Every finding on record at Gladwin Pines Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to ensure residents received timely and accurate assessments and monitoring for changes in condition for five of eight residents (Resident #77, Resident #45, Resident #51, Resident #7, and Resident #46) reviewed for quality of care. Findings: Resident #77 (R77) Review of an admission Record revealed R77 was an [AGE] year-old-male, originally admitted to the facility on [DATE] following a 15-day hospital stay, with pertinent diagnoses of a urinary tract infection (UTI), a stage 4 pressure ulcer of the sacrum, congestive heart failure, diabetes mellitus, low blood pressure, and retention of urine. R77 was admitted to the facility as a full code and was able to answer questions. Review of an Inpatient Discharge Summary for R77 dated 07-24-25 at 10:58 AM reflected the following information regarding R77's hospital stay and discharge orders: (a) on 07-14-25, R77 had a surgical excision and debridement of a stage 4 sacral wound, and a wound vacuum (negative pressure wound therapy) was placed, (b) continue wound vac (vacuum) at discharge, and (c) Outpatient Wound Treatment Clinic will need referral placed. An additional hospital consultation note indicated that a diverting colostomy was not advised by the surgeon at that time because the wound vac dressing fit well and provided a tight barrier against stool leaking into the sacral wound. Review of a Medical Equipment Work Order for R77 revealed an order, placed by facility staff and delivered to the facility on [DATE], for a wound vac kit. During an interview on 09-10-25 at 2:10 PM, Medical Records Coordinator (MRC) Q stated that the wound vac was delivered to the facility on [DATE] but staff had not signed for it, and MRC Q did not know where the wound vac was placed after it arrived at the facility. Review of a Skin Assessment for R77, completed by nursing on 07-26-25, reflected no wound measurements nor mention of the ordered and delivered wound vac. Review of a nursing Progress Note for R77, dated 07-27-25, revealed a moderate amount of drainage was noted in the sacral wound. Review of a nursing Progress Note for R77, dated 07-28-25, revealed no documentation regarding the condition of the stage 4 sacral wound. Review of a nursing Progress Note for R77, dated 07-29-25, revealed a large amount of drainage was noted in the sacral wound. Review of a nursing Progress Note for R77, dated 07-30-25, revealed a moderate to large amount of drainage and a faint odor were detected in the sacral wound. Review of an Electronic Treatment Administration Record (Etar) for R77, dated 07-31-25, revealed an order for Negative Pressure Wound Therapy (NPWT) to sacrum. Set vacuum at 125 mmHg (millimeters of mercury). Set to continuous. Inspect settings and visualize dressing is intact every shift. Change every 3 days starting 07-31-25 (seven days after the wound vac equipment had been delivered to the facility). Review of the corresponding Wound Measurement assessment, also completed 07-31-25 for R77, revealed the wound measured 8 cm (centimeters) long x 7.8 cm wide x 2 cm deep that included undermining from 7 o'clock to 12 o'clock that measured approximately 2 cm. Additional documentation on the 07-31-25 Wound Measurement assessment included questions/answers regarding additional descriptives of the sacral wound and the current condition of other skin areas, as well as a narrative written by the nurse regarding assessment notes and review of treatment effectiveness. Review of a nursing Progress Note for R77, dated 08-01-25, revealed no documentation that the dressing for the wound vac was sealed and functioning properly. Review of a nursing Progress Note for R77, dated 08-02-25, revealed no documentation that the dressing for the wound vac was sealed and functioning properly. Review of a nursing Progress Note for R77, dated 08-03-25, revealed no documentation about the change to the wound vac and the condition of the wound including the size, color, amount of drainage, if an odor was detected, or if the dressing for the wound vac was sealed and functioning properly when the dressing change was completed. Review of the next Wound Measurement assessment for R77, completed on 08-05-25, revealed the exact same measurements as those obtained on 07-31-25, the exact same answers to the questions regarding additional descriptives of the sacral wound as those documented on 07-31-25, and the exact same narrative written by nursing regarding assessment notes and review of treatment effectiveness. Review of a nursing Progress Note for R77, dated 08-05-25, revealed no documentation about the change to the wound vac and the condition of the wound including the size, color, amount of drainage, if an odor was detected, or that the dressing for the wound vac was sealed and functioning properly when the dressing change was completed. Additional review of the Etar for R77, dated July 2025, revealed an order for daily weight upon admission for three days. A weight was obtained on 07-25-25 but not on 07-26-25 and 07-27-25. Review of nursing progress notes for 07-26-25 and 07-27-25 revealed no documentation that explained why the last two daily weights were not obtained. Review of the Emar's (Electronic Medication Administration Record) and Etar's for R77 dated July 2025 and August 2025, revealed an order for staff to monitor and record urine output twice daily when emptying the foley (catheter in the bladder to evacuate urine) drainage bag. No documentation for urine output was found for 07-26-25 in the morning, 07-27-25 in the morning, 07-30-25 in the morning, 08-05-25 in the morning, 08-09-25 both in the morning and in the evening, and 08-10-25 in the evening. Review of the Inpatient Discharge Summary for R77 revealed an order to continue Midodrine 5mg (milligrams) twice daily. Midodrine was used to treat hypotension (low blood pressure) and was prescribed with parameters. The hospital administered the medication and used a blood pressure of 90/50 or lower for the parameter. The facility administered Midodrine to R77 without the use of any parameters starting the evening of 07-28-25 until the evening of 08-10-25. (24 doses) Review of an interdisciplinary progress note for an Admission-5 day MDS (minimum data set) review for R77, with the interview documented as completed on 07-28-25, revealed the following: (R77) is here to continue with skilled therapy to regain his strength and endurance so he can return home and (R77) is usually understood and usually understands others verbally. Review of a physician order for R77, dated 07-31-25, revealed an order for a U/A with C&S (urine analysis with a culture and sensitivity) due to a change in R77's mentation (cognitive status). Review of the U/A with C&S for R77, resulted on 08-03-25, revealed R77 had a UTI caused by the bacteria Escherichia Coli (E.Coli) and further noted the phenotypic resistance profile of this isolate is suggestive of an ESBL-producing Enterobacterale. During an interview on 09-11-25 at 10:40 AM, Infection Control Preventionist (ICP) E reported that he had not notified the physician about the results of the U/A and C&S for R77 that were completed on 08-03-25. ICP E stated that R77 was already taking an antibiotic for the UTI identified in the hospital. When ICP E was asked if the antibiotic that R77 was currently prescribed (Linezolid) was resistant or susceptible (effective or not) against E.Coli, ICP E reported not knowing. When ICP E was asked if he notified anyone of the U/A and C&S results for R77, ICP E stated no. Review of a facility prescriber Progress Note dated 08/05/25 reflected no documentation that indicated the nurse-practioner (NP) was made aware of the results of the U/A and C&S for R77 that had been resulted on 08-03-25. Further review of R77's electronic health record (EHR) revealed no documentation that any facility prescriber was made aware of U/A results from 08-03-25 prior to the resident's passing on 08-12-25. Resident #45 (R45) Review of an admission Record revealed R45 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: acute on chronic congestive heart failure (CHF). Review of R45’s “Heart Failure Clinic” consultation report dated 1/10/25 revealed, “…weigh yourself every morning; if you notice a weight gain of > 2 lbs in one day or > 5 lbs in one week, call our office…” Review of R45’s “Order Summary” dated 7/9/24 revealed, “Order Summary: Daily Weights for CHF.” Review of R45’s “Weight Summary” revealed her weights were not obtained on the following days: 7/3/25, 7/5/25, 7/7/25, 7/11/25-7/13/25, 7/16/25, 7/18/25, 7/20/25, 7/21/25, 7/26/25, 7/27/25, or 7/31/25. Confirming the order to notify the provider with a 2 lb weight increase in 1 day could not be completed due to insufficient monitoring. *7/9/25 a weight of 244 lbs, 7/10/25 a weight of 245.3 lbs, (no weights 7/11/25-7/13/25), 7/14/25 a weight of 249.5 lbs, 7/15/25 a weight of 249.6, and no weight obtained 7/16/25. Indicating R45 had a 5.6 lb weight gain in 1 week. There was no documentation that the provider was notified of the weight gain. *7/24/25 a weight of 238.2 lbs and 7/25/25 a weight of 242.2 lbs. Indicating R45 had a 4 lb weight gain in 1 day. There was no documentation that the provider was notified of the weight gain. Review of R45’s July “Treatment Administration Record” revealed: The weight obtained on 7/2/25 (240 lbs) was documented for the 7/3/25 weight assessment. The weight obtained on 7/4/25 (240.3 lbs) was documented for the 7/5/25 weight assessment. The weight obtained on 7/6/25 (240 lbs) was documented for the 7/7/25 weight assessment. The weight obtained on 7/15/25 (249.6 lbs) was documented for the 7/18/25 and 7/19/25 weight assessments. The weight obtained on 7/30/25 (242.4 lbs) was documented for the 7/31/25 weight assessment. Review of R45’s “Weight Summary” revealed her weights were not obtained on the following days: 8/1/25, 8/9/25, 8/12/25, 8/14/25-8/17/25, or 8/22/25. Review of R45’s August “Treatment Administration Record” revealed: The weight obtained on 8/11/25 (243.3 lbs) was documented for the 8/12/25 weight assessment. The weight obtained on 8/13/25 (243.5 lbs) was documented for the 8/14/25 and 8/17/25 weight assessments. Review of R45’s “Weight Summary” revealed her weights were not obtained on the following days: 9/3/25, 9/4/25, 9/5/25, or 9/6/25. Review of R45’s September “Treatment Administration Record” revealed: The weight obtained on 9/2/25 (243. lbs) was documented for the 9/3/25 weight assessment. Review of R45’s “Electronic Health Record” revealed no documentation for the rationale for not obtaining R45’s weights as ordered. Resident #51 (R51) Review of an admission Record revealed R51 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: systolic and diastolic congestive heart failure. Review of R51’s “Order Summary” dated 2/17/25 revealed, Weight M-W-F (Monday, Wednesday, and Friday). If weight increases by more than 2-3 lbs (pounds) on consecutive measurements or more than 5 lbs. in a week, let provider know in the morning for Fluid overload/CHF (Congestive Heart Failure).” Review of R51’s “Weight Summary” revealed that on 5/6/2025 R51’s weight was 177.8 pounds and on 5/9/2025 R51’s weight was 184.0 pounds (6.2-pound weight gain). Review of R51’s “Weight Summary” revealed her weight was not obtained on 8/1/25, 8/18/25, or 8/25/25. Review of R51’s “Weight Summary” revealed R51’s weight was obtained on 6/30/25 (180.4 lbs) and was not obtained again until 7/7/25. Review of R51’s July “Treatment Administration Record” revealed that the weight obtained on 6/30/25 was documented for the 7/2/25 and 7/4/25 weight assessment. Review of R51’s “Weight Summary” revealed R51’s weight was obtained on 8/6/25 (180.9 lbs) and was not obtained again until 8/11/25. Review of R51’s August “Treatment Administration Record” revealed that the weight obtained on 8/6/25 was documented for the 8/8/25weight assessment. Review of R51’s “Electronic Health Record” revealed no documentation for the rationale for not obtaining R51’s weight on 8/1/25, 8/18/25, or 8/25/25 or documentation that the provider was notified of the 6.2-pound weight gain. A request for documentation that the provider was notified of the 6.2-pound weight gain was requested via email on 09/11/2025 at 10:59 AM. No supporting documentation was received prior to survey exit. Resident #7 (R7) Review of an admission Record revealed R7 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: chronic atrial fibrillation (abnormal beating of the heart). Review of R7’s “Order Summary” dated 7/3/25 revealed, “daily weight one time a day for chf.” Review of R7’s “Weight Summary” revealed no weights were obtained on 7/11/25, 7/12/25, 7/14/25, 7/19/25/25, or 7/20/25. Review of R7’s July “Treatment Administration Record” revealed: The weight obtained on 7/13/25 (100.8 lbs) was documented for the 7/14/25 weight assessment. The weight obtained on 7/18/25 (99.6 lbs) was documented for the 7/19/25 weight assessment. Review of R7’s “Weight Summary” revealed no weights were obtained on 8/2/25, 8/8/25, 8/16/25-8/18/25, 8/22/25, 8/25/25, or 8/31/25 Review of R7’s August “Treatment Administration Record” revealed: The weight obtained on 8/1/25 (100.6 lbs) was documented for the 8/2/25 weight assessment. The weight obtained on 8/7/25 (101.9 lbs) was documented for the 8/2/25 weight assessment. The weight obtained on 8/15/25 (103 lbs) was documented for the 8/17/25 weight assessment. The weight obtained on 8/21/25 (103.2 lbs) was documented for the 8/22/25 weight assessment. The weight obtained on 8/24/25 (104.6 lbs) was documented for the 8/25/25 weight assessment. The weight obtained on 8/30/25 (105.6 lbs) was documented for the 8/31/25 weight assessment. Review of R7’s “Electronic Health Record” revealed no documentation for the rationale for not obtaining R7’s weights. Resident #46 (R46) Review of an admission Record revealed R46 was an [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: heart failure. Review of R46’s “Order Summary” dated 9/3/24 revealed, “Weigh M-W-F - If weight increase by more than 2-3 lbs. on consecutive measurements or more than 5 lbs. in a week, let provider know for chf.” Review of R46’s “Weight Summary” and “Medication Administration Record” revealed her weight was not obtained on 7/2/25, 7/9/25, 8/25/25 or 8/27/25. Review of R46’s “Electronic Health Record revealed no documentation for not obtaining R46’s weights. During an interview via email on 09/11/2025 at 4:23 PM, Regional Nurse Consultant (RNC) “A” confirmed the above residents had missing daily weights and confirmed licensed nurses were utilizing the previous weights in the “Treatment Administration Record” documentation. RNC “A” reported the licensed nurses would receive education regarding the assessment and documentation of daily weights. The facility did not have a policy for congestive heart failure. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Daily weights are an important indicator of fluid status. Each kilogram (2.2 lb) of weight gained or lost overnight is equal to 1 L of fluid retained or lost…Weigh patients with heart failure daily…” [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1059). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, A weight gain of 0.9 to 1.4 kg (2–3 lb) in 1 day indicates fluid-retention problems… daily weight is measured at the same time of day and on the same scale (Ball et al., 2019). This allows an objective comparison of subsequent weights. Accuracy of weight measurement is important because health care providers base medical and nursing decisions (e.g., drug dosage, medications) on changes…” [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 558). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the facility failed to implement the facility policy for pressure injury/wound management and ensure treatments were ordered and completed, for 3 of 17 residents (Resident #15, #7, and #5), reviewed for the treatment and prevention of pressure injuries.Findings:Resident #15 (R15) Review of an admission Record revealed R15 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of the sacral region with osteomyelitis (infection in the bone.) Review of R15’s “Order Summary” dated 7/27/25 revealed an active order (as of 9/11/25) for “Dakins (full strength) External Solution 0.5 % (Sodium Hypochlorite) Apply to Coccyx Wound topically every shift for Wound cleansing.” Review of R15’s wound clinic “Physician Orders Details” dated 8/1/25 revealed, “…The periwound skin appearance exhibited: Maceration, Rubor…Wound Treatment-Wound #2 Coccyx Cleanser: Dakins Solution 0.5 % 3 X Per Day…Use FULL STRENGTH DAKIN’S SOLUTION to rinse wound then use to apply wet-to-dry dressing Peri-Wound Care: Clotrimazole and Betamethasone 3 X Per Day… Peri-Wound Care: Coloplast CitricAid Clear AF Antifungal 3 X Per Day…every 2 hours and as needed after incontinence episodes Secondary Dressing: Woven Gauze Sponge…3 X Per Day… Secondary Dressing: Tegaderm Film 4x4…3 X Per Day…use to secure dressing, sealed down on three sides, open at the top…” The top of the document was time stamped 08/01/2025 at 4:44 PM with the wound clinics name indicating a fax to the facility was successful/received. The document did not include a fax cover page (page 1) but pages 2-5 were present. Per the State Operations Manual, “Macerated skin has a white appearance and a very soft, sometimes “soggy” texture. The persistent exposure of perineal skin to urine and/or feces can irritate the epidermis and can cause severe dermatitis, skin erosion and/or ulcerations.” Review of R15's Wound Measurement dated 8/1/25 revealed her wound measured 4.1cm length x 1.4cm width x 1.5cm depth. The periwound skin assessment indicated “intact-unbroken skin. Maceration was not documented. Chronic sacral wound, managed by wound care clinic. The wound vac was discontinued by the wound clinic. New orders for cleansing with Dakin's solution 0.5% and wet to dry with Dakin's solution. Cleaning is provided day shift and day shift as well as PRN after bowel movements due to the location of the wound. Her stool tends to go up towards the wound when she has a bowel movement. Wound Clinic requests for resident to reposition every two hours and in a chair for only up to 1 hour maximum. Complicating factors include continued pressure on wound, uncleanly practices, lack of proteins and pt's (patients) dementia, incontinence, educated both pt and spouse about importance of offloading to treat this wound . The facility referenced a diagnosis of dementia indicating R15 would require reminders for offloading/repositioning. The interventions to reposition every two hours and for the resident to be up in a chair for only 1 hour maximum were not implemented on R15’s care plan. Review of R15's Wound Measurement dated 8/7/25 revealed her wound measured 4.0cm length x 1.4cm width x 1.4cm depth. The periwound skin assessment indicated “intact-unbroken skin. Maceration was not documented. Chronic sacral wound, managed by wound care clinic. Orders for cleansing with Dakin's solution 0.5% and wet to dry with Dakin's solution. Cleaning is provided day shift and day shift (sic-presumed night shift) as well as PRN (as needed) after bowel movements due to the location of the wound .Wound Clinic requests for resident to reposition every two hours and in a chair for only up to 1 hour maximum. Complicating factors include continued pressure on wound, uncleanly practices, lack of proteins and pt's (patients) dementia, incontinence, educated both pt and spouse about importance of offloading to treat this wound . The interventions to reposition every two hours and for the resident to be up in a chair for only 1 hour maximum were not implemented on R15’s care plan. Review of R15’s “Order Summary” dated 8/7/25 revealed, “Wound (Coccyx): 1. Use full strength Dakin's solution to rinse wound. 