad and Pack/Fluff with saline-dampened (well-wrung-out) gauze bid (twice a day) and prn (as needed) . R#704's progress notes and treatment records were reviewed and revealed no documentation of the malodorous odor from R#704's buttock wound from the daily nursing assessment of R#704's buttock wound or any notification to the physician regarding the odor. The odor is first documented by the Wound physician on 3/29/19 at R#704's initial wound consultation. On 3/31/19 R#704's Treatment Record documented (by nursing staff) in part the following regarding R#704's buttock wounds: Resident skin warm to touch with open area on coccyx. Dark eschar tissue on wound, pink drainage . No measurements are documented with this entry. On 4/8/19 at 11:51 AM, a Wound Progress note was entered for the date of (service completed on) 4/3/19 documented in part, . About 1/3 of the eschar on the sacral wound was debrided at the bedside last week. The remainder was debrided today. Recommendations: Continue PU (pressure ulcer) Precautions including LAL (low air loss) Bed and frequent turning, Clean with saline or wound cleanser, Apply Silver Aliginate to the wound and cover with ABD (abdominal dressing), Change daily and prn (as needed) . There are no measurements documented with this consultation of R#704's buttock/sacral wounds. On 4/3/19 R#704's Treatment Record documented by nursing staff R#704's buttock wounds as: C) (left buttock) 4 width, 11 length, .3 depth, (odor and drainage are blank), stage UTD (unstageable), L (left) buttock open are <sic> with yellow slough and drainage with odor present pink base with minor tunneling. D) (right buttock) 4 width, 11 length, .3 depth, (odor and drainage are blank), stage UTD (unstageable), R (right) buttock open are <sic> with yellow slough, odorous drainage. Pink base, irregular edges. R#704's progress notes and treatment records were reviewed and revealed no documentation of the minor tunneling being reported to the physician. On 4/3/19 a Clarification on R#704's Treatment Record documented the following (by nursing staff) regarding R#704's buttock wounds: C & D 4 width, 11 length, 1.0 depth, odor is checked off, 2 drainage, stage UTD (unstageable), C & D are merged together. wound is open with 6% slough & 40% (?) eschar. edges are irregular, odorous & minimal drainage. R#704's progress notes and treatment records were reviewed and revealed no documentation of notification to the physician regarding R#704's merged buttock wounds. On 4/3/19 at 1:55 PM, a Nurse Practitioner note documented in part, . WBC (white blood cell) count 11.2 (H) (high) . Leukocytosis: slight increase in WBC's (white blood cells). No fevers. Per staff, no s/s infection. (Wound Doctor name redacted) following wound. Repeat CBC diff (lab work) tomorrow . Will follow. On 4/4/19 at 1:35 PM, a Physician Assistant (Internal Medicine) Discharge Summary note documented in part, His stay at (facility name redacted) complicated by wounds and pain. Wound care has been following. Patient admits to pain at buttocks . Musculoskeletal : states he has a sore bottom- unable to adjust himself in bed . integument- 13.9cm (centimeters) irregular open area at buttocks/coccyx with undeterminable depth; base is bright pink with eschar and scattered yellow slough . wounds- he should follow closely with wound care; continue [MEDICATION NAME] prn (as needed) for pain; monitor for s/s (signs and symptoms of infection) . On 4/4/19 at 1:37 PM, a Physician Assistant (Internal Medicine) note documented in part, . labs reviewed in f/u (follow up) of leukocytosis (increased white blood cells) . leukocytosis- resolved; WBC normal . On 4/6/19 at 11:16 AM, a Nurse Practitioner (Internal Medicine) note documented in part, . He states the sore to his bottom is quiet painful today and needs a pain pill . Integ (Integument): large, deep sacral wound present- green hanging slough noted with pink granulation tissue with the wound, sight serosanguineous drainage to dressing, no odor . Temperature 99 F Oral 04/05/2019 at 01:12 AM . Had slight elevated temp yesterday and WBC (white blood cell count) elevation on 4/4 (but is trending down) . Pain to sacral wound: Does not appear infected. [MEDICATION NAME] PRN. D/C (discontinue) scheduled [MEDICATION NAME] d/t (due to) Will