2. Use Dakin's to apply wet-to-dry dressing. 3. Secondary dressing: Woven Gauze Sponge. 4: Secure with Tegaderm Film 4x4, sealed down on three sides, leave open at the top. Peri-Wound (Coccyx): Apply Clotrimazole and Betamethasone to the peri-wound with dressing changes. three times a day for Wound Care.” Indicating the treatment change wasn’t implemented for 6 days following the order change at the wound clinic. Additionally, Coloplast CitricAid was not initiated as directed by the wound clinic. Review of R15’s wound clinic “Physician Orders Details” dated 8/15/25 revealed, “…Her wound is still being contaminated with her loose stool and it had to be extensively cleansed of stool contamination today and the debrided… the peri-wound skin appearance exhibited: Rash, Maceration, Rubor…” Additional treatments to initiate with the previous order included: “Impressions/Recommendations: Peri-Wound Care: Duoderm 3x Per Day…apply around wound as a donut Peri-Wound Care: Stoma paste 3 x Per Day…” Review of R15’s wound clinic “Consultation Report” (completed at the time of the wound clinic appointment) dated 8/15/25 revealed, “…Pt (patient) to be checked + (and) changed Q1 hr (every hour), while awake. Q2 (every 2 hours) during sleep. Peri wound- -ostomy paste-duoderm to periwound -Dakins W – D (wet to dry) to wound bed -Top Layer Tegaderm (change) BID +PRN (twice a day and as needed) Cheeks & between legs -Acetic acid wash -ATF & Lotrisone (antifungal cream)…” The fax cover indicated the fax was successful/received on 8/15/25. Review of R15's Wound Measurement dated 8/15/25 revealed her wound measured 2.7cm length x 1.9cm width x 1.5cm depth. The periwound skin assessment indicated “intact-unbroken skin. Maceration was not documented. Chronic sacral wound, managed by wound care clinic. Orders for cleansing with Dakin's solution 0.5% and wet to dry with Dakin's solution. Cleaning is provided day shift and day shift as well as PRN after bowel movements due to the location of the wound Wound Clinic requests for resident to reposition every two hours and in a chair for only up to 1 hour maximum. Complicating factors include continued pressure on wound, uncleanly practices, lack of proteins and pt's dementia, incontinence, educated both pt and spouse about importance of offloading to treat this wound. Wound clinic notes that stool continues to contaminate the wound The facility confirmed the wound clinic notes were reviewed, however, R15's treatment order was not changed in the TAR at that time. Additionally, the wound note indicated the dressing change was being completed twice a day and not three times as directed by the wound clinic. The interventions to reposition every two hours and for the resident to be up in a chair for only 1 hour maximum were not implemented on R15’s care plan. Review of R15's Wound Measurement dated 8/19/25 revealed her wound measured 2.7cm length x 1.9cm width x 1.5cm depth. The periwound skin assessment indicated “intact-unbroken skin. Maceration was not documented. Chronic sacral wound, managed by wound care clinic. Orders for cleansing with Dakin's solution 0.5% and wet to dry with Dakin's solution. Cleaning is provided day shift and day shift as well as PRN after bowel movements .Wound was cleaned as instructed by orders. No measurement changes since the wound clinic visit on Friday .She was given education on calling to be changed as soon as she realizes she has had an incontinence episode to help reduce the amount of feces that gets into the dressing and wound . The note indicated wound care completed as instructed by orders however R15's treatment changes from 8/15/25 continued to go unchanged. The interventions to reposition every two hours and for the resident to be up in a chair for only 1 hour maximum were not implemented on R15’s care plan. The wound was not assessed again until 8/29/25 (10 days). Review of R15's Wound Measurement dated 8/29/25 revealed her wound measured 2.6cm length x 1.9cm width x 1.5cm depth. The periwound skin assessment indicated “intact-unbroken skin. Maceration was not documented. Chronic sacral wound, managed by wound care clinic. Orders for cleansing with Dakin's solution 0.5% and wet to dry with Dakin's solution. Cleaning is provided day shift and day shift as well as PRN after bowel movements due to the location of the wound .Education provided about offloading, protein intake, hygiene, and letting staff at SNF (skilled nursing facility) know when she is incontinent. She states understanding, but has dementia . Confirming the facility was aware that R15 required reminders to offload pressure and frequent check and changes. R15's treatment changes from 8/15/25 continued to go unchanged. The interventions to reposition every two hours and for the resident to be up in a chair for only 1 hour maximum were not implemented on R15’s care plan. Review of R15's Wound Measurement dated 9/5/25 revealed her wound measured 2.5cm length x 1.5cm width x 1.5cm depth. The periwound skin assessment indicated “intact-unbroken skin. Maceration was not documented. Chronic sacral wound, managed by wound care clinic. Orders for cleansing with Dakin's solution 0.5% and wet to dry with Dakin's solution. Cleaning is provided day shift and day shift as well as PRN after bowel movements. Wound Clinic requests for resident to reposition every two hours and in a chair for only up to 1 hour maximum. Complicating factors include continued pressure on wound, uncleanly practices, lack of proteins and pt's dementia, incontinence, educated both pt and spouse about importance of offloading to treat this wound . The interventions to reposition every two hours and for the resident to be up in a chair for only 1 hour maximum were not implemented on R15’s care plan. Review of R15’s “Order Summary” dated 9/9/25 revealed, “Gently cleanse buttocks, groin and peri area and pat dry. Apply Bag Balm ointment to macerated areas. every shift for Skin protectant on macerated skin.” Bag Balm was ordered prior to the implementation of the wound clinic treatments for the periwound. The wound clinics treatment orders continued to go unordered (25 days). Review of R15’s “Interdisciplinary Documentation” dated 9/9/2025 revealed, “Wound: dressing to coccyx completed, large amount of wetness noted. wound bed is moist and pink, surrounding tissue red as well as buttocks and groin hot red, no odor. Bag balm being applied. (R15) is sleeping on a pressure reduction mattress. She does fairly well with bed mobility herself…” Indicating the resident required assistance with bed mobility and offloading pressure. Review of R15’s “Interdisciplinary Documentation” dated 9/10/2025 revealed, “(R15) dressing to her coccyx done large amount of drainage she has a red excoriated rash to her groin, peri area, between her legs and buttocks. She seems to have a constant stream of urine making it a wet environment. Bag balm being applied as ordered…” Indicating the worsening of R15’s skin breakdown. Review of R15’s “Order Summary” revealed no order for ostomy paste and Duoderm to periwound or for acetic acid wash and ATF & Lotrisone for “cheeks & between legs” as of 9/11/25 (27 days). Review of R15’s “Electronic Health Record” revealed no documentation/rationale for the lack of implementation of the wound clinics treatment orders. Review of R15’s “Interdisciplinary Documentation” dated 9/10/2025 revealed, “Resident experiencing frequent episodes of urinary incontinence. Spoke to resident about placing a foley catheter to help with moisture control in order to heal her macerated skin and coccyx wound. Resident voiced understanding and agreed with placement of indwelling foley cath…” Indicating R15’s wound did not show improvement and continued to present with maceration. The facility placed a foley catheter to prevent ongoing breakdown prior to implementing the wound clinics treatment for her periwound. Review of R15’s “Order Summary” dated 9/10/25 revealed, “Place foley catheter for skin integrity one time only for wound healing.” Review of R15’s August “Treatment Administration Record (TAR)” revealed multiple missed treatments for the coccyx treatment ordered on 8/7/25. Missed treatments as follows: 8/8/25 9:00 AM and 2:00 PM treatments, 8/9/25 10:00 PM treatment, 8/13/25 10:00 PM treatment, 8/16/25 10:00 PM treatment, 8/22/25 10:00 PM treatment, 8/25/25 9:00 AM, 2:00 PM, and 10:00 PM treatments, 8/31/25 2:00 PM treatment. Review of R15’s “Order Summary” and July, August, and September “Treatment Administration Record (TAR)” revealed: *An order for Dakins (full strength) External Solution 0.5 % (Sodium Hypochlorite) Apply to Coccyx Wound topically every shift (day shift and night shift)…” Began on 7/27/25 and was ongoing as of 9/10/25. The facility nurses continued to document on the TAR that the treatment was completed. *An order for Betamethasone Dipropionate External Cream 0.05 % (Betamethasone Dipropionate (Topical)) Apply to peri-wound (coccyx) topically every shift…” Began on 7/27/25 and continued until it was put on hold on 9/7/25. The facility nurses continued to document on the TAR that the treatment was completed. Review of R15's wound clinic “Physician Orders Details” intervention recommendations from 8/1/25, 8/15/25, and 8/29/25 revealed, .Off-Loading .Turn and reposition every 2 hours-limit time in wheelchair to 1 hour with each meal and then return to bed .Bathing/Shower/Hygiene .may shower, rewash wound after showering . Additionally, the wound “Consultation Report” dated 8/15/25 recommended R15 to be checked and changed every hour, while awake and every 2 hours during sleep. Review of R15’s “Care Plan” with revisions revealed none of the wound clinic’s intervention recommendations were transcribed or implemented. During an interview on 09/11/2025 at 9:57 AM, Regional Nurse Consultant (RNC) “A” was notified of concerns pertaining to R15’s treatment orders not initiated promptly or at all, her care plan not updated with wound clinic recommendations, treatments not completed, and previous treatments not discontinued. Resident #7 (R7) Review of an admission Record revealed R7 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: pressure ulcer of buttock. Review of R7’s “Order Summary” dated 7/17/25 revealed an active order (as of 9/11/25) for “Left Ischium: cleanse with acetic acid, apply Collagen prism to wound bed, Apply Mepilex border dressing 4x4. Every day shift for wound care.” Review of R7’s wound clinic “Physician Orders Details” dated 8/20/25 revealed, “Wound #3 (left ischium) is healed today…” Review of R7’s “Wound Measurement” report dated 8/21/25 revealed, “…The right Ischial wound has been noted as healed by the wound clinic. We will continue to monitor for changes but will heal the wound for weekly assessments. Wound care notes 8/20/25 Left ischium healed…” Confirming the facility reviewed the wound clinic “Physician Orders Details.” Review of R7’s wound clinic “Physician Orders Details” dated 8/27/25 revealed no documentation/assessments or any new treatments for R7’s Left Ischial wound. Confirming the wound had healed. Review of R7’s “Skin Assessment” dated 8/27/25 revealed, “…Left ischium wound is healing with continued treatment order…” Indicating an inaccurate assessment of R7’s skin. Review of R7’s “Wound Measurement” report dated 8/28/25 revealed, “…The right Ischial wound has been noted as healed by the wound clinic. Discontinue wound treatment .” Review of R7’s wound clinic “Physician Orders Details” dated 9/3/25 revealed no documentation/assessments or any new treatments for R7’s Left Ischial wound. Confirming the wound had healed. Review of R7’s “Skin Assessment” dated 9/3/25 revealed, “…Left ischium wound is healing with continued treatment order…” Indicating an inaccurate assessment of R7’s skin. Review of R7’s “Wound Measurement” report dated 9/3/25 revealed, “…The right Ischial wound has been noted as healed by the wound clinic. We will continue to monitor for changes but will heal the wound for weekly assessments after 2 weeks have passed and it remains healed. Wound clinic notes…” Review of R7's wound clinic “Physician Orders Details” dated 8/20/25, 8/27/25, and 9/3/25 revealed, “Wound Treatment…Wound #2-Sacrum-Cleanser: Acetic Acid Irrigation…with each dressing change do a 5 minute wound soak with acetic acid… Wound #3 (Left Ischium) Secondary Dressing: Mepilex Border Dressing, 4x4 every other day.” Review of R7’s “Order Summary” revealed no order for the Mepilex Border Dressing for the left ischium or for the acetic acid wound soak for the sacrum as ordered by the wound clinic. Review of R7’s August and September “Treatment Administration Record” revealed the treatment for “Left Ischium: cleanse with acetic acid, apply Collagen prism to wound bed, Apply Mepilex border dressing 4x4 every day shift for wound care” continued to be completed through 9/11/25. Review of R7's wound clinic “Physician Orders Details” intervention recommendations from 8/20/25, 8/27/25, and 9/3/25 revealed, .Off-Loading .Turn and reposition every 2 hours *Other: - Time in chair must be limited to 30 minutes to 1 hour MAX at a time (at mealtimes 3 times per day). Pressure on buttocks MUST be limited . Bathing/Shower/Hygiene *May shower with protection but do not get wound dressing(s) wet. Protect dressing(s) with water repellant cover (for example, large plastic bag) and may then take shower . Review of R7’s “Care Plan” with revisions revealed none of the wound clinic’s intervention recommendations were transcribed or implemented. During an interview via email on 09/11/2025 4:23 PM, RNC “A” stated, “treatment for (R7) should have been discontinued when noted (the left ischial wound) healed and was not.” During an interview on 09/11/2025 at 9:57 AM, RNC “A” and the Director of Nursing (DON) were notified of treatment order discrepancies and wound clinic care planned interventions not implemented for R15 and R7. RNC “A” and DON reported additional and/or supporting documentation would be provided if found. RNC “A” reported that they had identified that there was a delay in the wound clinic providing their progress notes/consultation reports which resulted in treatment order changes not being implemented promptly. On 09/11/2025 at 1:26 PM a request for any additional supporting documentation regarding R15 and R7’s pressure injuries was requested to be submitted by 5:30 PM. No additional documentation was received. R5 Review of an “admission Record” revealed R5 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and complete paraplegia (loss of motor and sensory function). Review of a current end of life Care Plan intervention for R5, initiated revised 2/24/2025, revealed “…Hospice has been elected and the facility & hospice will coordinate care & services…” Review of activities of daily living “Care Plan” intervention for R5, initiated 9/6/2024, revealed R5 was using an Alternating Pressure Air Mattress (APM). (APM mattresses use a pump to inflate and deflate cells or channels within the mattress in a cyclical pattern to prevent the body’s weight from resting on one area too long to prevent pressure ulcers.) Further review revealed an intervention revised 4/9/2025 to “ensure mattress is on soft setting and static feature is not activated.” Review of R5’s “Wound Measurement”, dated 1/13/2025, revealed his left heel wound was healed and he had no other wounds at that time. Review of R5’s “Interdisciplinary Documentation” note, dated 1/30/2025 at 3:36 PM, revealed a new open area on his sacrum measuring 0.8 by 0.6 by 0.1 cm. Review of R5’s “Interdisciplinary Documentation” note, dated 2/3/2025 at 5:45 PM, revealed R5’s coccyx wound was significantly worsening, and Clinical Care Coordinator (CCC) “F” was notified. Review of R5’s “Interdisciplinary Documentation” note, dated 2/19/2025 and documented by former CCC/Wound Nurse “F”, revealed “…(R5) treated for wound infection with cephalexin (anti-biotic) …Wound occurred from unfavorable mattress setting…” Review of R5’s “Wound Measurement” documentation during this time frame revealed: 2/4/2025- Coccyx pressure- 8.5 by 5.0 by 0.2 cm, stage IV Left buttock blister- 4.0 by 2.0 cm, stage II Right scapula pressure- 11.2 by 9.0 cm, suspected deep tissue injury Left heel pressure- 7.4 by 6.0 cm, suspected deep tissue injury “…New orders placed for daily cares, confirmed air mattress on correct settings…” 2/10/2025- Coccyx pressure- 10 by 14.5 cm, stage IV Right scapula pressure- 4 by 3.8 by 0.2 cm, stage II Left heel pressure- 2.4 by 3.5 cm, suspected deep tissue injury “…buttock wound merged with coccyx wound…” 2/19/2025- Coccyx pressure- 8 by 5 by 4 cm, stage IV Left buttock pressure- 3 by 3 by 0.1 cm, stage II Right scapula pressure- 3 by 2.6 by 0.1 cm, stage II Left heel pressure- 2.6 by 3.6 cm, suspected deep tissue injury In a telephone interview on 9/10/2025 at 2:50 PM, former CCC/Wound Nurse “F” reported she performed an investigation when she was informed of R5’s new wounds and found that his APM mattress was in static mode (a setting where the mattress maintains a firm, constant pressure rather than the usual cyclic inflation and deflation of air cells). Former CCC/Wound Nurse “F” reported she could not confirm how long the bed had been in static mode and staff were educated to ensure that the bed was not left in static mode in the future. In in interview on 9/11/2025 at 8:15 AM, Regional Nurse “A” reported she completed an audit on the air mattresses in the facility on 2/4/2025 when R5’s APM mattress was found to be in static mode. Regional Nurse “A” reported R5’s mattress should always be left in alternating mode and not in static mode, according to his individualized care plan. R5’s Treatment Administration Record (TAR) was reviewed. Undocumented wound treatments in August 2025 were discussed, as well as incorrectly ordered frequency of dressing changes (scheduled too often in some cases). Regional Nurse “A” reported dressings should be performed as ordered, with no missing documentation. Regional Nurse “A” reported treatments should not be completed more often than ordered, as this can also cause wounds to worsen. Review of R5’s August 2025 TAR revealed: “Apply border foam dressing to right knee for skin breakdown preventative. Change every 5 days”- Dressing documented as completed on 8/1/25, 8/2/25, 8/3/25, 8/4/25, 8/5/25, 8/6/25, 8/11/25, 8/12/25, 8/16/25, 8/18/25, 8/19/25, 8/20/25, and 8/21/25 (more often than every 5 days). “Coccyx: cleanse with (normal saline), soap and water, or wound cleanser, apply calcium alginate dressing (cut to size), cover with nonstick telfa and foam every day shift for wound care”- Undocumented dressing changes on 8/17/25, 8/22/25, 8/24/35, and 8/25/25. “Coccyx: cleanse with (normal saline), soap and water, or wound cleanser, apply wet to dry dressing, cover with abd secure with paper tape every day shift for wound care”- Undocumented dressing changes on 8/1/25, 8/3/25, 8/7/25, 8/8/25, 8/9/25, 8/10/25, 8/13/25, 8/14/25, and 8/15/25. Review of facility policy/procedure “Skin at Risk Assessment: Documentation, Staging, & Treatment”, revised 1/2020, revealed “…It is the policy of this facility to assess resident risk factors for the development of impaired skin integrity and intervene as indicated utilizing the admission assessment, plan of care, and Minimum Data Set as formal assessment tools. It is the policy of this facility to assess skin on a regular basis to determine whether changes in the patient’s skin condition have occurred. Weekly measurements and narrative assessments are conducted on existing pressure injuries…”

Based on observation, interview, and record review, the facility failed to maintain best practices in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 9/09/2025 at 11:00AM, during the initial walkthrough, it was observed that there was a resident's personal food item in the Therapy Room refrigerator dated 9/1-9/4. Certified Dietary Manager (CDM) L said that resident's personal food items were not usually stored in the Therapy Room refrigerator, and she noted it was past the use-by date on the sticker. According to the 2022 FDA Food Code section 3-501.18 Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition. (A) A FOOD specified in 3-501.17(A) or (B) shall be discarded if it: (1) Exceeds the temperature and time combination specified in 3-501.17(A), except time that the product is frozen; (2) Is in a container or PACKAGE that does not bear a date or day; or (3) Is inappropriately marked with a date or day that exceeds a temperature and time combination as specified in 3501.17(A) . On 09/09/2025 at 1:05PM, two wastewater drain lines were observed draining from the ice machine and the attached ice bin, and the wastewater drain lines did not have air gaps. When asked CDM l indicated that they were unaware that the lines were not air gapped.According to the 2022 FDA Food Code section 5-402.11 Backflow Prevention. (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. P

Based on interview and record review the facility failed to implement an effective Infection Prevention and Control Program for a physically compromised Resident (R74) resulting in frequent infections and frequent and aggressive antibiotic therapy without analysis of recurrence, efforts to determine root cause, or actions to ensure proper implementation of infection prevention measures. Findings include:Review of the admission Record reflected R74 originally admitted to the facility 4/12/21 with current diagnoses that included: Chronic Respiratory Failure with Dependence on a Ventilator, Tracheostomy, and Gastrostomy (feeding or peg tube). The medical record reflected R74 also had a nephrostomy catheter. The medical record reflected Enhanced Barrier Precautions (EBP. An elevated level in the use of personal protective equipment) during high contact resident care.Review of the Electronic Medical Record (EMR) revealed a history of frequent infections with antibiotic therapy and included:April 2025The EMR reflected in April R74 had received Amoxicillin (an antibiotic) via peg tube for an oral infection. On 4/4/25 Doctor's Orders reflected this was discontinued and changed to intramuscular injections of Rocephin (an antibiotic) for the oral and an added bronchitis infection until 4/9/2025. On 4/16/25 at 7:02 PM the EMR Progress Notes reflected R74 presented with a fever and low oxygen saturation. The EMR Progress Notes on 4/17/25 at 9:21 AM reflected R74 was ultimately admitted to the Intensive Care Unit for treatment of septic shock. The EMR reflected R74 returned from the hospital at 7:00 PM on 4/24/25 and received an additional intramuscular injection of Rocephin for sepsis. May 2025The EMR Progress Note dated 5/4/25 at 11:00 PM reflected R74 had a temperature of 100.7 and had vomited. On 5/5/25 the Doctor's Order reflected the antibiotic Levofloxacin was ordered for five days to treat pneumonia. The EMR Progress Note of 5/14/25 at 11:25 AM reflect R74 had a notable swelling of her right cheek and antibiotic therapy of Amoxicillin had been initiated for an oral infection.June 2025 The EMR Progress Note dated 6/19/25 at 7:49 PM reflected R74 had an elevated temperature the previous day, presented with edema (swelling) in her right lower extremity and a lower than normal blood pressure. The EMR reflected lab work and a chest x-ray was ordered. The Medication Administration Record (MAR) for June 2025 reflected on 6/19/25 R74 received an intramuscular injection of Ertapenem (antibiotic) and started Amoxicillin for ten days due to an elevated white blood cell count (an indicator of an infection). The medical record reflected on 6/27/25 another chest x-ray was completed on R74, and antibiotic therapy was escalated to intramuscular injections of Cefepime for leukocytosis (elevated white blood cell count) and bilateral lung opacities for seven days. Additionally, an increased dose of the diuretic Lasix from 20 milligrams (mg) to 40 mg was initiated. The antibiotic intramuscular injection continued through 7/3/25.July 2025Review of the EMR Progress Notes of R74 reflected on 7/16/25 at 10:15 AM large amounts of yellow/green secretions were removed from the Residents airway. On 7/18/25 at 1:47 AM the Progress Notes reflected R74 again was suctioned of large amounts of yellow/green sputum, had increased work of breathing, a respiratory rate over forty breaths per minute, oxygen saturation levels in the 70 percent range and a heart rate over 130 beats per minute. The next Progress Note documented approximately one hour later at 2:46 AM reflected that R74 had been to and returned from the hospital. The documentation reflected that R74 had been diagnosed with pneumonia and an elevated white blood cell count. Antibiotic therapy of Levofloxacin for seven days with concurred orders for Zithromax for six days. Furthermore, a topical antifungal for an apparent fungal infection was ordered to be applied to the Resident's neck. The EMR reflected Interdisciplinary Documentation on 7/18/25 at 10:30 AM summarized that the condition of R74 meets the criteria for Loeb and McGeer (infection control tools used to determine an infectious process) and concluded R74 had a respiratory infection. This documentation reflected that the Resident was on a ventilator . had an increase of secretions and decreased (oxygen saturation levels) and termed these symptoms as the Root cause. The extent of the post-incident analysis involved medications were reviewed and the Resident would be monitored. August 2025Review of the medical record for R74 reflected on 8/11/25 the antibiotic therapy of Amoxicillin was initiated for oral infection for 10 days. September 2025Review of the medical record for R74 reflected a Doctor's Order on 9/6/2025 for treatment of a urinary tract infection (UTI) with intramuscular injections of ceftriaxone. This was discontinued on 9/9/25 and was changed to an intramuscular injection of Ertapenem (antibiotic) for five days. In summary, since April of 2025 R74 was admitted to the hospital for treatment of septic shock, treated with three antibiotics for an elevated white blood count of undetermined origin, one urinary tract infection, treated three times for pneumonia/bronchitis, and three times for oral infections with 14 antibiotics. Over this period the medical record reflected one root cause analysis that determined secretions and low oxygen levels were the root cause. No documentation was found in the medical record that reflected a review was conducted to ensure Enhanced Barrier Precautions were implemented. No documentation was identified that proper care of the peg tube and nephrostomy catheter were verified, or that sterile technique was executed with tracheotomy care, suctioning and oral care.In an interview conducted with 9/11/25 at 10:48 AM, Infection Preventionist (IP) E reported he assumed the role of IP on 7/2/25. IP E reported he had not detected any pattern of infections or antibiotic use and had not noted that anything had stuck out regarding the care of R74. IP E reported he had been to one monthly Quality Assurance meeting since assuming the role and did not indicate the collective infection and antibiotic use history had been reviewed. A review was conducted of the provided policy titled Infection Prevention and Control Plan, last reviewed by the facility 2/25/25. The policy reflected Policy: It is the policy of this facility to implement the Infection Prevention and Control Program utilizing . (established regulations) pertaining to infection control. The policy reflected 1, The infection control committee incorporates. on an ongoing basis .Surveillance, prevention and control of infections throughout the facility.Selects and implements the evidence-based processed to minimize adverse outcomes.Continually evaluates and monitors the results and presents recommendations for revision to policies and techniques. 2. Surveillance includes (Healthcare Acquired Infections - HAI's) among.residents. Infections are monitored when a treatment plan is ordered by a Health Care Practitioner.c, A collaborative corrective action plan is formulated when surveillance and/or evaluation detects an area of concern or opportunity for improvement.d. The Infection Prevention Manager (IP) assumes direct accountability for the surveillance, aggregation, and analysis of the data.e. Surveillance data may prompt auditing of specific procedures and/or a thorough infection control assessment.3. Targeted analysis will be conducted that are high risk. 4. Monitoring and evaluation of key performance aspects of infection control through preventing, identifying, reporting, investigating and controlling infections.8. Infection prevention is a multi-disciplinary activity with collaboration amongst departments to identify any HAI trends or patterns that may occur or opportunities to improve outcomes in the reduction ad control of infections.10. Confirmed infections are evaluated to assure proper implementation of blood and body fluid barriers. 11. A Departmental infection control inspections are completed and designated monthly.13. Monitoring is achieved through. i. Implementation of infection control practices for resident care such as urinary catheter care, wound care, IV care, incontinence care, respiratory care, dialysis or other invasive treatment.On 9/11/25 at 11:14 AM, an interview was conducted with the Director of Nursing (DON) and Regional Nurse A in the office of the DON. The DON acknowledged that three IP's held the position from April to July 2025. The DON indicated that the interim IP in May and June 2025 was in a corporate position and was onsite weekly or every couple of weeks. The DON was informed of the prevalence of infections and antibiotic treatment of R74 since April 2025. The DON was asked if she was aware of these and if the totality of these infections and treatment had been discussed in Quality Assurance meetings. The DON and Regional Nurse A indicated this would be reviewed.On 9/11/25 at 12:12 PM Regional Nurse A reported that since May of 2025 skin infections were reviewed at Quality Assurance meetings.As of survey exit, no additional information had been provided on the care and treatment of R74 from April to September 2025. No additional information was provided that concerned the implementation of the Infection Prevention and Control Plan consistent with facility policy.

Based on interview and record review, the facility failed to ensure a qualified Infection Preventionist was in place to properly maintain, manage, and monitor the Infection Prevention and Control Program. Findings include: Review of the document provided by the facility reflected Infection Preventionist (IP) E was awarded an IP certification on 7/2/2025.On 9/11/2025 at 11:14 AM an interview was conducted with the Director of Nursing (DON) in her office. The DON reported, due to a staff vacancy, prior to 7/2/2025 an interim IP was in place. The DON later reported the previous IP left the position on 4/26/2025. The DON indicated an interim IP at the corporate level was in place from 4/26/2025 until 7/2/2025. The DON reported the interim IP monitored the Infection Prevention and Control Program from afar. The DON reported the Interim IP was in weekly or every couple of weeks. The DON reported she was not certain of the interim IP's schedule. As of survey exit no additional information was provided by the facility.

Based on observation, interview, and record review, the facility failed to follow standards of practice during medication administration for three residents' (Resident #29, Resident #67, and Resident #58) out of 17 residents reviewed. Findings: Resident #67 (R67) Review of an admission Record revealed R67 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R67’s “Order Summary” dated 2/2/22 revealed, “Ultram Tablet 50 MG (traMADol HCl) .Give 1 tablet by mouth every 6 hours as needed for pain.” Review of R67’s “Controlled Drug Receipt/Record/Disposition Form” revealed that on 8/4/25 a dose of Ultram was dispensed at 5:08 AM and again at 8:04 AM. (Approximately 3 hours apart). Review of R67’s August “Medication Administration Record” confirmed that the doses of Ultram were administered at 5:08 AM and 8:04 AM. During an interview via email on 09/11/2025 at 4:23 PM, Regional Nurse Consultant (RNC) “A” confirmed R67’s Ultram was administered 3 hours apart which did not follow the providers order of every 6 hours. RNC “A” stated, “We filled out a medication discrepancy for the tramadol (Ultram) given too soon and we are doing education with the nurse.” Resident #29 (R29) Review of an admission Record revealed R29 was a [AGE] year-old-male, admitted to the facility on [DATE], with pertinent diagnoses of respiratory failure requiring a tracheostomy and dependence on a ventilator and muscular dystrophy. Review of a Physician Order Summary (POS) for R29 reflected an order for Ativan (an anti-anxiety medication and controlled substance) 0.5 mg (milligrams) one tablet by mouth three times a day. The POS also reflected an order for Morphine Sulfate (a pain reliever and controlled substance) 15 mg one tablet every 12 hours. Review of an Electronic Medication Administration Record (Emar) for R29 dated September 2025 revealed documentation that R29 received three doses of Ativan on 9-7-25. Review of a Controlled Drug Receipt/Record/Disposition Form (CDRRDF) reflected documentation that only two doses of Ativan 0.5 mg were signed out on 9-7-25 for R29. Further review of the Emar for R29 revealed documentation that on 9-7-25, the resident received two doses of Morphine 15mg. Review of the CDRRDF for R29 revealed that only one dose was signed out on 9-7-25. During an interview on 09-10-25 at 1:45 PM, the Director of Nursing stated that documentation on the Emar and CDRRDF's must match because that was the process used to reconcile controlled substances. Resident #58 (R58) Review of the admission Record reflected R58 originally admitted to the facility 10/21/2016 with a pertinent diagnosis of Diabetes Mellitus. Review of the medical record for R58 reflected current Doctor’s Orders for insulin to be administered from the Novolog FlexPen and a Lantus SoloStar pen injector. Review of the manufacturer’s instruction for the Novolog FlexPen reflected that after attaching a new needle onto the device the instructions reflect “Giving the airshot before each injection…Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: …E. Turn the selector to select 2 units (see diagram…) F. Hold your Novolog FlexPen with the needle pointing up. Tap the cartridge gently with your fingers a few times to make any air bubbles collect at the top of the cartridge (see diagram…) G. Keep pointing the needle upwards, press the push-button all the way in (see diagram…) The dose selector returns to 0. A drop of insulin should appear at the needle tip, If not, change the needle and repeat the procedure no more than 6 times. If you do not see a drop of insulin after 6 times, do not use the Novolog FlexPen”. The instructions reflect if a drop of insulin does appear the user may proceed to set the dose selector to the required number of units and continue the administration process. Review of the manufacturer’s instructions for the Lantus SoloStar pen reflect a similar process as above and the user is to “Always perform the safety test before each injection” and “Do not select a dose or press the injection button without a needle attached”. The instructions reflect the safety test ensures an “accurate dose”, …” that pen and needle work properly” and removes “air bubbles”. The safety test requires selecting a dose of 2 units, tapping the device and ensuring insulin comes out of the needle tip as previously described. However, the Lantus SoloStar reflects two unsuccessful repeat attempts may indicate the device, or needle is “damaged” and to not use. On 9/10/2025 at 7:23 AM a medication administration observation and interview were conducted with Registered Nurse (RN) “I”. RN “I” was observed preparing two insulin pens for administration to R58. RN “I” was observed applying new needles to a Novolog Flexpen and a Lantus Solostar pen injector. RN “I” then dialed each pen to dispense the prescribed dose of insulin from each device when administered. RN “I” was asked if any preparation of the pen was required prior to dosing and administration. RN “I” stated, “No need, it has the volume”. Following administration of both insulins from the respective devices RN “I” was again asked if the insulin devices required any preparation prior to use. RN “I” stated “No”. On 9/10/2025 at 12:43 PM at interview was conducted with RN “I” at the nurse’s station. RN “I” reported she had reviewed the instructions on the use of insulin pens and had identified that the pens must be primed prior to use for administration. RN “I” stated “I didn’t know”. The document titled “Medication Administration” “Policy 5.3.9A Insulin Administration” effective 6/21/2017 provided by Regional Nurse “A” was reviewed. The document reflected “Procedure…2. There are also several insulin devices on the market, it is essential that the nurse is also familiar with the device prescribed. Always follow the manufacturer’s instructions .”.

Based on observation and interview, the facility failed to provide a safe, functional and sanitary environment resulting in an increased potential for contamination of the water supply and a possible decrease in safety for all residents: Findings include: On 9/9/2025 at 2:50PM, observed, in Hall 100 shower room, there was a call light cord wrapped around the handrail next to the toilet. Environmental Services Manager (ESM) M indicated the cord was not supposed to be wrapped around the handrail. On 9/9/2025 at 3:08PM, observed, in Hall 300 soiled linen room, the atmospheric vacuum breaker (AVB) on the sprayer line began spilling water when the foot pedal for the sprayer was engaged. ESM M was not aware the AVB was not working correctly.

Based on observation, interview, and record review the facility failed to determine a resident as safe to self-administer medication for 1 resident (R73) of 2 residents reviewed for self-administration of medication. Findings include:Review of an admission Record revealed R73 admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction and cognitive communication deficit (difficulty with effective verbal and nonverbal communication, stemming from impairments in cognitive functions like attention, memory, reasoning, and problem-solving). Review of R73's Self-Administration of Medication assessment, completed upon admission on [DATE], revealed R73 was deemed unsafe to self-administer medication. Further review revealed .The resident is able to identify the medications prescribed & verbalize knowledge of potential side effects.No.The resident is capable of getting medication out of the locked drawer.No.The resident has demonstrated the capability of asking for his/her medications at appropriate times of the day for two days.No. Review of R73's Physician's Orders on 9/10/2025 at 9:00 AM revealed an active order, started 8/7/2025, for Latanoprost (a prescription eye drop used to lower high pressure inside the eye) eye drops, instill 1 drop in both eyes one time a day. Review of R73's nursing Orders Administration Notes revealed the following:8/31/2025- Latanoprost.states she takes them independently at night9/8/2025- Latanoprost.independently administers9/9/2025- Latanoprost.self administers In an observation and interview on 9/10/2025 at 8:41 AM in R73's room, R73 reported her eye drops were in her top drawer and pointed across the room to a drawer on the wall. Two bottles of Latanoprost eye drops were in the drawer. Licensed Practical Nurse (LPN) G reported she was not sure whether R73 had been evaluated as safe to self-administer medication. In an interview on 9/10/2025 at 9:20 AM, the Director of Nursing (DON) reported she was not sure why R73's eye drops were in her room and the facility would re-assess her to determine whether she was safe to self-administer medication. Review of facility policy/procedure Self-Administration of Medication, revised 5/2020, revealed .Each resident has a right to self-administer drugs unless the interdisciplinary team. has determined that this practice is unsafe.Self-Administration is assessed only for those residents who. Have expressed the desire to self-administer. Have demonstrated minimal cognitive, visual, and physical abilities as determined by the interdisciplinary team. Have a written health care practitioner order to self-administer.