schedule Tylenol for pain . On 4/7/19 at 8:03 PM, a Nursing note documented in part, . Pt. (patient) requires extensive help with Transfers & Repositioning; at times requires 3 staff members . On 4/10/19 R#704's Treatment Record documented by nursing staff of R#704's buttock wounds as: C & D 4 width, 11 length, 1.0 depth (odor and drainage are blank), stage UTD (unstageable), Open would <sic> with slough, egdes <sic> are irregular, with odor and minimal drainage (merged together C +D). On 4/10/19 at 2:28 PM, a Nurse Practitioner (Internal Medicine) noted documented in part, . seen this afternoon in f/u (follow up) reports of inability to tolerate sitting in the chair during therapy. He states it made his bottom sore and he became short of breath. He was placed back in bed. He requests a pain pill . patient intolerant to sitting in chair d/t (due to) debility and pain from sacral wound. He was repositioned in bed and felt better. Asked nursing to give patient a pain pill. Will monitor vitals closely q (every shift) at this time . On 4/11/19 at 1:32 PM a Physician Assistant (Internal Medicine) Discharge Summary note documented in part, . His stay at (facility name redacted) complicated by wounds and pain. Wound care has been following. Patient admits to pain at buttocks . integument- 13x9 irregular open area at buttocks/coccyx with undeterminable depth; base is bright pink with eschar and scattered yellow slough (same note and wound measurements as Physician Assistant previous documentation) . Wounds- he should follow closely with wound care; continue [MEDICATION NAME] and [MEDICATION NAME] for pain; updating labs tomorrow to ensure no elevation in WBC (white blood cell), given staff concern of possible odor to wound; wound care has been following . On 4/12/19 at 3:05 PM a Nurse Practitioner (Internal Medicine) note documented in part, . seen this afternoon to review lab results. He is in his room lying in bed. His friend is with him, helping him to eat lunch . Integ (Integument): sacral wound present- extends deep into muscle, slough present. No odor. No purulent drainage . Leukocytosis with [DIAGNOSES REDACTED]ia: Wound appears stable . On 4/12/19 at 5:05 PM, a Nursing note documented in part, . 2 person assist with ADLs (Activity of Daily Living). Resident refused to eat breakfast and lunch. Staff, and resident's Family member attempted to feed resident, but were unsuccessful . On 4/15/19 at 1:07 PM, a Nursing note documented in part, . Abnormal Lab Results Reviewed and Logged BMP (Basic Metabolic Panel) Physician/NP/PA will be in to review. On 4/15/19 at 1:07 PM, a Nursing note documented in part, . Abnormal Lab Results Reviewed and Logged CBC (Complete Blood Count) Physician/NP/PA will be in to review. On 4/15/19 at 1:15 PM, a Nurse Practitioner (Internal Medicine) note documented in part, . seen this morning in f/u (follow up) daughter's (daughter's name redacted), request. She states she placed a phone call to his PCP (primary care physician) on Saturday 4/13, to discuss his wound. She wants him sent to Sinai Grace for a wound evaluation. His wound has been stable since he has been here and I have seen it numerous times. (Wound Doctor name redacted) has been following as well and appropriate treatments are in place. His pain is well controlled today. (Daughter's name redacted) feels there can be a surgical intervention i.e. skin flap, that can fix his wound . 4/15/2019 at 06:50 WBC (white blood cell count) 10.6 (H), Blood Urea Nitrogen (BUN): 42 (H) . Imp (Impression)/Plan 1. Sacral wound: I have evaluated this wound multiple times, (wound doctor name redacted) has been following as well and ordered appropriate treatments. Daughter, (daughter name redacted), called PCP (primary care physician) on 4/13, who recommends wound evaluation at Sinai Grace to evaluate for possible surgical flap. Do not feel this hospitalization is medically necessary at this time. Patient is supposed to discharge home this evening, Home care has been ordered RX (prescription) have been written for labs and medications. He is medically stable to d/c (discharge) home. However, daughter, (daughter named redacted) adamant he have further evaluation at Sinai Grace, as this is what his PCP (primary care physician) recommended from their phone conversation on 4/13. 