This citation pertains to intake # 2569423Based on interview and record review, the facility failed to ensure facility staff immediately reported an allegation of neglect to the abuse coordinator for 1 resident (Resident #79) reviewed for neglect.Findings:Resident #79 (R79)Review of an admission Record revealed R79 was an [AGE] year-old female, admitted to the facility on from 6/24/25 to 7/17/25.Review of R79's Resident Assistance Form completed by R79's Family Member (FM) C revealed, It was reported to me when I arrived (07/04 ~9:45-10 AM) by (Certified Nursing Assistant [CNA] B) that PT (physical therapy) found mom soaked head to toe (and bed soaked) with urine and that the stench from her room was overwhelming. Her room still smelled when I arrived. PT almost had to cut of mom's clothes to remove them because they were so heavily soaked and clinging to her body.(CNA B) stated that he was told mom's assistant claimed mom refused care. For mom, this cannot be true! Mom is extra conscientious about her toileting and personal care. She was placed in bed, fully clothed, at 3:30 pm on 07/03. She fell asleep and I left @ 4:20 pm. She was still wearing those clothes when she was found by PT and (CNA B) in a urine soaked bed (on 7/4/25).Further review of the Resident Assistance Form revealed a handwritten note RECEIVED UNDER DOOR 7/7/25 REVIEWED AT 11AM. (3 days following the alleged neglect was identified).Review of the Facility Reported Incident (FRI) investigation revealed: Date/Time Incident Discovered: 7/7/2025 11:00 AMDate/Time Incident Occurred: 7/4/2025 07:00 AM.Allegation Details: Family member (daughter) completed a Resident Assistance Form and left under Administrators office door on 7/4/2025 along with other papers put there over the weekend and wasn't identified until 11:00am on 7/7/2025. The Assistance Form revealed an allegation of neglect for not being provided with incontinence care from the night of 7/3/2025.Review of CNA B's Witness Statement dated 7/11/25 revealed, (CNA B) reported to (FM C) on 7/4/2025 that Me and the therapist discovered (R79) soaked in urine. I explained the measures we took to clean her up. I found it strange because she always requests the bed pan. (FM C) expresses to her that this is bullshit she is a mandated reported and will be reporting it and I told her I was also reporting it to (Director of Nursing [DON]). (CNA B) did not report to (DON) he expressed his concerns to (Licensed Practical Nurse [LPN] D) the Charge nurse.On 7/14/2025 at 3:55pm a Clarification interview with (CNA B) revealed he did feel it was neglectful at the time. CNA B did not immediately notify the abuse coordinator at the time he identified the alleged neglect.Review of LPN D's Witness Statement dated 7/7/25 revealed, .(LPN D) was not called into the room to witness or assess the resident at the time staff discovered she was very wet. She states she was notified 2 hours into the shift the resident was very wet and explained she did not refuse care on the last rounds from nights. LPN D did not immediately notify the abuse coordinator at the time she was notified of the alleged neglect.During an interview on 09/11/2025 at 9:45 AM, the Nursing Home Administrator (NHA) reported that all staff are educated on the regulations of abuse reporting upon hire and during ad-hoc facility in-services. Review of CNA B's employee file confirmed completed education on abuse reporting in October 2024.During an interview on 09/11/2025 at 11:54 AM, R79's FRI investigation was reviewed with NHA. NHA confirmed that CNA B had not immediately reported the alleged neglect to the abuse coordinator per the facility policy and federal regulations and reported that there was no PNC (past noncompliance) completed regarding the deficient practice.Review of the facility policy Abuse Prevention Overview last revised March 2019 revealed, .1. Alleged incidents are reported immediately to the facility administrator and to the State Agency as required and outlined in the facility policy for reporting abuse.Review of the facility policy Abuse/Suspected Abuse; Crime Investigation & Reporting last revised February 2023 revealed, .2. Any person(s) witnessing or having knowledge of potential or actual abuse or crime must immediately report the incident to the Administrator and / or designee. In the case of a resident or family member, such a report can be made to the charge nurse or person assigned to receive complaints, who is responsible to follow through with reporting procedures. 3. When allegations of resident (S483.5) mistreatment, abuse, crime, neglect, exploitation, misappropriation, or injuries of unknown source are reported, the administrator and designees will investigate the allegation with the assistance of appropriate personnel.

Based on interview and record review the facility failed to honor bathing preferences for one resident (R39). Findings include:Review of the admission Record reflected R39 originally admitted to the facility 7/1/2022 with current pertinent diagnoses that included infection and inflammatory reaction due to internal right knee prothesis, polyneuropathy (a disease affecting peripheral nerves and features weakness and burning pain), and need for assistance with personal care. Review of the Minimum Data Set (MDS) dated [DATE] reflected R39 was cognitively intact and required partial/moderate assistance with transfers from bed to chair and to get in and out of a tub or shower.During an interview conducted on 9/9/2025 at approximately 10:45 AM, R39 reported he did not take showers because the beating of the water from the shower was too painful. R39 reported his last shower was about six months ago and has had only bed baths since then. R39 reported bed baths are not the same. R39 reported he had been offered a jacuzzi bath (whirlpool tub) but has not had any because no one knows how to use it.The Care Plan titled Altered functional mobility and ADL's (Activities of Daily Living) related to weakness. initiated 10/17/2023 was reviewed. Under Interventions for this Care Plan revealed Bathing: One person assist with bathing, encouraging the resident to do as much as for self as able. (R39) prefers bed baths only for comfort. Encourage whirlpool tub bathing experience initiated 10/17/2023 and revised 4/18/2025.On 9/10/2025 at 1:04 PM, the Director of Nursing (DON) reported she believed the whirlpool tub was operational. The DON was informed that the Care Plan reflected that R39 was to be encouraged to use the whirlpool tub but that R39 had been told by staff they do not know how to use it. The DON reported she believed that the Peer Mentors were to be the trainers on the use of the whirlpool.On 9/10/2025 at 12:51 PM Certified Nurse Aide (CNA) K reported she had showered residents but did not know how to use the whirlpool tub.On 9/10/2025 at 1:57 PM CNA N reported she had given residents showers but had never used the whirlpool tub.

Based on observation, interview, and record review, the facility failed to provide tracheostomy care using sterile technique for one of three resident's (Resident #74) reviewed. Findings:Resident #74 (R74) Review of an admission Record revealed R74 was an [AGE] year-old female, last admitted to the facility on [DATE], with pertinent diagnoses of Parkinson's Disease, Alzheimer's, and a tracheostomy and ventilator dependent. During an observation on 09-09-25 at 11:45 AM, Registered Nurse (RN) P provided trach care to R74 which included replacing the inner cannula. RN P did not don sterile gloves to handle and place the inner cannula into the tracheostomy and while placing the sterile inner cannula, touched the flange of the outer cannula. During an interview on 09-09-25 at 1:46 PM, Respiratory Therapist (RT) O stated that trach care was completed twice daily and replacing the inner cannula was done utilizing sterile technique. During an interview on 09-10-25 at 8:45 AM, the Director of Nursing and the Regional Clinical Support Nurse stated that replacing the inner cannula when nurses performed tracheostomy care was completed with sterile technique.

Based on interview and record review, the facility failed to effectively communicate and coordinate resident care with hospice for one resident (R5) of 1 resident reviewed for hospice. Findings include: Review of an admission Record revealed R5 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and complete paraplegia (loss of motor and sensory function). Review of R5's active Physician's Orders, revised 2/17/2025, revealed .Hospice to Eval and treat. Review of a current end of life Care Plan intervention for R5, revised 2/24/2025, revealed .Hospice has been elected and the facility & hospice will coordinate care & services. Review of R5's Electronic Medical Record (EMR) on 9/10/2025 at 1:58 PM revealed no hospice notes uploaded since the middle of August 2025. In an interview on 9/11/2025 at 9:39 AM, undocumented treatments of dressing changes on the Treatment Administration Record (TAR) were discussed with the Director of Nursing (DON) and Regional Nurse A. The DON reported some of the dressing change undocumented treatments on the TAR could be times when the hospice nurse changed the dressing. Regional Nurse A reported whether the hospice nurse or the facility nurse changed the dressing, the EMR should reflect the completion of the dressing change and there should be no undocumented treatments. Review of Hospice Registered Nurse (RN) Visit Note Report for R5, dated 8/28/2025, revealed .redness noted to back of (left) knee and top of (right) ankle, notified floor nurse, collaboration of care completed with (Clinical Care Coordinator (CCC) J) . Further review of the EMR revealed no documentation that these skin concerns were assessed or followed up by facility staff. In an interview on 9/11/2025 at 11:12 AM, the DON reported facility staff should have assessed the new areas of skin concern identified by the hospice nurse on 8/28/2025, documented an assessment, and initiated appropriate follow up. CCC J reported she responded to the conversation with the hospice nurse on 8/28/2025 by repositioning R5. CCC J reported she did not know whether the areas of redness identified by the hospice nurse were blanchable (skin that turns white or pale when pressed and returns to its original color indicating blood flow to the area) and she did not document an assessment of the skin concerns. Review of Hospice Licensed Practical Nurse (LPN) H Visit Note Report for R5, dated 8/21/2025, revealed identification of a new right heel unstageable deep tissue injury. Further review of the documentation revealed no clarification of whether this new wound was discussed with facility staff. Review of a hospice order written by Hospice LPN H on 8/21/2025 revealed .Cleanse with wound cleanser, pat dry wipe with skin prep wipe and apply heel foam cup. Further review of the EMR did not show any documentation the facility was aware of this new wound. Review of the TAR revealed no documentation this right heel wound dressing was completed by the facility. In an interview on 9/11/2025 at 12:59 PM, Hospice LPN H reported she discussed the new right heel deep tissue injury with the facility floor nurse and the facility Nurse Practitioner (NP) when she identified the wound on 8/21/2025. Hospice LPN H reported the facility NP instructed her to write an order for the dressing change. Hospice LPN H reported she was not aware whether R5 had a hospice binder to communicate with the facility. In an interview on 9/11/2025 at 11:12 PM, the DON reported the facility should be writing the orders for dressing changes and not hospice, and hospice should be following the facility orders. No documentation could be found that the facility was aware of R5's new right heel wound or that the hospice dressing order was completed by facility staff. R5's hospice binder was viewed and the last Hospice and Facility Coordinated Plan of Care was dated February of 2025 and the last time hospice staff had used the Sign in Log was 6/16/2025. The DON reported the Hospice and Facility Coordinated Plan of Care is updated quarterly and the up-to-date copy should be in the hospice binder. In an interview on 9/11/2025 at 1:21 PM, the DON acknowledged communication between the facility and hospice for R5 needed to improve. The DON reported the facility was unaware they had not received the last 30 days of hospice notes until this surveyor had requested them that day. Review of facility policy/procedure Hospice Care, Revised 6/2018, revealed .The plan of care will reflect the residents' current medical, physical, psychosocial, and spiritual needs. Hospice will reflect these coordinated services on the facilities template for the plan of care within the medical record. The plan of care will reflect which services are provided by the nursing facility and which are provided by hospice. The facility and hospice are responsible for performing their respective functions, which have been agreed upon and included in the jointly developed Plan of Care.

This citation refers to MI00152903. Based on interview and record review, the facility failed to conduct a thorough investigation for 1 of 3 residents (R2) reviewed for abuse/neglect. Findings include: A review of R2's admission Record, dated 7/8/25, revealed they were an [AGE] year-old resident that was admitted to the facility on [DATE]. In addition, R2's admission Record revealed multiple diagnoses that included late onset Alzheimer's Disease, anxiety, and generalized muscle weakness. A review of R2's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 5/20/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 1 which revealed R2 was severely cognitively impaired. A review of the facility's 5-Day Investigation, dated 5/7/25, revealed on 5/1/25 at 2:40 PM the social worker (Social Services Director (SSD) D) was assessing R2's psychosocial status when R2 indicated the night aide pushed her against the wall. R2 stated she reported this to someone from activities. R2's roommate, who was alert and oriented, stated she was awake all night and she did not hear anything. A skin assessment was completed, and no signs of redness or bruising were noted. In addition, the facility's 5-Day Investigation revealed R2 had documented bowel movements and care on 4/30/25 at 9:21 PM (afternoon shift) and 5/1/25 at 12:30 AM (night shift). A further review of the facility's 5-Day Investigation revealed the facility interviewed R2, Certified Nursing Assistant (CNA) A (the alleged perpetrator), CNA B (CNA A's hall partner from 2:30 PM to 10:30 PM), and Activity Aide (AA) C (who R2 named). However, the facility's 5-Day Investigation failed to reveal that CNA F (CNA A's hall partner from 10:00 PM to 6:30 AM), SSD D (whom R2 reported the allegation to), and/or Licensed Practical Nurse (LPN) G (who was R2's assigned nurse from 6:00 PM to 6:30 AM) provided written statements and/or were interviewed. During an interview on 7/9/25 at 8:40 AM, SSD D stated she did not document a statement or progress note in R2's medical record. She stated she probably gave a written note to the Nursing Home Administrator (NHA) about her interview with R2 when she reported the allegation to her but could not recall if she did. During an interview on 7/9/25 at 10:15 AM, the NHA stated she did not interview any staff members that worked from 10:00 PM to 6:00 AM the night of the alleged incident. She stated she realized that the alleged incident occurred at 12:30 AM, but she only interviewed CNA 's that worked with CNA A from 6:00 PM to 10:30 PM. The NHA confirmed that she also did not interview LPN G who worked from 6:00 PM to 6:30 AM the night of the alleged incident. The NHA also verbalized since she did not interview any staff members (besides CNA A) who worked from 10:30 PM to 6:30 AM (4/30/25 to 5/1/25), she does not know for sure what may/may not have happened when CNA A provided incontinence care to R2 on 5/1/25 at 12:30 PM. The NHA further stated CNA A would have provided incontinence care to R2 alone unless R2's care plan indicated two people were required. A review of R2's Altered Functional Mobility and ADL's (Activities of Daily Living) care plan, revised on 10/17/24, revealed R2 was a two-person assist for elimination (e.g., using the toilet and incontinence care). Therefore, CNA F should have been interviewed to determine if they assisted CNA A with incontinence care on 5/1/25 at 12:30 AM and what, if anything, they witnessed. A review of the State Operations Manual (SOM), revised 4/25/25, revealed, The facility must take the following actions in response to an alleged violation of abuse, neglect, exploitation or mistreatment: Thoroughly investigate the alleged violation . For all alleged violations of abuse, neglect, exploitation, misappropriation of resident property, exploitation, and mistreatment, including injuries of unknown source . the facility must thoroughly collect evidence to allow the Administrator to determine what actions are necessary (if any) for the protection of residents. Depending upon the type of allegation received, it is expected that the investigation would include, but is not limited to . Conducting interviews with, as appropriate, the alleged victim and representative, alleged perpetrator, witnesses . A review of the facility's Abuse/Suspected Abuse Investigation & Reporting Policy and Procedure, revised February 2023, revealed the facility's investigation may consist of an interview with the person(s) reporting the incident, interviews with any witnesses, and an interview with staff members having contact with the resident during the period/shift of the alleged incident. However, the facility's policy is not entirely consistent with the SOM as the facility's policy implies that interviews with the person(s) reporting the incident, witnesses, and staff members having contact with the resident during the period/shift of the alleged incident may be optional and the SOM indicates that interviews of witnesses (e.g., staff having contact with the resident during the period/shift of the alleged incident and the person(s) reporting the incident) are expected, as appropriate.

This citation refers to MI00152903. Based on interview and record review, the facility failed to maintain a complete and accurate medical record for 1 of 3 residents (R2) reviewed. Findings include: Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice . Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines . It also provides a basis for demonstrating and understanding nursing's contributions both to patient care outcomes and to the viability and effectiveness of the organizations that provide and support quality patient care . High quality documentation, however, is a necessary and integral aspect of the work of registered nurses in all roles and settings . Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care . Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. (ANA's (American Nursing Association) Principles for Nursing Documentation- Guidance for Registered Nurses, 2010, www.nursingworld.org, retrieved on 7/10/25). A review of R2's admission Record, dated 7/8/25, revealed they were an [AGE] year-old resident that was admitted to the facility on [DATE]. In addition, R2's admission Record revealed multiple diagnoses that included late onset Alzheimer's Disease, anxiety, and generalized muscle weakness. A review of R2's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 5/20/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 1 which revealed R2 was severely cognitively impaired. A review of the facility's 5-Day Investigation, dated 5/7/25, revealed on 5/1/25 at 2:40 PM the social worker (Social Services Director (SSD) D) was assessing R2's psychosocial status when R2 indicated the night aide pushed her against the wall. R2 stated she reported this to someone from activities. R2's roommate, who was alert and oriented, stated she was awake all night and she did not hear anything. A skin assessment was completed, and no signs of redness or bruising were noted. In addition, the facility's 5-Day Investigation revealed the Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified on 5/1/25 at 2:20 PM, the local authorities (law enforcement) was notified on 5/1/25 at 3:55 PM, the health care provider (HCP) was notified on 5/1/25 at 4:10 PM, and R2's guardian was notified on 5/1/25 at 4:10 PM. A review of R2's progress notes, dated 4/23/25 to 7/8/25, revealed the following: - Interdisciplinary Documentation, dated 5/9/25, revealed, SSD talked with [name of R2]. [Name of R2] said she was tired but doing ok. [Name of R2] was at activities enjoying reading and music. [Name of R2] was enjoying everyone's company. There were no signs of distress at all. However, the note did not indicate the reason for SSD's discussion with R2 (e.g., routine assessment/evaluation, follow-up for an incident, impromptu visit). - No note mentioning R2 reporting an incident to SSD D on, or around, 5/1/25. A review of R2's Skin Assessment, dated 5/1/25, failed to reveal any skin abnormalities, except for R2's heels were slightly red and mushy. However, it did not reveal why the skin assessment was performed (e.g., post-incident, routine). A further review of R2's complete electronic medical record (EMR), dated 4/23/25 to 7/8/25, failed to reveal any mention that R2 had alleged that a staff member had pushed her against the wall. In addition, R2's EMR failed to reveal that the NHA and DON, R2's guardian, the HCP, and/or the local authorities were notified of any alleged incident with R2. During an interview on 7/9/25 at 8:40 AM, SSD D stated when a resident makes an accusation, she will document it in a progress note. She stated she would also document if she notified anyone. SSD D reviewed R2's medical record and stated she did not see where she wrote a note. She stated she probably gave a written note to the NHA when she reported the incident to her. SSD D also stated that she reviewed her follow-up note on 5/9/25 and stated the note was not very clear on why she was interviewing R2 (e.g., follow-up to an incident, routine assessment, routine conversation about care and how the resident is doing). She stated she usually documents the reason why she talks to a resident in the progress note along with their response. During an interview on 7/9/25 at 9:00 AM, Registered Nurse (RN) E stated when a resident falls or has an incident with another resident or staff member, she would report it to the DON. She stated she would also document the incident in a progress note and who she called. RN E stated she would always document that she called someone for anything related to a resident. During an interview on 7/9/25 at 11:30 AM, the NHA stated SSD D should have written a progress note when R2 reported to her that staff had pushed her against the wall. She also stated that staff should have documented when they notified her, the DON, R2's guardian, the HCP, and local authorities (law enforcement) in a progress note.

This citation pertains to intake #MI00149026. Based on interview and record review, the facility failed to prevent significant medication errors for 1 resident (Resident #101) of 4 residents reviewed for medication administration, resulting in Resident #101 (R101) becoming bradycardic (low heart rate) and requiring to be transferred to a local hospital for treatment. Findings include: Review of an Admission Record revealed Resident #101 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and congestive heart failure. Review of R101's Medication Discrepancy report, dated 12/13/2024 at 7:40 AM, revealed R101 received the wrong resident's medications the morning of 12/13/2024. Further review revealed the facility Medical Doctor (MD) K was contacted by Registered Nurse (RN) A. Facility MD K gave orders for nursing staff to monitor R101's vital signs and hold his morning medications. Review of R101's Provider Progress Notes, dated 12/13/2024 at 11:07 AM, revealed MD K documented R101 received the wrong patient's medications including 1) Colace 100mg (a stool softener laxative), 2) Aspirin 81mg (a nonsteroidal anti-inflammatory used to reduce pain, fever, and inflammation), 3) metoprolol 25mg (a beta-blocker used to treat high blood pressure that can cause bradycardia), 4) Renflexis 75mg (used to treat arthritis), 5) atorvastatin 20mg (used to treat hyperlipidemia), 6) sotalol 80mg (a beta-blocker used to treat arrhythmias that can cause bradycardia), 7) leflunomide 20mg (used to treat arthritis), 8) pantoprazole 40mg (used to treat gastroesophageal reflux disease, 9) gabapentin 100mg (used to treat nerve pain), 10) MiraLAX 17g (a laxative used to treat constipation), 11) bupropion 75mg (used to treat depression), 12) ibuprofen 400mg (a nonsteroidal anti-inflammatory used to reduce pain, fever, and inflammation), and 13) metformin 850mg (used to treat diabetes). Further review revealed R101's morning medications were held on 12/13/2024. R101's vital signs were monitored, and he developed bradycardia with his pulse confirmed by MD K to be in the high 40's (normal pulse range is between 60-100 beats per minute). Further review revealed .Given that low heart rate and that he got patient's wrong medications including metoprolol and sotalol will have ER (emergency room ) evaluate . Review of R101's Emergency Department Provider Notes, dated 12/13/2024 at 4:45 PM, revealed R101 was evaluated and monitored at the local Emergency Department for 8 hours following the ingestion of the wrong medications per recommendations from Poison Control. In a telephone interview on 1/16/2025 at 9:10 AM, RN A reported that she set up R101's medications the morning of 12/13/2024 and another resident's medications with the same first name. RN A reported it was busy, and she asked RN E to give R101 the medications that she had prepared. RN A stated, We shouldn't do that, reporting nurses are expected to administer medications that they prepare. In at telephone interview on 1/17/2024 at 9:00 AM, RN E reported RN A handed medication to her the morning of 12/13/2024 and asked her to administer them to R101. RN E reported she administered the medications that RN A had prepared to R101, and then RN A realized that the medications were given to the wrong resident. RN E reported nurses should not give medications that were prepared by another nurse under normal circumstances. In an interview on 1/16/2025 at 9:50 AM, the Director of Nursing (DON) reported nursing staff should not administer medication that another nurse prepared. Review of facility policy/procedure Medication Administration by the Various Routes, reviewed December 2024, revealed .Only authorized personnel who prepare the medication may administer it . Medications supplied for one resident are not administered to another resident .

This citation pertains to intake #MI00147001. Based on interview and record review, the facility failed to document resident concerns according to facility policy for 2 residents (Resident #102 and #103), of 4 residents reviewed for grievance resolution. Findings include: R102 Review of an Admission Record revealed Resident #102 (R102) admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction (stroke), weakness, and hypertension. In an interview on 1/16/2025 at 2:40 PM, R102 reported ongoing issues with the facility regarding optometry care, receipt of mail, voting privileges, receipt of requested documents, and access to medical providers of her choice. R102 reported she had discussed these unresolved concerns many times with staff, including the Director of Nursing (DON), and had never received any written or formal response to her ongoing complaints. Review of R102's Progress Notes revealed a note written by the DON on 11/5/2023 at 10:34 AM at which time R102 was described as becoming angry after discussing her optometry complaints and told the DON that she would call the state and file a complaint. Per email correspondence from the Nursing Home Administrator (NHA) received on 1/16/2025 at 9:23 AM, the facility did not have any grievance/concern forms for R102 in the previous 3 months. In an interview on 1/16/2025 at 12:30 PM, the DON reported she had discussed some of R102's ongoing complaints with her, including her ongoing optometry complaint described in the Progress Note on 11/5/2024. The DON reported that she had not assisted R102 to fill out a formal grievance. The DON acknowledged she should have initiated the formal grievance process which includes a written response to the resident. R103 Review of an Admission Record revealed Resident #103 (R103) admitted to the facility on [DATE] with pertinent diagnoses which included dementia, Parkinson's disease, and need for assistance with personal care. In a telephone interview on 1/15/2025 at 9:47 AM, Family Member (FM) of R103 J reported ongoing complaints regarding the care of R103 including being left wet, not being repositioned, inconsistent shaving, and care of R103's nails. In a telephone interview on 1/17/2025 at 10:17 AM, FM J reported she had frequent conversations with staff, including the DON and NHA, regarding her ongoing and unresolved complaints about the care of R103. FM J reported she had not received any written response from the facility regarding her concerns. In an interview on 1/17/2025 at 11:40 AM, the NHA reported the facility had not filled out any grievance forms regarding the concerns of Family Member of R103 J and had not provided a written response to the concerns. The NHA stated the facility needed to do better regarding concern documentation and follow up. Review of facility policy/procedure Complaint, Reviewed June 2010, revealed .Purpose . To ensure that complaints are investigated and the results of the investigation are reported back to the complainant within a reasonable time period . Any resident, guardian of a resident, authorized representative, or any interested party . may file a formal complaint related to: The care and service a resident is or is not receiving . Any violation of the resident's rights . Complaints made to the facility may be oral or in writing . If an oral complaint is not resolved to the satisfaction of the complainant, the individual receiving the complaint will assist in reducing an oral complaint to writing . Within 30 days, a written report of the investigation or a written report indicating when the report may be expected shall be delivered to the complainant .

Based on interview and record review, the facility failed to maintain an accurate Electronic Health Record (EHR) for two residents (Resident #101 and #102), of 5 residents reviewed for accuracy of medical records. Findings include: R101 Review of an Admission Record revealed Resident #101 (R101) admitted to the facility on [DATE] with pertinent diagnoses which included dementia and congestive heart failure (CHF). Review of R101's Medication Discrepancy report, dated 12/13/2024 at 7:40 AM, revealed R101 received the wrong resident's medications the morning of 12/13/2024. Further review revealed Facility Medical Doctor (MD) K was contacted by Registered Nurse (RN) A. Facility MD K gave the order for nursing staff to monitor R101's vital signs and hold his morning medications. Review of Resident #101's December 2024 Medication Administration Record (MAR) revealed 3 medications were documented as being given to R101 the morning of 12/13/2024 by Registered Nurse (RN) A, including 1) Claritin 10mg (used to treat allergic rhinitis), 2) Donepezil 10mg (used to treat dementia), and 3) furosemide 20mg (a diuretic used to treat CHF). In a telephone interview on 1/16/2025 at 9:10 AM, RN A reported she did not give any of R101's scheduled medications the morning of 12/13/2024 based on orders received from the medical provider. RN A stated, I thought I unchecked these. In an interview on 1/16/2025 at 9:50 AM, the Director of Nursing (DON) reviewed R101's December 2024 MAR and confirmed that Claritin, Donepezil, and furosemide were documented as being given by RN A the morning of 12/13/2025. R102 Review of an Admission Record revealed Resident #102 (R102) admitted to the facility on [DATE] with pertinent diagnoses which included cerebral infarction (stroke), weakness, and hypertension. Further review revealed Family Member (FM) of R102 I to be R102's active Durable Power of Attorney (DPOA) as of 1/16/2025. Review of R102's Progress Notes revealed a note documented by Social Services Director (SSD) H on 10/22/2024 at 4:20 PM indicating R102 revoked FM I as her DPOA on that date. In an interview on 1/16/2025 at 11:20 AM, SSD H reported R102 revoked FM I from being her DPOA on 10/22/2024 and the EHR was incorrect and needed to be updated. SSD H reported FM I should be listed as a responsible party and not as the DPOA. Review of facility policy/procedure Interdisciplinary Documentation and Admission Assessments, revised January 2017, revealed .Purpose: To communicate about the care provided, promote good interdisciplinary care and provide support to meet professional and legal standards. To enhance the continuity of care and decrease duplication of data collection and ensure that all those involved in resident care have access to reliable, pertinent, and up-to-date resident information upon which to plan and evaluate interventions .