2. I last checked his wound on 4/12/19- did not appear infected. Labs from today show reduction in WBC (White Blood Cell). No fevers noted . ARF (Acute [MEDICAL CONDITION]): Per (daughter's name redacted), he has been eating and drinking better this weekend when he receives assistance. Creat improved from 4/12- was 2.84, today down to 1.08 . On 5/10/19 at 12:31 PM, a Nursing noted documented, Late Entry 4/15/19- Resident sent to Sinai Grace per Daughter request for wound evaluation. Vitals signs 97.3 141/80 89 97% on 3L NC (nasal cannula). Resident discharged by ambulance. All belongings taken with family. A review of the facility's Braden Scale documentation for R#704 revealed the following: 03/13/19- 13 Moderate Risk 03/20/19- 15 Mild Risk 03/27/19- 13 Moderate Risk 04/03/19- 14 Moderate Risk The Resident CNA (Certified Nursing Assistant) Documentation was provided by the Director of Nursing (DON) as R#704's turning and repositioning schedule (Bed Mobility) which documented the following date's as Not Performed- Not Performed (Indicating R#704 was not turned or repositioned, with no further documentation indicating why the task was not completed): 3/14/19 at 9:59 AM for schedule 8:00 AM- 2:45 PM 3/14/19 at 10:07 PM for schedule 4:00 PM- 10:45 PM 3/15/19 at 9:21 PM for schedule 4:00 PM- 10:45 PM 3/16/19 at 10:50 PM for schedule 4:00 PM- 10:45 PM 3/17/19 at 10:59 PM for schedule 4:00 PM-10:45 PM 3/18/19 at 10:38 AM for schedule 8:00 AM- 2:45 PM 3/18/19 at 10:18 PM for schedule 4:00 PM-10:45 PM 3/19/19 at 3:25 PM for schedule 4:00 PM- 10:45 PM 3/20/19 at 11:18 AM for schedule 8:00 AM-2:45 PM 3/20/19 at 10:02 PM for schedule 4:00 PM- 10:45 PM 3/21/19 at 7:58 PM for schedule 4:00 PM- 10:45 PM 3/25/19 at 8:59 PM for schedule 4:00 PM- 10:45 PM 3/26/19 at 7:29 PM for schedule 4:00 PM- 10:45 PM 3/28/19 at 10:42 AM for schedule 8:00 AM- 2:45 PM 3/28/19 at 8:05 PM for schedule 4:00 PM- 10:45 PM 3/29/19 at 7:46 PM for schedule 4:00 PM- 10:45 PM 3/31/19 at 10:36 PM for schedule 4:00 PM- 10:45 PM 4/1/19 at 3:05 PM for schedule 8:00 AM- 2:45 PM 4/1/19 at 4:00 PM for schedule 4:00 PM- 10:45 PM 4/4/19 at 10:15 AM for schedule 8:00 AM- 2:45 PM 4/5/19 at 4:55 PM for schedule 4:00 PM- 10:45 PM 4/6/19 at 10:53 AM for schedule 8:00 AM- 2:45 PM 4/6/19 at 10:29 PM for schedule 4:00 PM- 10:45 PM 4/7/19 at 8:59 PM for schedule 4:00 PM- 10:45 PM 4/8/19 at 10:44 AM for schedule 8:00 AM- 2:45 PM 4/8/19 at 9:04 PM for schedule 4:00 PM- 10:45 PM 4/9/19 at 10:54 AM for schedule 8:00 AM- 2:45 PM 4/9/19 at 7:03 PM for schedule 4:00 PM- 10:45 PM 4/10/19 at 10:16 PM for schedule 4:00 PM- 10:45 PM 4/11/19 at 11:01 PM for schedule 8:00 AM- 2:45 PM 4/11/19 at 9:52 PM for schedule 4:00 PM- 10:45 PM 4/12/19 at 10:01 PM for schedule 4:00 PM- 10:45 PM 4/13/19 at 11:06 PM for schedule 8:00 AM- 2:45 PM 4/13/19 at 8:02 PM for schedule 4:00 PM-10:45 PM 4/14/19 at 1:27 AM for schedule 11:59 PM- 6:45 AM 4/14/19 at 10:43 AM for schedule 8:00 AM- 2:45 PM 4/14/19 at 4:28 PM for schedule 4:00 PM- 10:45 PM 4/14/19 at 3:38 AM for schedule 11:59 PM- 6:45 AM A review of R#704's physician orders [REDACTED]. 3/13/19 at 6:41 PM, Assess sacral area daily for redness or open areas. Notify physician of abnormal findings. (Document on paper treatment sheet) 3:00 pm- 11:00 pm. *No treatment to buttocks ordered on Admission. 3/14/19 at 1:50 PM, Triad Wound dressing paste apply topical route every shift to coccyx R&L (right and left) buttocks (7AM-3PM, 3PM-11PM, 11PM-7AM). 3/14/19 at 8:13 PM, Medi honey 100% topical paste, Apply by topical route once daily to buttocks/coccyx wound after wash with NS (normal saline) and pat dry; pack with wet to dry; follow with Medi honey and Vaseline gauze; may cover with ABD (Abdominal dressing) and secure (7AM-3PM). 