This citation pertains to intake # MI00141875 Based on interview and record review, the facility failed to 1.) implement the facility policy for pressure injury/wound management 2.) ensure pressure injury/wound assessments were comprehensive and accurate, and 3.) ensure treatments were ordered and completed, for 3 of 6 residents (Resident #42, #44, and #17) reviewed for alterations in skin integrity, resulting in incomplete wound assessments, a delay in wound healing, and the worsening of wounds. Findings: Resident #42 (R42) Review of an Admission Record revealed R42 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dependence on ventilator, heart failure, and pressure injuries. Review of R42's Wound Measurement dated 5/1/24 revealed, .right heel 3.2 x 3.4 unstageable . Heel has large eschar cap . Consider wound care clinic referral . No additional wound description reflected in the wound assessment. Comprehensive wound assessments are to include location, dimensions, description of wound bed, exudate type, exudate amount, presence of odor, wound edges, peri-wound assessment, tunneling/undermining, and pain. Review of R42's Wound Measurement dated 5/21/24 revealed no measurements. The right heel was documented as unstageable, however, documentation then showed .The following questions apply to: abdomen, right and left lower leg, heel .Pressure wounds have beefy red granulation tissue at base . (The wound base on R42's right heel was documented as unstageable and therefor staff would be not be able to visualize the wound base). No additional wound description reflected in the wound assessment. Per [NAME] and [NAME], Unstageable pressure injury: Obscured full-thickness skin and tissue loss *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 (see Fig. 48.4F). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Review of R42's Wound Measurement dated 6/5/24 revealed R42's right heel measured 3 x 3.1 x 0.2 and was documented as a Stage 4 pressure injury.R HEEL- sharp debridement of black eschar tissue completed by provider, lidocaine 4% applied 5 minutes prior to procedure, 80% of slough tissue to wound bed noted, minimal bleeding controlled with pressure, Vaseline gauze covered with dry gauze wrapped with Kerlix. resident tolerated well. No additional wound description reflected in the wound assessment. Debridement is the removal of non-viable/dead tissue: necrotic material, slough and biofilm. (15 days after the last wound assessment.) Review of R42's Wound Measurement dated 6/12/24 revealed, .R (right) HEEL- 3.5 X 3.2 X 0.5 sharp debridement of slough tissue completed by provider, see updated orders. resident tolerated well . No additional wound description reflected in the wound assessment. Review of R42's Order Summary dated 6/12/24 revealed, Right heel: cleanse with normal saline, apply santyl, cover with gauze, wrap with kerlix. every shift for wound. Review of R42's Wound Measurements revealed no comprehensive wound assessment was completed on 6/19/24. Review of R42's Wound Measurement dated 6/26/24 revealed the right heel measured 3.0 x 2.5 x 1.8 and was documented as a Stage 4 pressure injury.R HEEL- (nurse practitioner name omitted) performed sharp debridement to right heel immediately prior to wound measurements. no s/s of infection. no change to tx . No additional wound description reflected in the wound assessment. (14 days after the last wound assessment) Review of R42's Wound Measurements revealed no comprehensive wound assessment was completed on 7/3/24. Review of R42's Skin assessment dated [DATE] revealed R42's right heel was documented as vascular indicating an inaccurate wound assessment. Review of R42's Wound Measurement dated 7/10/24 revealed the right heel measured 3 x 2 x 1.5 N/A stage.R HEEL- after wound measurements were taken by writer, (nurse practitioner name omitted) performed sharp debridement to right heel and obtained cultures r/t (related to) odor and purulent (pus filled) drainage . Indicating the worsening of the wound from the previous assessment. No additional wound description reflected in the wound assessment. (14 days after the last wound assessment). Review of R42's Wound Measurements revealed no comprehensive wound assessments were completed after the assessment dated [DATE] through her transfer to the hospital. Review of R42's Provider Progress Note dated 7/10/24 revealed, .multiple chronic wounds, measurements in (Electronic Health Record), right heel noted with foul smelling drainage . Sharp debridement completed to right heel, after procedure minimal bleeding was controlled with light pressure, wound measures 3.0 cm x 2.5 cm x 1.8 cm. Indicating the worsening of the wound. No additional wound description reflected in the progress note. Treatment changes for R42's right heel were not made despite the deterioration of the wound with increased exudate and odor documented. The treatment order had been in place since 6/12/24 (4 weeks). Review of R42's Provider Progress Note dated 7/11/24 revealed, There is open skin on the heel with foul odor . No additional wound description or measurements reflected in the progress note. Review of R42's Skin assessment dated [DATE] revealed R42's right heel was documented as vascular indicating an inaccurate wound assessment. Review of R42's Provider Progress Note dated 7/15/24 revealed, .Start cefepime 1 g IV x 1 then cefepime IV 500 mg every 24 hours for wound infection . No additional wound description or measurements reflected in the progress note. Review of R42's Provider Progress Note dated 7/17/24 revealed, .Patient is being seen today for wound evaluation . right heel wound measures 2.2 cm x 2.5 cm x 1.5cm . No additional wound description reflected in the progress note. Review of R42's Skin assessment dated [DATE] revealed R42's right heel was documented as vascular indicating an inaccurate wound assessment.Right heel has been recently debrided as well as continuing with Santyl application BID (twice a day) with noted signs of improvement . There were no measurements or further wound descriptions reflected in the skin assessment. (Improvement was noted despite the lack of assessment and inaccurate staging of the pressure injury.) Review of R42's Provider Progress Note dated 7/22/24 revealed, .Patient is being seen for irregular lab results .Nursing has no acute concerns at this time . There was no wound assessment and measurements reflected in the progress note. Review of R42's Skin assessment dated [DATE] revealed no measurements or wound assessments.wound to right heel dressing bid wound is odorous and no improvement noted . Review of R42's Provider Progress Note dated 7/29/24 revealed, .worsening odor of wound (Rt heel) .staff reports of worsening right heel wound .Right heel noted with foul smell, boggy, skin is very thin and fragile . Right heel wound culture C&S (culture and sensitivity) if indicated . Indicating the worsening of the wound. A debridement was completed to remove dead tissue during this visit. This assessment was completed 12 days after last provider wound assessment. Review of R42's Skin assessment dated [DATE] revealed the right heel was documented as vascular and measured 7.5 x 8 (centimeters). No additional wound description or measurements reflected in the skin assessment. Review of R42's Provider Progress Note dated 8/1/24 revealed, .Patient is being seen today for irregular labs and worsening heel wound .right lower extremity, without measurements .start cefepime 2g IV q 24 hours x 10 days .right heel xray stat . No treatment changes noted. Review of R42's vital signs dated 08/01/24 at 8:59 AM revealed a blood pressure of 82/50, a pulse of 100, and respirations of 30. R42's vital signs were indicative of sepsis. Review of R42's xray results revealed the xray was obtained on 8/1/24 and was reviewed by the radiologist on 8/3/24. Ulceration at the posterior aspect of the heel with underlying calcaneal osteomyelitis and extensive soft tissue gas that is concerning for necrotizing/gas-forming infection . Review of R42's Interdisciplinary Documentation dated 8/2/24 revealed, Wound care completed to BLE (bilateral lower extremities) and Right heel. right heel noted increased brown drainage and increased involvement of entire heel area. Notified on-call provider (name omitted) of findings . Review of R42's Interdisciplinary Documentation dated 8/3/24 revealed, Received orders to send [NAME] to ER for an evaluation of x-ray results showing possible osteomyitis (sic). Osteomyelitis is an infection in the bone. Review of R42's Interdisciplinary Documentation dated 8/3/24 revealed, Called (emergency department) for update on resident. Spoke with RN who stated that resident was slated to be transferred to [NAME] Ford Hospital in Detroit for further evaluation d/t (due to) necrotizing fasciitis in Right heel . Necrotizing fasciitis is a severe, rapidly spreading bacterial infection of the skin. During an interview on 08/07/24 at 01:25 PM, Regional Nurse Consultant (RNC) D confirmed R42 did not have wound assessments completed weekly and the wound assessments were not complete/comprehensive. RNC D reported that wound assessments were to be completed weekly utilizing the Wound Measurement assessment tool and should include a comprehensive description of the wounds, not just the measurement of the wound. There were no treatment changes for R42's right heel from 6/12/24 through her discharge to the hospital despite the deterioration of the wound and/or lack of wound healing. Wound assessments were not completed weekly, and the assessments were not thorough/comprehensive as required to promptly identify the deterioration of the wound. A time related assessment has also been applied to the process of healing of a wound that is diagnosed as chronic. If during 4 weeks of standard of care, the wound surface area is reduced by 50%, it is likely to heal on the same treatment in 12 weeks. If less than a 50% reduction occurs, it is unlikely to heal on this treatment and a reassessment and change of treatment should be considered. [NAME] E, [NAME] PY, [NAME] GS, [NAME]-Green MM, [NAME] R, [NAME] D, Gould LJ, [NAME] DG, [NAME] GW, [NAME] R, Olutoye OO, [NAME] RS, [NAME] GC. Chronic wounds: Treatment consensus. Wound Repair [NAME]. 2022 Mar;30(2):156-171. doi: 10.1111/wrr.12994. Epub 2022 [DATE]. Erratum in: Wound Repair [NAME]. 2022 Jul;30(4):536. doi: 10.1111/wrr.13035. PMID: 35130362; PMCID: PMC9305950. Chronic wounds are those that do not progress through a normal, orderly, and timely sequence of repair. They are common and are often incorrectly treated .The mainstay of treatment is the TIME principle: tissue debridement, infection control, moisture balance, and edges of the wound. After these general measures have been addressed, treatment is specific to the ulcer type . Assessment of wounds should begin with a thorough physical examination. A more focused examination of the wound itself can then help guide treatment. The wound location, size, and depth; presence of drainage; and tissue type should be documented. Based on the location and appearance, most chronic wounds can be categorized by etiology, which allows for adequate workup and treatment recommendations . Venous ulcers are the Moisture balance is an essential part of wound care. Chronic wounds should never be exposed to air to dry out, as is often recommended. Moist wounds heal more quickly and have less risk of infection. If a wound appears dry, moisture needs to be added; this is accomplished by choosing an appropriate dressing (Table 3). Conversely, if a wound is draining, the drainage needs to be controlled and kept off of the periwound. The proper dressing should hold the moisture on the wound bed to prevent desiccation. [NAME] S, [NAME] E. Chronic Wounds: Evaluation and Management. Am Fam Physician. 2020 [DATE];101(3):159-166. PMID: 32003952. Resident #44 Review of an Admission Record revealed R44 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: dementia. Review of R44's Skin assessment dated [DATE] revealed R44 had redness identified on her coccyx . Addendum 07/06/24: Res has a red area near her coccyx approximately 4cm round. It is not open at this time . Review of R44's Electronic Health Record revealed no documentation that R44's responsible party or the wound nurse were notified. There was no treatment ordered/initiated at that time. A short term care plan was not initiated and/or the care plan was not updated. Review of R44's Provider Progress Note dated 7/8/24 revealed, .nickel-sized area over coccyx that needs to be 'watched' per nursing XXX[AGE] year-old female with a long-term care resident being seen for staff reporting redness over coccyx .Skin: 1 cm x 1 cm x 0.1 cm circular open area noted to right buttock, skin is very thin and fragile . No treatment ordered for the Stage II open area. Review of R44's Skin assessment dated [DATE] revealed no breakdown to coccyx. Review of R44's Provider Progress Note dated 7/17/24 revealed, .Nursing reports no significant concerns. Seen earlier this month by nurse practitioner (name omitted); had a nickel sized area over coccyx she started some treatment to the area . Skin not fully examined today but there is mention of her stage II buttock sore . No treatment ordered for the Stage II open area. Review of R44's Skin assessment dated [DATE] revealed, .Redness to bilateral buttocks . Review of R44's Skin assessment dated [DATE] revealed no breakdown to coccyx. Review of R44's Skin assessment dated [DATE] revealed, .Res (resident) has an area of less than one cm in diameter open area where epidermis is missing on the inner aspect of the right buttock . Review of R44's Electronic Health Record revealed no documentation that R44's responsible party or the wound nurse were notified. Review of R44's Skin assessment dated [DATE] revealed an open area Stage II to her right buttock measuring 1cm x 1cm.Res has an area of less than one cm in diameter open area where epidermis is missing on the inner aspect of the right buttock . Review of R44's Order Summary dated 7/31/24 revealed, right buttocks: cleanse with normal saline or soap and water, pat dry apply TAO and 2x2 q 2 (every 2) days and prn one time a day every 3 day(s) for wound care. Resident #17 (R17) Review of an Admission Record revealed R17 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses which included: stroke. Review of R17's Skin assessment dated [DATE] revealed, .Redness to bilateral buttocks . Review of R17's Provider Progress Note dated 6/26/24 revealed, .being seen today for staff reported impaired skin integrity . Skin: 1.5cm x 1.0cm x 0.2 area of shearing noted to left buttocks, minimal drainage noted to dressing, skin is very thin and fragile . Indicating a Stage II pressure injury. Review of R17's Order Summary dated 6/26/24 revealed, Left buttocks: cleanse with soap and water, pat dry, apply TAO, cover with border foam dressing q day. one time a day for wound care. Review of R17's Electronic Health Record revealed no documentation that R17's responsible party or the wound nurse were notified or that a short term care plan was initiate/care plan was updated. Review of R17's Skin assessment dated [DATE] revealed, .Skin is unremarkable other than on going (sic) redness to bil buttocks . Review of R17's Skin assessment dated [DATE] revealed, .ADDENDUM; During care this morning it was observed that the inner aspect of res right thigh and groin area is excoriated, and has an open area. The first few layers of skin have open related to excoriation . Review of R17's Interdisciplinary Documentation dated 7/6/24 revealed, During personal care it was observed that res had excoriation with an open area to her inner right thigh/peri area. Area cleansed with mild soap and water, barrier cream applied and moisture wicking pad placed to help relieve some of the moisture that is causing the excoriation. Review of R17's Electronic Health Record revealed no documentation that R17's responsible party or the wound nurse were notified or that a short term care plan was initiate/care plan was updated. Review of R17's Skin assessment dated [DATE] revealed R17 had redness noted to bilateral buttocks. There was no documentation of open areas. Review of R17's Provider Progress Note dated 7/11/24 revealed, .Skin: Treatment in place for groin excoriation, left buttock wound, treatment in place . Review of R17's Skin assessment dated [DATE] revealed R17 had redness noted to bilateral buttocks. Coccyx-other (specify) was documented with no additional assessment findings. Review of R17's Skin assessment dated [DATE] revealed R17 had redness noted to bilateral buttocks. Coccyx-other (specify) was documented with no additional assessment findings. Review of R17's Skin assessment dated [DATE] revealed R17 had redness noted to bilateral buttocks. Coccyx-other (specify) was documented with no additional assessment findings. Review of R17's June Treatment Administration Record revealed the left buttock treatment was not completed on 6/28/24 or 6/30/24. Review of R17's July Treatment Administration Record revealed the left buttock treatment was not completed on 7/11/24, 7/17/24, 7/18/24, 7/20/24, 7/21/24, 7/27/24, 7/28/24, or 7/31/24. Review of R17's August Treatment Administration Record revealed the left buttock treatment was not completed on 8/3/24. During an interview on 08/07/24 at 02:37 PM, Director of Nursing (DON) and RNC D confirmed the R44 and R17's care plans were not updated/STCP initiated following the identification of the skin impairment. RNC D reported that changes in resident condition, including skin breakdown, was discussed in the managers morning meetings utilizing a 24-hour report. An addendum was made to R44 and R17's Skin Assessments and a progress note was not completed causing it to be missed by management in the morning meeting. Additionally, the nurse did not notify the responsible party and wound nurse of the skin breakdown. Review of the facility policy Skin at Risk Assessment Documentation, Staging & Treatment last revised January 2020 revealed, Policy: It is the policy of this facility to assess resident risk factors for the development of impaired skin integrity and intervene as indicated utilizing the admission assessment, plan of care, and Minimum Data Set as formal assessment tools. It is the policy of this facility to assess skin on a regular basis to determine whether changes in the patient's skin condition have occurred. Weekly measurements and narrative assessments are conducted on existing pressure injuries. Purpose: To provide prompt identification and intervention for residents at risk of impaired skin integrity corresponding to risk factors. To limit the development of avoidable pressure ulcers and provide evidenced based guidance on effective strategies to promote pressure ulcer healing . 6. The following guidelines are reviewed and implemented as indicated for each individual risk factors: a. Daily skin inspections with am and pm care b. C.N.A. reporting of abnormal skin inspections to the charge nurse . h. Communication of skin concerns to other team members on the 24 hour report summary . q. Implement standing orders for impaired skin and / or Consult the physician prn for treatment and orders for impaired skin integrity . 9. Re-assess and measure a pressure ulcer a minimum of weekly. a. Whenever possible assign a consistent licensed nurse to an individual wound measurement to improve the uniformity, accuracy and reliability of the measurement and documentation. b. With each treatment observe the ulcer for signs that indicate a change in treatment is indicated (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection or other complication) 10. Document the appearance of the wound with considerations to the physical characteristics as applicable to the resident; a. Location b. Stage c. Size d. Color e. Peri-wound condition f. Wound edges g. Sinus tracts or tunneling h. Exudate i. Odor 11. Reassess the resident, the pressure ulcer and the plan of care if the ulcer does not show signs of healing as expected despite appropriate local wound care, pressure redistribution, and nutrition. a. Expect some signs of pressure ulcer healing within two weeks. b. Adjust expectations for healing in the presence of multiple factors that impair wound healing . Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, When you care for a patient with a chronic complex wound, contact the wound care team if you note a change in the volume and/or consistency of the drainage, a presence of a strong odor in the drainage, and change in wound-healing status. It is also important to plan a dressing change with the wound care team to assess the wound together to determine effectiveness of the treatment plan and if the wound is showing progress toward healing. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1338). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, A wound assessment provides the foundation for developing a care plan, revealing data that aid in identification of nursing diagnoses and the selection of wound therapies best targeted for the condition of the patient's wound. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1384). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, When you identify the presence of a skin wound or pressure injury, closer assessment is required. Assess the type of tissue in the wound base and the factors influencing the patient's risks for poor healing so that you can plan appropriate interventions. The assessment includes the amount (percentage) and appearance (color) of viable and nonviable tissue .Measurement of the wound size provides information on overall changes in dimensions, which is an indicator for wound-healing progress ([NAME], 2016). This includes measuring the length and width of a wound, as well as determining its depth (see Skill 48.2). Use a disposable wound-measuring device to measure wound width and length. This approach offers a uniform, consistent method for measuring meaningful comparisons of wound status across time (EPUAP/NPIAP/PPPIA, 2019b). Measure depth by using a cotton-tipped applicator in the wound bed . Assessment of wound exudate should describe the amount, color, consistency, and odor of wound drainage. Normally a closed surgical wound has minimal serosanguineous drainage immediately after surgery (see Chapter 50). Excessive exudate indicates the presence of infection. Wound pain, including the location, distribution, type, quality, and intensity, and any aggravating or relieving factors also should be assessed ([NAME], 2016) (see Chapter 44). Examine the skin around a wound (periwound) for redness, warmth, and signs of maceration, and palpate the area for signs of pain or induration. The presence of any of these factors on the periwound skin indicates wound deterioration. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1333). Elsevier Health Sciences. Kindle Edition. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, Unstageable pressure injury: Obscured full-thickness skin and tissue loss o 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 (see Fig. 48.4F). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1322). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the facility failed to ensure that policies and procedures were developed and implemented for one resident (R47) of five reviewed for Medication Regimen Review (MRR) that address time frames for steps in the MRR process and steps the pharmacist must take when an irregularity requires urgent action. Findings: Resident #47 (R47) Review of a Significant Change Minimum Data Set assessment dated [DATE] reflected R47 admitted to the facility on [DATE] with diagnoses that included high blood pressure, thyroid disorder, anxiety and depression. Review of R47's Pharmacist Medication Review 2.0 assessments in the Electronic Medical Record (EMR) reflected that in March and April 2024 the pharmacist documented potential irregularities noted. The Miscellaneous tab in the EMR did not include a written notice from the pharmacist to the physician indicating what potential irregularity was identified. During an interview on 8/7/2024 at 1:30 PM, the Nursing Home Administrator (NHA) was able to produce the memo distributed to the facility by the pharmacist pertaining to the irregularities, however the Physician/Prescriber Response section was left blank. The NHA reported at this time the facility did not have a written policy or procedures in place pertaining to Medication Regimen Reviews.

Based on interview and record review, the facility failed to implement an effective and current system of surveillance for staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak, resulting in the potential for an outbreak to go undetected. Findings: During an interview on 08/07/24 11:14 AM, Regional Nurse Consultant (RNC) D and Director of Nursing (DON) reported that they had been without an Infection Control Preventionist since July 15th/July 16th. RNC D reported that the infection control program had been a collaborative effort with the herself, the DON and the Regional Infection Control Preventionist (ICP). RNC D reported that the ICP was responsible for the tracking/surveillance of employee illness. RNC D reported that the process for employee call offs was for the personal taking the call to fill out a call-off slip and submit it to the Human Resource Director. The Human Resource Director would then turn the slips over to the ICP for tracking. RNC D reported that employee call offs were reviewed weekly in the Interdisciplinary Team meetings and were tracked in real time by the Infection Control Preventionist. Review of the February employee Nosocomial Infections Monthly Report revealed 2 employees had called off of work sick. Review of the February Employee Call-Off Log revealed: On 2/27/24 a CNA called off as sick. The employee last worked on 2/25/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the unit last worked, or a specific date the employee could return to work. On 2/28/24 a CNA called off as sick. The employee last worked on 2/25/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the unit last worked, or a specific date the employee could return to work. On 2/29/24 a CNA called off as sick. The employee last worked on 2/25/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the unit last worked, or a specific date the employee could return to work. On 3/1/24 a CNA called off as sick. The employee last worked on 2/25/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the unit last worked, or a specific date the employee could return to work. Further review of the February Employee Call-Off Log revealed that 2 additional CNAs called off on 2/27/24 and 2/28/24 for vomiting. Both CNAs last worked on 2/25/24. There was no documentation of the unit those CNAs last worked on and no investigation into 6 CNAs calling off for illness with the date of 2/25/24 as their date last worked. Review of the March employee Nosocomial Infections Monthly Report revealed 6 employees had called off of work sick. Review of the March Employee Call-Off Log revealed: On 3/1/24 a CNA called off as sick. The employee last worked on 2/25/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the unit last worked, or a specific date the employee could return to work. On 3/3/24 a CNA called off as sick. The employee last worked on 2/28/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the unit last worked, or a specific date the employee could return to work. On 3/4/24 a housekeeping staff member called off as sick. The employee last worked on 2/26/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the residents they came in contact with, or a specific date the employee could return to work. On 3/11/24 a dietary staff member called off as sick. The employee last worked on 3/7/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the residents they came in contact with, or a specific date the employee could return to work. On 3/12/24 a dietary staff member called off as sick. The employee last worked on 3/10/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the residents they came in contact with, or a specific date the employee could return to work. On 3/27/24 a nurse called off as Not feeling good. The employee last worked on 3/24/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the unit last worked, or a specific date the employee could return to work. On 3/28/24 a CNA called off as sick. The employee last worked on 3/24/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the unit last worked, or a specific date the employee could return to work. A total of 7 employees called off of work without adequate tracking and surveillance from the Infection Control Preventionist in the month of March. There were no April employee Nosocomial Infections Monthly Reports or Employee Call-Off Logs available for review in the Infection Control Binder. There was no May employee Nosocomial Infections Monthly Report to review in the Infection Control Binder. Review of the May Employee Call-Off Log revealed: On 5/1/24 a medical records staff member called off as sick. The employee last worked on 4/29/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the residents/staff they came in contact with, or a specific date the employee could return to work. On 5/2/24 a CNA called off as In ER (emergency room ). The employee last worked on 4/27/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the unit last worked, or a specific date the employee could return to work. On 5/5/24 a CNA Left at 11:30 AM and could return to work on their Next Shift. There was no documentation of the type of illness, the unit last worked, or a specific date the employee could return to work. On 5/7/24 a dietary staff member called off as Not feeling good. The employee last worked on 4/27/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the residents they came in contact with, or a specific date the employee could return to work. On 5/8/24 a nurse called off as sick. The employee last worked on 5/5/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the unit last worked, or a specific date the employee could return to work. On 5/9/24 a CNA called off as sick. The employee last worked on 5/5/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the unit last worked, or a specific date the employee could return to work. On 5/13/24 a CNA called off as sick. The employee last worked on 5/6/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the unit last worked, or a specific date the employee could return to work. On 5/17/24 a CNA called off as Not feeling good. The employee last worked on 5/15/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the unit last worked, or a specific date the employee could return to work. On 5/19/24 a nurse called off but there was No slip (call off slip). The employee last worked on 5/17/24 and could return to work on their Next Shift. There was no documentation of follow up to rule out illness, the unit last worked, or a specific date the employee could return to work. On 5/21/24 a CNA left at 10PM. There was no documentation of follow up to rule out illness, the unit last worked, or a specific date the employee could return to work. On 5/22/24 a CNA called off as Not feeling good. The employee last worked on 5/21/24 and could return to work on their Next Shift. There was no documentation of the type of illness, the unit last worked, or a specific date the employee could return to work. On 5/24/24 a CNA called off for In ER. The employee last worked on 5/23/24 and could return to work on their Next Shift. There was no documentation of follow up to rule out illness, the unit last worked, or a specific date the employee could return to work. A total of 12 employees called off of work without adequate tracking and surveillance from the Infection Control Preventionist in the month of May. Review of the June employee Nosocomial Infections Monthly Report revealed 5 employees had called off of work not feeling good. Review of the June Employee Call-Off Log revealed: On 6/3/24 a nurse called off for Not feeling good. The employee last worked on 5/29/24 and could return to work on their Next Shift. There was no documentation of the type of illness or a specific date the employee could return to work. On 6/12/24 a CNA called off for Not feeling good. The employee last worked on 6/11/24 and could return to work on their Next Shift. There was no documentation of the type of illness or a specific date the employee could return to work. On 6/27/24 a nurse called off for illness. The employee last worked on 6/19/24 and could return to work on their Next Shift. There was no documentation of the type of illness or a specific date the employee could return to work. There were no August Employee Call-Off Logs available for review in the Infection Control Binder. During an interview on 08/07/24 at 01:25 PM, RNC D reported she would look for the missing employee surveillance for April and May. No reports/logs for April were received prior to survey exit. RNC D reported employee surveillance had not been completed for the month of August. Review of the facility policy Reportable health Symptoms; Return to Work Guidelines last revised May 2023 revealed, Employees are required to report information about their health and activities as they relate to transmissible diseases .1. The following symptoms are reportable to your supervisor or designated person in charge to receive a call-off notice; a. Vomiting b. Diarrhea c. Jaundice d. Sore throat with fever, or e. A lesion containing pus such as a boil or infected wound that is opening or draining .5. The infection control practitioner and/or the designated person in charge shall assume responsibility for excluding or restricting employees from work according to the guidelines set forth in Attachment A . Review of the facility policy Infection Prevention and Control Plan last updated March 2024 revealed, .1. The infection control committee incorporates the following on an ongoing basis: a. Surveillance, prevention and control of infections throughout the facility .d. Continually evaluates and monitors the results and presents recommendations for revision to policies and techniques as indicated. 2. Surveillance includes HAIs among staff and residents. Infections are monitored when a treatment plan is ordered by a Health Care Practitioner. a. Continuously collect and screen data to identify potential outbreaks .