3/29/19 at 2:04 PM Clean coccyx/buttock with Darkins, pack with Saline dampened gauze, cover with ABD (abdominal dressing). Apply Calmospeptine peri wound (7AM-3PM and 3PM-11PM). The wound physician recommendations made on 3/29/19 was documented as follows: .Recommendations: . Clean with Dakins and allow to dry, Protect surrounding tissue with [MEDICATION NAME] or Triad and Pack/Fluff with saline-dampened (well-wrung-out) gauze bid (twice a day) and prn (as needed) . The order that was entered for R#704 did not reflect the wound care physician exact orders. On 9/5/19 at 12:37 PM, the DON was queried regarding the initial order for R#704's consultation with the wound doctor and why it took over two weeks for the initial wound care consultation. The DON stated, He was on vacation and we don't have anyone that covers for him. When asked if worsening or any changes to the wound are supposed to be reported to the physician, the DON acknowledged any new concerns or changes are supposed to be reported to the physician. When queried on the multiple dates that R#704 didn't receive assistance with turning and repositioning, the DON stated, I can't speak on that because that CNA no longer works here. When queried on why R#704's buttock ulcer assessment was not completed and documented according to the facility's pressure ulcer policy which documented a physician and nurse must evaluate the pressure ulcer progress at least weekly and document his/her assessment. The documentation must include those items listed in the guideline section (Size, Location, Depth, Stage, Presence or absence of necrosis/slough, tunneling/sinus tract, condition of wound bed progress toward healing, potential complications), the DON acknowledged the lack of documentation from the Nurse Practitioner and Physician Assistant. The DON was queried on the facility's weekly documentation of R#704's left and right buttock wound measurements and how they differed with the wound care physician and emergency room physician measurements and the DON stated We plan to do training on the measuring of wounds. It's difficult to measure some wounds. The DON was asked to provide any additional information or documentation regarding R#704's buttock ulcer care and no additional documentation was provided by the exit of survey. A care plan titled Alteration in Mobility (effective 3/13/19) documented in part, . Reposition with ADL (Assistance Daily Living), as tolerated, Up in chair or wheelchair as tolerated . A care plan titled Potential for Impaired Skin Integrity (effective 3/13/19) documented in part, . Administer pain medication if required for a resident's comfort with positioning changes, Braden assessment upon admission, then weekly for one month and then quarterly with implementation of appropriate interventions . Monitor skin for changes during daily bathing and routine care, especially over bony prominences for color changes, warmth and induration . Notify physician and the responsible party for health care of all new skin breakdown and worsening of pressure areas . Encourage or assist the resident, if needed, to turn and change positions every 2-3 hour prn . A care plan titled Skin- Pressure Ulcers, Site: Left Buttock (Size 3x3x2) and Site Right Buttock (3x3x1) (effective 3/19/19, 6 days after admission) documented in part, . Resident will receive stage appropriate wound care while here at facility, Encourage/assist resident to reposition every 2 hours as able and as tolerated, Monitor pressure ulcer for signs or symptoms of infection, Notify doctor is treatment is ineffective . Skin assessments upon admission, then weekly and PRN. Implement skin protocol as appropriate, treatment(s) per orders . A care plan titled Self-Care Deficit was reviewed and contained no documentation regarding staff needed assistance with R#704's turning and positioning. A care plan titled, Anticipated Decline, As Evidenced by: Dementia (effective 3/19/19) documented in part, . Anticipate weight loss, delayed healing, new or worsening skin breakdown, decline in activities and cognitive processing, ADL (Assistance Daily Living) needs will be anticipated by staff . Monitor for decline in ADLs, increased need of staff support, and report . Anticipate needs, Report all noted decline to physician and responsible party, Provide information, education and emotional support to resident, family and responsible party . A facility policy titled, Skin- Pressure Ulcer Guideline dated 6/05 with revision dates of 5/08, 5/13 and 5/18 documented in part, . When assessing an ulcer, it is important to do the following: . Size, Location, Depth & Stage of ulcer, The presence of absence of necrosis and slough, Tunneling or sinus tract, Condition of the wound bed, evidence of healing such as granulation (where visible), the