This citation pertains to intake # MI0013669. Based on observations, interviews, and record reviews, the facility failed to provide adequate supervision and assistance to prevent falls for 3 residents (R26, R40 and R122) of 4 Residents reviewed for falls resulting in, R40 sustaining multiple injuries including a fracture of spine and hip, and R26 and R122 having multiple falls with injuries that required emergency room treatment. Findings included: R40 Review of R40's face sheet, dated 6/14/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: left femur fracture (4/24/23), Alzheimer's Disease, muscle weakness, dysphagia (difficulty swallowing), unsteadiness on feet, and cognitive communication deficit. R40 was not her own responsible party. Review of R40's incident and accident report dated 2/11/2023 at 6:43 PM revealed she had an unwitnessed fall and staff were notified of the fall by another resident. There was no indication if the resident's care plan was being followed at the time of the fall. The root cause listed was impaired cognition. There was no indication of the facility implementing any increased supervision or assistance after this fall. Review of R40's incident and accident report dated 2/20/2023 at 9:03 PM revealed R40 had an unwitnessed fall, R40 was found in her room on her back. R40 sustained a laceration on her left lower leg and a bruise on her left index finger. R40 was sent to the emergency room for treatment. When R40 returned to the facility she had 15 steri-strips and 5 sutures. R40 was noted to be wandering prior to being placed in bed. Root Cause: R40 was unable to state what she was attempting to do at the time of this incident due to her Dementia. She was toileted and ready for bed prior to the incident. After the investigation, it was conducted (sic) R40 was wandering with no known purpose due to Dementia. There were no interventions placed to increase supervision or assistance after this fall. Review of R40's incident and accident report dated 3/14/2023 at 12:45 AM revealed R40 was found on the bathroom floor. R40 had blood on the back of her head. R40 was sent to the emergency room for evaluation and treatment. The root cause was cognitive impairment and resident transferred herself to the bathroom. No intervention to increase supervision or assistance was noted. Review of R40's incident and accident report dated 3/21/2023 at 3:50 PM revealed R40 had an unwitnessed fall. R40 was found in her room on the floor with her head leaning against the bed and her nose was bleeding. R40 was sent to the emergency room for evaluation and treatment. The root cause was cognitive impairment. No intervention to increase supervision or assistance was noted. Review of R40's incident and accident report dated 4/11/2023 at 5:30 AM revealed R40 had an unwitnessed fall. R40 was found on the floor by the nurse's station with her head next to the fireplace. R40 had a hematoma and a laceration on the right side of her face. R40 was sent to the emergency room for evaluation and treatment. R40 was diagnosed with a T9 (spinal) fracture at the emergency room and was sent to another hospital for further treatment. The root cause was impaired cognition and resident does not understand her physical limitations. No interventions to increase supervision or assistance were noted. The intervention placed was adding anti-roll back device to wheelchair (Resident was care planned to have assistance with transfers and ambulation). Review of R40's incident and accident report dated 4/17/2023 at 10:16 PM revealed R40 had an unwitnessed fall. R40 was found on the floor near the nurse's station in the fetal position crying in pain. R40's left elbow and knee were bleeding. R40 was sent to the emergency room for evaluation and treatment. The root cause was impaired cognition. The intervention was to encourage R40 to be in a highly visible area when out of bed. R40 was in a highly visible area at the time of this fall and her last fall, however no staff witnessed this fall or the last fall. There was no indication that the facility had a plan to supervise R40 when she was awake. The physician note dated 4/25/23 revealed R40 returned from the hospital after this fall with a femur fracture and another spinal fracture at T1. Review of R40's physician note dated 4/14/23 revealed, 93 y.o. (year old) female is being re-admit. Patient was transferred to [name of emergency room ] after a fall on 4/11/23. Patient was noted to have a fracture at T9 (spinal area). She was subsequently transferred to [name of town] for T9 fracture monitoring. Xray of right arm, shoulder, hip neg (negative) in addition to CT (computed tomography) of the head. Review of R40's physician note dated 4/25/23 revealed, [AGE] year-old female is being seen today for readmission related to fall with injury. Patient sustained a fracture of the neck of left femur, closed T1 (spinal area), closed fracture of the eighth thoracic vertebrae, scalp hematoma on 4/18/2023, in addition to T9 vertebral fracture on 4/14/23. Patient denies pain at rest during interview however movement of hands and lower extremities did cause significant disc comfort (sic) as evidenced by facial grimacing and moaning with grunting. Patient complains of lower left leg pain during wound treatment. Patient is alert to self only. Patient denies shortness of breath, chest pain or pressure, does not appear to be in acute distress patient is up in wheelchair. Care conference completed with patient's daughter-in-law regarding option for safety including clip alarm or seatbelt alarm and current interventions including bedroom layout, mattress next to bed, bed in low position, soft touch call light, antirollback (sic) breaking system on wheelchair and winged mattress. During an interview with the Director of Nursing (DON) and Clinical Specialist (CS) C on 6/15/23 at 9:19 AM, R40's timeline of falls provided by the DON was reviewed. R40 had 5 falls between 2/20/23 and 4/17/23. The DON and CS C were not able to locate any interventions placed to increase R40's supervision and assistance after her last 4 falls. R26 Review of R26's Minimum Date Set (MDS), nursing assessment tool dated 3/14/23 revealed R26 was admitted on [DATE] and had a primary diagnosis of stroke. She was [AGE] years old and required physical assistance of one person to transfer and walk. Her Brief Interview of Mental Status score was 4/15 (severely cognitively impaired). Review of R26's incident and accident report dated 12/12/2022 at 11:45 AM revealed she had an unwitnessed fall. Staff were notified by R26's roommate that R26 was on the floor in her room. The investigation revealed R26 was severely cognitively impaired. Root cause was resident does not consistently apply wheelchair brakes while transferring herself in and out of wheelchair. Intervention was to add anti-roll backs to resident's wheelchair. R26 was already assessed to need supervision and assistance for transfers and walking. No intervention was located to supervise R26 when she was awake. Review of R26's incident and accident report dated 2/17/23 at 11:06 PM revealed she had an unwitnessed fall in her room. There was no indication if the resident had been in bed and when the last time she was seen, or care had been provided. The root cause was impaired cognition. There was no indication of any increased supervision or assistance being implemented. Review of R26's incident and accident report dated 3/25/23 at 10:35 PM revealed R26 had an unwitnessed fall. R26 had been in bed and was found on the floor. R26 told staff she was trying to get to her recliner. There was no indication if R26 had been sleeping or when she had last received care. The root cause was R26 was attempting to self-transfer from bed to a recliner. R26 was assessed to have assistance with transfers. No interventions were located that would ensure R26 would be provided assistance with transfers and supervised when awake. Interventions in place were to encourage the use of gripper socks when in bed, mat next to bed, bed in lowest position when not providing care, soft touch call light for easy activation, and perimeter mattress for positioning. Review of R26's incident and accident report dated 5/11/23 at 11:22 PM revealed R26 had an unwitnessed fall. The report indicated that as the staff entered R26's room they saw her lower herself to the floor. R26 was not using her walker. There was no indication of the last time R26 was observed by staff or when care was last provided. There was no indication how long R26 was up walking. R26 was assessed to need assistance with walking and the report indicated R26 was walking independently. The intervention placed was to have R26 rest when walking. R26 was not her own responsible party and was severely cognitively impaired. There was no indication of how the facility planned to supervise R26 when she was walking. Review of R26's incident and accident report dated 5/20/23 at 9:41 PM revealed she had an unwitnessed fall. Staff reported R26's roommate alerted them R26 had fallen. R26 was found on the floor next to her bed. There was no indication how long R26 had been in bed. There was no indication when R26 last had any care provided. The interventions were to remove the green soaker pad from the bed and rearrange the room or remove the recliner. There was no indication of how the facility planned to supervise R26 when she was awake or meet her care needs to prevent R26 from doing unsafe transfers. During an interview with the Director of Nursing (DON) and Clinical Specialist (CS) C on 6/15/23 at 10:00 AM, R26's fall incident reports from 12/12/22 to 5/20/22 were reviewed. They confirmed that they had not implemented any increased supervision or assistance for R26 after the 5 known falls. They did not remove R26's recliner from her room. They reported they were aware that when R26 wakes up she immediately tries to get out of bed and remains at high risk for continued falls due to her impaired cognition. They reported they have had discussions in the quality assurance meeting of the need to improve safety and prevent falls. R122 Review of R122's face sheet dated 6/14/23 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: fracture of the first lumbar vertebra (4/24/23), unspecified fall (4/24/23), difficulty walking, need for assistance with personal care, diabetes mellitus II, and age-related physical debility. R122 was not her own responsible party. R122 was observe sitting on the edge of her bed yelling for help on 6/13/23 at 2:51 PM. R122 said she kicked the mat out of the way, and she needed to go to the bathroom now. R122's call light was on. No staff were observed in the hall and the light over the door was not on (no indication R122 had her call light on). The red light on the wall near the call light cord was lit. The Surveyor told R122 she would find help. Two staff were located at the nurse's station. The nurse's station was not in view of R122's hall or room. Certified Nurse Aide (CNA) D responded to come help R122. The Surveyor reported the call light over R122's door was not functioning. CNA D reported none of the lights over the doors are functional. CNA D said the call system uses pagers. The Surveyor asked CNA D where her pager was and CNA D reported when she started at 2:00 PM there were no more pagers. CNA D said her hall partner would have to yell out for her if a call light was on. CNA D denied knowing R122's call light was on prior to the surveyor notifying her it was on. CNA D took R122 to the bathroom. However R122 was wet prior to reaching the bathroom. Review of R122's incident and accident report dated 4/20/23 at 3:50 PM, revealed she had an unwitnessed fall. R122 was found on the floor in her room. R122 was bleeding from the back of her head and was sent to the emergency room for evaluation and treatment. The root cause was R122 stubbed her toe walking. The intervention was for R122 to slow down when walking and encourage her to wear shoes not slippers. The investigation indicated R122 required assistance of one person to transfer and walk with a walker. The investigation indicated the need for assistance had changed but did not give the date of the change. Review of R122's incident and accident report dated 4/28/23 at 6:30 AM revealed she had an unwitnessed fall. R122 was found on the floor in her room. Resident did not have grippy socks on, her bed was in a low position and her call light was in reach. (no indication if the call light was on). The root cause was R122 had a UTI (urinary tract infection). There was no indication when R122 had last been assisted with care. There was no indication of any interventions placed to increase supervision or assistance. Review of R122's incident and accident report dated 5/5/23 at 12:17 PM revealed she had an unwitnessed fall in her room. The root cause was R122 is very self-determined and prefers to do most things for herself and she does not use the call light to get assistance. R122 self-transfers. The intervention was to encourage R122 to be in the lounge area when awake (R122 is cognitively impaired and not her own responsible party). There was no indication of how the facility planned to supervise R122 if she did not want to sit in the lounge area when awake. Review of R122's incident and accident report dated 5/12/23 at 11:10 PM revealed she had an unwitnessed fall. Resident was found on the bathroom floor with a bump on the back of her head. There was no indication of the last time R122 had been provided assistance with care or using the toilet. The intervention placed was 15-minute checks for 3 days. No long-term intervention for increased supervision or assistance was located. The root cause was R122 needed to use the bathroom and failed to use the call light (R122 was cognitively impaired and not her own responsible party). Review of R122's incident and accident report dated 5/22/23 at 10:00 AM revealed she had an unwitnessed fall. R122 was on the floor in her room. R122 had been in her wheelchair and was reaching for her shoes and slid to the floor. The root cause was R122 is self-determined and chooses not to utilize the call light. (R122 was cognitively impaired and was not her own responsible party). There was no intervention located to increase R122's supervision or assistance. Review of R122's incident report dated 5/26/23 at 7:22 AM revealed R122 was found on the floor in her room bleeding from the back of her head. R122 reported she was getting up and putting on her shoes. Interventions were to place shoes in reach, mat next to bed and R122 is the first to get up and dressed. R122 was sent to the emergency room for evaluation and treatment of the head wound. During an interview with the Director of Nursing (DON) and Clinical Specialist (CS) C on 6/15/23 at 10:00 AM, the observation of the call light not functioning outside R122 door and the CNA not having a pager on 6/13/23 at 2:51 PM was discussed. The DON confirmed she has had problems with not having enough pagers for all staff when they come to work as staff are taking the pagers home. The DON reported she purchased 17 new pagers in May and sent a message out to staff Monday (6/12/23) that they needed to bring the pagers back. The DON said the lights above the door were made inactive years ago. The DON confirmed that R122 was cognitively impaired, has poor safety awareness and was not her responsible party. R122's incident and accident reports were reviewed along with her care plan. The DON was not able to locate any interventions that ensured the facility was supervising R122 when she was awake or ensuring they were able to assist her with her care needs. The DON confirmed that R122 continues to self-transfer and remains at risk for injuries when she is not supervised with her care.