presence of eschar and the status of surrounding skin. Monitor progress toward healing and for potential complications, Determine if infection is present . Assess, treat and monitor pain, if present; and Monitor dressings and treatments . If there is any change in the patient's skin conditions, the nurse or nurse manager should review and revise the patient's care plan accordingly and consult with the director of nursing, physician and/or wound care specialist as needed .worsening of previous areas must be reported to the resident and/ or their legal representative by the nursing department. Documentation of communication will be put in the progress notes by the nurse. Please include the person you spoke with . For Stage III or IV sores, the attending will be contacted upon discovery of the sore after the nurse has completed her/his initial assessment of the wound . If a determination is made that the development of a pressure sore was unavoidable, it must be documented by the nurse and physician that the elements for an unavoidable pressure ulcer were met . The CENA/Primary nurse involved in the resident's personal care will do daily skin inspection and report/document if a change or abnormal findings occur . Upon discharge from the facility, each patient will have a skin assessment performed and documented on the paper treatment sheet, unless the patient is transferred to the hospital 911 and the nurse is unable to do so . STAGE III OR STAGE IV WITH SHALLOW FULL THICKNESS- Protect/Manage exudate . The physician and the nurse must evaluate the pressure ulcer progress at least weekly and document his/her assessment. The documentation must include those items listed in the guideline section of the pressure ulcer policy. If NO IMPROVEMENT IN 2 WEEKS, Contact the ADON/Wound Care nurse .

Based on observation, interview, and record review the facility failed to assess a resident for the ability to safety handle hot liquids and provide appropriate supervision while consuming hot liquids for one (#915) of four residents reviewed for accidents and hazards from a total of twenty-five, resulting in the resident sustaining discomfort and first degree (superficial burn to first layer of the skin) and second degree (partial thickness burn affecting the first and second layer of the skin) burns. Findings include: On 11/15/16 at 11:45am, Resident #915 was observed seated in a geriatric chair in the Cedar unit dining room. Resident #915 was observed to not respond to questions when prompted at this time. On 11/15/16 at 3:00pm, the clinical record for Resident #915 was reviewed and revealed the resident was admitted into the facility on [DATE], and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's minimum data set (MDS) assessment dated [DATE], the resident scored 7/15 on a brief interview for mental status exam, which indicated that the resident was cognitively impaired. Per this MDS assessment, the resident required supervision and set-up assistance for eating. On 11/16/16 at 8:00am, a Non Fall Related Team Report dated 4/25/16 at 11:40am for Resident #915 was reviewed and revealed, in part, the following: Upon completion of AM exercises in MDR (main dining room), resident requested a cup of coffee from activities asst (assistant). Resident on HTL (honey thick liquids). Asst prepared thickened coffee, capped cup, returned resident to room and placed coffee on overbed table Resident removed cap off coffee cup, as is her practice, per staff and daughter. Staff to called to room by resident, having spilled coffee on lap Pants removed, cold compresses applied to thighs. When 1st compress removed, broken open blister to top of right thigh, approx (approximately) 3cm (centimeter) by 3cm-dermis (skin) [DIAGNOSES REDACTED]tous (reddened), [DIAGNOSES REDACTED] surrounding 50% of bilateral inner thighs. NP (nurse practitioner) in to evaluate. Silvadene cream ordered. Scheduled and PRN (as needed) pain Rx (prescription) ordered for c/o (complaints of) soreness and discomfort. Activities dept inserviced on not procuring coffee for confused residents. At this time, review of the coordinating Incident/Accident (I/A) report for Resident #915 dated 4/25/16 at 11:40am was reviewed and revealed, in part, the following: Resident stated she spilled her coffee on her lap .observed resident sitting in wheelchair with pants covered in coffee. Per the examination section of the report, the following was noted: Observed redness and blistering of the thighs. Per the comments section of the report, the following was documented: Please do not leave patient unattended with hot drinks. On 10/16/16 at 8:10am, an Employee Counseling and Corrective Action Record dated 4/27/16 was reviewed and revealed the following: You provided a confused resident c (with) a cup of hot coffee s (without) providing a clothing protector and left her unattended. The resident removed the cap off the cup of HTL coffee, spilling it on her lap/bilateral thighs, resulting in 1st and 2nd degree burns. On 10/16/16 at approximately 8:15am, further review of Resident #915's progress notes and careplans revealed, in part, the following: Per a note written by the internal medicine nurse practitioner dated 4/25/16, Patient seen today in f/u (follow up) reports of spilling hot coffee on her bilateral thighs, resulting in [DIAGNOSES REDACTED] and blistering she c/o (complains of) soreness to the burn areas Per the plan section of the note, the following was documented, First and second degree burns to bilateral thigh from spilling hot coffee on herself Will schedule Tylenol for pain. Per review of a late entry progress note dated 4/25/16 at 5:53pm the following was revealed: Writer entered residents room due to her yelling out for help. When writer entered the room residents pants were covered with coffee. Writer removed pants cleaned resident and observed her skin on her thighs were red and blistered Per Resident #915's cognitive deficit careplan dated 2/9/16, the resident was identified as having a Cognitive Deficit r/t (related to) Dx (diagnosis) of dementia as evidenced by BIMS and Orientation. On 11/16/16 at 11:33am, a Resident Safety Assessment dated 2/5/16 for Resident #915 was reviewed and revealed the resident was coded as having poor insight and intermittent confusion. Review of the resident's nursing admission assessment dated [DATE] revealed Resident #915 was alert, oriented to person, and displayed forgetfulness. On 11/16/16 at 8:30am, Activities Director (AD) 'A' was queried in regards to the process for distributing hot liquids to residents. AD 'A' responded that prior to the incident with Resident #915, if a resident (who was not on a fluid restriction or no fluids by mouth) was in their room and asked for a beverage, activity staff would get the resident a beverage, and would get a clothing protector for confused residents. AD 'A' was queried if Resident #915 was wearing a clothing protector on 4/25/16 at the time of the incident, and responded that she was unsure. When queried if Resident #915 should have had a clothing protector at this time, AD 'A' responded She should. AD 'A' stated that if a resident required supervision, the resident would be in the small dining room. Per AD 'A', Resident #915 was placed in the small dining room for increased supervision when she was first admitted to the facility, and the resident's family had requested that Resident #915 spend more time in her resident room. On 11/16/16 at 11:10am, the Director of Nursing (DON) was queried in regards to the process for assessing a resident's capability to safely handle hot liquids. When queried if Resident #915 had such an assessment, the DON responded that the resident did not have a formal assessment from nursing related to hot liquids. At this time, the DON was queried as to the process of supervising a resident who required supervision during eating. The DON responded that if a resident was to have supervision, staff could supervise the resident from a distance, and could be within eyesight of the resident. When queried as to if staff were within eyesight of Resident #915 when it was documented that a staff member responded to the resident when they heard the resident yelling, the DON offered no response. The DON was queried in regards to if the facility had a nursing policy for hot liquid assessments, and responded that the facility did not. A Hot Beverages policy from the dietary department dated 11/3/16 was reviewed at this time, and did not address assessing a resident for safety in handling hot liquids. ( )