Based on observation, interview, and record review, the facility failed to develop care plans for five residents with pressure wounds (Resident #51, Resident #33, Resident #217, Resident #27, and Resident #220), resulting in an immediate jeopardy when, beginning on 07/31/19, facility staff did not develop a comprehensive care plan for 5 residents to treat, monitor, and promote the healing of pressure wounds. This deficient practice lead to the worsening or potential worsening of wound conditions for all 5 residents and the hospitalization of 1 resident, and placed all residents at risk for developing pressure wounds and the lack of monitoring and treatment if acquired. Findings include: Resident #51 Review of a Face Sheet revealed Resident #51 was an [AGE] year old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) revealed a score of 11 out of 15 which indicated slight short term memory impairment. Review of an Admission Assessment, dated 10/30/19, revealed Resident #51 was admitted with a left buttock pressure wound that measured 1cm x 1cm stage 2, and a sacral pressure wound measuring 3cm x 1cm stage 2. Review of a Treatment Administration Record (TAR) dated 10/1/19-10/31/19 revealed no orders for wound care treatment for [REDACTED]. Review of a TAR dated 11/1/19-11/30/19 revealed no orders for wound care treatment for [REDACTED]. Review of a TAR dated 12/1/19-12/31/19 revealed no orders for wound care treatment for [REDACTED]. Review of Care Plans for Resident #51 revealed that the resident was identified to have altered functional mobility and the intervention was SKIN: Apply barrier cream with incontinence care prn; inspect skin with bathing and care; report impaired skin integrity to charge nurse. Increase frequency of repositioning every 1 1/2 to 2 hours. Report increased drainage non intact dressings to right buttock or coccyx to charge nurse. No specific wound care orders were specified. No interventions to promote the healing of the two stage 2 wounds was specified. Review of Care Plans revealed the resident was identified to have 'impaired skin integrity and the interventions were to: measure open areas to coccyx and right hip weekly and prn. Review of a Progress Note- Skin Assessment, dated 11/1/19, read as follows: Moderate amount of serosangeous drainage noted to old drs on left hip. Incision cleansed with NS, and abd applied. Incision is well approximated, no s/s of infection noted. Skin tear to left hand cleansed and changed as ordered. Small scattered bruises to bi-lateral upper extremities noted. Rest of residents skin is clear, dry, warm, and intact. Mucous membranes moist. House lotion applied after residents shower. The progress note did not address either stage 2 pressure wound identified on the Admission Assessment. Review of a Progress Note- Interdisciplinary Documentation, dated 11/3/19, did not mention the two stage 2 pressure wounds identified on the Admission Assessment. Review of a Progress Note- Skin Assessment, dated 11/5/19, did not mention the two stage 2 pressure wounds identified on the Admission Assessment. Review of a Progress Note- Interdisciplinary Documentation, dated 11/8/19, mentioned the two stage 2 pressure wounds identified on the Admission Assessment and indicated that Resident #51 did admit to the facility with the need for surgical wound care along with two stage 2 pressure ulcers on her bottom, one on her coccyx and the other on her left buttock that have treatment orders as well. However, no treatment orders were located on the Treatment Administration Records dated 10/30/9 through 12/31/19. Review of a Progress Note- Skin Assessment, dated 11/10/19, did not mention the sacral stage 2 pressure wound identified on the Admission Assessment. Review of all Progress Notes for Resident #51 did not reveal a skin assessment for the week of 11/17/19. Review of Progress Notes-Skin Assessment, dated 11/26/19, read as follows: Residents skin is clean, warm and dry. Lt hip incision cont to heal. MMM, skin turgor is WNL. No new skin issues noted at this time. The two stage 2 pressure wounds were not addressed. Review of a Progress Note-Skin Assessment, dated 12/3/19, read as follows: Incision to left hip healing well. Redness and [MEDICAL CONDITION] continues to knee. The assessment did not mention the two stage 2 pressure wounds that Resident #51 had at admission. According to the nurses note dated 12/5/19 at 7:05 AM, Resident #51's blood pressure was low at 91/43, it was retaken at 8:33 AM and continued to remain low at 101/46 and the Resident reported that she was not feeling good. The nurse noted continued warmth and redness to the left lower extremity. At 1:05 PM, Resident #51 had a temperature of 100.4 degrees and the physician ordered a hospital transfer. There was no note or assessment of the pressure ulcers to determine if they could be the source of the infection prior to the ER transfer. On 12/5/19 at 2:50 PM, this Surveyor, (accompanied by another Surveyor) went to the ER attached to this facility, to see Resident #51. The emergency room (ER) nurse assigned stated that Resident #51 was sent over approximately 40 minutes prior and when the initial assessment was completed the ER nurse stated Resident #51 had an open area on her bottom. In the presence of two Surveyors, the ER nurse turned Resident #51 to her right side and measured the wound. The wound measured 9.0 cm x 9.0 cm with an open area in the center that measured 1.0 cm x 0.5 cm x 0.2 cm. The wound covered the entire sacrum, dark red in color, and did not have a dressing covering it when the nurse received Resident #51 in the ER, only a brief. Resident #33 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #33 admitted to the facility on [DATE], with a readmission date of [DATE]. Brief Interview for Mental Status (BIMS), reflected a score of 11 out of 15 which represents Resident #33 had moderate cognitive impairment. During an interview and observation on 12/4/19 at 4:45 PM, this surveyor observed Nurse FF provide a dressing change to Resident #33's pressure ulcer to the right heel. There was an opened area to the right heel with eschar and slough to the wound bed. A progress note dated 10/22/19 at 4:31 PM, authored by CCC R, reflected the development of a new stage 2 pressure ulcer (2 weeks after readmission) that measured 0.4 cm x 0.5 cm. The progress note reflected, Note left for provider. The weekly wound measurements were requested for review and reflect the following measurements and assessments were located within the providers note: -10/25/19 at 3:36 PM, Resident #33's pressure ulcer measured 0.5 cm x 1.2 cm x 0.2 cm and documented that the pressure ulcer was now a stage 3 (evolved from stage 2 on 10/22/19). -11/4/19 at 4:44 PM, Resident #33's pressure ulcer measured 2.0 cm x 1.5 cm x 0.1 cm and had an eschar cap. This assessment was 13 days after the first and revealed a larger measurement. -12/2/19 at 2:34 PM (4 weeks since the last assessment), Resident #33's pressure ulcer measured 2.0 cm x 1.5 cm x 0.1 cm and had increased drainage from the ulcer. The provider started [MEDICATION NAME] (an antibiotic) to treat the wound infection. The facility failed to assess and monitor the wound weekly which resulted in a wound infection. During an interview on 12/4/19 at 3:23 PM, the Clinical Care Coordinator R stated that she expected the nurses to do weekly skin checks, notify the doctor, Nurse Practitioner and the CCC of any new skin issues. For the wound assessments she expected the nurses to include a measurement, description of the wound bed, and surrounding tissue, odor and then notify the doctors and obtain treatment orders, start a short-term care plan for pressure ulcers, and implement the doctor's orders. CCC R checked the short-term care plan binder and the electronic medical record and stated there was no care plan initiated for Resident #33's stage 3 pressure ulcer that developed on 10/22/19 (after his readmission on 10/8/19). There was an incomplete short-term care plan dated 12/2/19 for wound and skin but it did not reflect what and where the wound was located only that it had become infected and antibiotic treatment started on 12/2/19. When asked if the pressure ulcer was avoidable or unavoidable, CCC R stated, Avoidable, we could have done more with positioning and elevating to avoid it. When asked how staff notified the physician of the significant change in condition for Resident #33's new pressure ulcer, the CCC R stated that the providers come Monday through Friday and she left them a note. During an interview on 12/5/19 at 11:15 AM, after reviewing the initial note dated 10/22/19 and the providers note dated 10/25/19, the DON stated, I can't speak to why she did that (wrote it in the book instead of calling and notifying the physician). The DON stated that she expected the nurses to call the doctor with anything new such as a pressure ulcer and then write it in the book for the doctor to see on the next visit day. The progress notes reflected a skin assessment dated [DATE] and not again until 10/22/19 (13 days later), the day the pressure ulcer was noted. The DON stated that she expected nurses to do weekly head to toe skin checks and document a complete narrative under skin assessments, in the progress notes. According to the October, November, and (MONTH) 2019 Treatment Administration Record (TAR) an order was initiated on 10/25/19 (3 days after the pressure ulcer developed) for an off-loading boot to be worn to the right foot while in bed. During an observation on 12/5/19 at 9:00 AM, this surveyor asked to observe Resident #33's off-loading boot. Resident #33 was lying in his bed when this surveyor and RN Q entered the room. RN Q pulled the blanket off the right foot and we observed Resident #33's heel had a dressing on and a grip sock. Resident #33's heel was lying directly on the mattress and no off-loading boot was in sight. RN Q searched every closet and drawer in the room and was unable to find the off-loading boot. When asked how the CNA's would know to apply the off-loading boot, RN Q stated, It should say it on the ADL (activities of daily living) care plan. RN Q opened the closet door to review the care plan. There was no intervention listed to apply the boot. When asked to review the pressure ulcer care plan, RN Q checked the computer and the short-term care plan book and stated, There isn't one. When asked how the care givers would know that Resident #33 has a Stage 3 pressure ulcer to his right heel, RN Q stated, I only know because there is a treatment on the TAR for it. During an interview on 12/5/19 at 9:10 AM, when asked if Resident #33 had a care plan for the Stage 3 pressure ulcer to the right heel, RN CCC R stated, No, not yet. Resident #217 According to the Minimum Data Set (MDS) assessment, dated 9/27/19, Resident #217 had multiple [DIAGNOSES REDACTED]. Resident #217 required extensive assistance of two staff members for bed mobility, transferring, dressing and other activities of daily living including toileting needs. Staff assessed Resident #217 as having moderate cognitive impairment. This same assessment revealed Resident #217 had a stage four pressure ulcer present upon re-admission on 7/30/19. Review of Resident #217's care plan reveals on 10/25/18 the facility initiated a Potential risk for impaired skin integrity related to poor nutritional intake, impaired functional mobility, and or incontinence care plan, this care plan was not updated to reflect current wound care needs. Staff revised the care plan goals on 10/7/19 which read, will show improvement of impaired skin integrity as evidence by no s/s of infections and decreased measurements and/or prevention of avoidable impaired skin integrity will be achieved. Staff did not identify specific measurable goals on the care plan. There were no care plan intervention updates since 10/25/18. The interventions on the care plan did not indicate when or how staff should be relieving pressure points to promote healing and prevent additional skin impairment such as turning and repositioning every one or two hours. One of the care planned interventions, dated 10/25/18, indicated staff were to Measure open areas upon admission, weekly, prn. When asked for weekly wound measurements on 12/4/19, the facility provided wound tracking documentation with measurements completed on 6/5/19, 6/24/19, 7/12/19, 7/16/19, 10/2/19 and 11/5/19. The last measurement on 11/5/19, a month prior, indicated Resident #217's wound on the right buttock measured 2.5 centimeters (cm) by 1 cm by 2.5 cm deep, there was no wound description identifying wound bed, surrounding skin, drainage amount, or odor. The facility reported Resident #217 went to the wound clinic every two weeks, the facility did not have wound measurements in Resident #217's chart from those appointments. Most current wound assessment/measurements were requested by this surveyor and on 12/6/19 the facility provided an assessment performed by the wound clinic on 12/3/19 and stated that the document was faxed on this day from the wound clinic and had not been in the resident electronic medical record. Resident #27 According to the Minimum Data Set (MDS) admission assessment, dated 1/8/19, Resident #27 had multiple [DIAGNOSES REDACTED]. At that time, Resident #27 required assistance of one staff member to move in bed and two staff members for transferring. Staff had assessed Resident #27 as being severely cognitively impaired. Resident #27's Admission Assessment, dated 1/1/19, read, Right heal (sic) ulcer, warm to touch, painful to touch, redressed wound the section of the Admission Assessment titled Skin provided a space to document wound measurements. Staff did not record wound measurements. Progress notes dated 1/2/19 described Resident #27's right heel ulcer as tan in color and surrounding skin as pink. There were no wound measurements. Progress notes on 1/3/19 indicated the right heel wound measures 5 centimeters (cm) by 7 cm by 0.5 cm deep and wound description reads, Discoloration noted on whole heel. Eschar (dead tissue) noted in center of wound, pink granulation tissue noted around eschar. Macerated yellow sloughing noted around border of open area in wound. According to the progress notes, dated 12/6/19, measurements of Resident #27's right heel was 2.4 cm by 2.0 cm by 0.5 cm, no further wound description was documented. Review of Resident #27's Impaired Skin Integrity care plan, initiated 1/8/19, revealed a goal of (name of Resident #27) will show improvement of impaired skin integrity as evidence by no S/S (signs or symptoms) of infection and decreased measurements and/or prevention of avoidable impaired skin integrity will be achieved, there were no specific goals identified that were measurable nor was there evidence that this goal was achieved, partially met, or not met. The listed interventions, all initiated on 1/8/19, included, in part, pressure reducing cushion to wheelchair and pressure reducing mattress, were not specific to Resident #27's needs to promote wound healing. Resident #220 According to the Minimum Data Set (MDS) assessment, dated 9/21/19, Resident #220 had multiple [DIAGNOSES REDACTED]. This same assessment indicated Resident #220 required extensive assistance of two staff members to move in bed, and for transferring, dressing, and other hygiene needs including bathroom needs. Staff assessed Resident #220 as having severe cognitive impairment. According to the admission MDS assessment, dated 8/16/19, Resident #220 admitted to the facility with two pressure ulcers. The pressure ulcer on the right buttock measured 1 cm (centimeters) x 1 cm x 0.1 cm and staff coded this pressure ulcers as a Stage 2. The pressure ulcer on the coccyx measured 2 cm x 1 cm x 0.1 cm, staff coded this pressure ulcer as a Stage 2. Resident #220 care planned interventions for skin, revised 8/19/19, read, Assist with repositioning with use of draw sheet as needed to prevent friction/shear, bridge heels in bed if indicated (DC if contraindicated) to protect heels, Consult RD/CDM (Registered Dietician/Certified Dietary Manager) prn (as needed) to evaluate nutritional approaches i.e., enhanced foods vitamin or protein supplements, measure open areas upon admission, weekly, prn, skin inspections with am/pm care and showering report abnormal to the charge nurse. There were no specific interventions such as turn schedules to limit pressure to bony prominences. Review of physician notes revealed staff were instructed to turn Resident #220 on the following dates: On 10/9/19 Nurse Practitioner CC wrote, nursing instructed to lift (Resident #220's) buttocks off bed with position changes and turn from side to side q2h (every 2 hours) limit sitting on buttocks to less than 2 hours. On 10/21/19, Nurse Practitioner CC wrote, turn q (every) 2 hours from side to side and avoid more than 30 min (minutes) on his back to prevent deep tissue injury. And on 10/30/19, Nurse Practitioner CC wrote, discussed q (every) 1-2 hour turn to prevent further pressure damage, discussed with both the nurse and CNA (certified nursing assistant) about the importance of diligent repositioning. These instructions were not listed as an intervention to prevent additional skin impairment on Resident #220's care plan. On 12/06/19 at 1:25 P.M., the Administrator was verbally notified and received written notification of the immediate jeopardy, that was identified on 12/06/19, due to the facility's failure to develop care plans to monitor, direct treatment, and promote the healing of pressure wounds for 5 residents. A written plan for removal for the immediate jeopardy was received on 12/06/19 and the following was verified on 12/07/19: The (facility) submits the following Credible Allegation of Compliance outlining the measures it has completed to remove the findings of immediate jeopardy to resident health and safety identified by the survey team regarding the facility's alleged failure to develop comprehensive care plans to treat, monitor and promote the healing of pressure wounds. This serves as response to the Immediate Jeopardy citation received by (the facility) on 12/06/19 at 1325. The facility Quality Assurance committee immediately met ad hoc to resolve the alleged failure that the facility did not initiate care plans on a timely basis for residents #51, 33, 217, 27, and 220. The Quality Assurance Committee implemented the following abatement procedure. 1. The facility QA committee met ad hoc, on 12/6/19 at 1325. 2. On 12-06-2019 the facility reviewed the plan of care for resident #33 to ensure the care plan is updated to reflect treatment, monitoring, and promotion of wound healing. 3. Resident #51 is not currently residing in the facility and is anticipated to return. Immediately upon return the facility will assess and implement a plan of care to promote healing and prevention of additional impaired skin integrity. 4. On 12-06-2019 the facility reviewed the plan of care for resident #27 to ensure the care plan is updated to reflect treatment, monitoring, and promotion of wound healing. 5. On 12-06-2019 the facility reviewed the plan of care for resident #217 to ensure the care plan is updated to reflect treatment, monitoring, and promotion of wound healing. 6. All residents had a review of their skin at risk plan of care. 7. All residents with the potential for impaired skin integrity had a complete skin inspection. 8. Nursing staff education began on 12/06/19, continuing with shift to shift until all licensed nursing staff are educated. Although the immediate jeopardy was removed on 12/06/19, the facility remained out of compliance at a scope of pattern and severity of actual harm due the fact that not all facility staff have received education and sustained compliance has not been verified by the State Agency.

Based on observation, interview, and record review, the facility failed to perform necessary assessments, treatments, and interventions to prevent the development of and promote the healing of pressure ulcers for 3 of 9 residents (Residents #33, #51 and #220) reviewed for pressure ulcers. This deficient practice resulted in an immediate jeopardy when Residents #51, who had been identified as having pressure ulcers (Stage 2 pressure) upon admission did not receive weekly skin monitoring, and weekly wound monitoring for 5 weeks, despite signs and symptoms of infection, prior to sending Resident #51 to the emergency room and the pressure ulcer evolved to a Stage 3. Resident #33 developed a facility acquired Stage 2 pressure ulcer that evolved to a Stage 3 did not receive routine skin assessments, preventative measures, and interventions in spite of the pressure ulcers increase in size and the development of a systemic infection the facility failed to ensure appropriate off-loading to the pressure ulcer. And Resident #220 admitted to the facility with two Stage 2 pressure ulcers that progressed to unstageable with necrotic tissue and developed a new Stage 4 pressure ulcer. This deficient practice places all facility residents, who the facility identified with impaired skin integrity and at risk for pressure ulcer and promote healing for all residents with pressure ulcers at risk for serious harm, injury, and/or death. Findings include: During an interview on 12/04/19 at 6:00 PM, this surveyor requested to review the facility's policy/procedure for pressure ulcers. The DON stated there is no specific pressure ulcer policy. This surveyor requested any education that would be provided to nurses to prevent, identify, stage, monitor and treat pressure ulcers. The facility failed to have a systematic method to prevent and treat pressure ulcers including consistently documenting routine weekly skin checks. Resident #51 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #51 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS), reflected a score of 11 out of 15 which represents Resident #51 had moderate cognitive impairment. The facility provided the CMS 802 roster/matrix after the entrance conference for the annual survey. According to the form, Resident #51 did not have a pressure ulcer. According to the MDS dated [DATE], Resident #51 had 2, Stage 2 pressures ulcers on admission. According to the Care Area Assessment (CAA) portion of the MDS, care planning for the pressure ulcer would be initiated. The admission assessment dated [DATE] reflected, a Stage 2 pressure ulcer to the sacrum that measured 3 cm x 1 cm x 0 cm and a Stage 2 pressure ulcer to the left buttock that measured 1.0 cm x 1.0 cm x 0 cm. A record review of the care plans on the electronic health record and the short-term care plan binder at the nurse's desk reflected no care plan for the pressure ulcers that staff noted upon admission to the facility 10/30/19. According to the (MONTH) and (MONTH) 2019 treatment administration record Resident #51 had treatment orders for the buttock pressure ulcer but no treatment in place for the sacrum pressure ulcer. According to the nurses note dated 12/5/19 at 7:05 AM, Resident #51's blood pressure was low at 91/43, it was retaken at 8:33 AM and continued to remain low at 101/46 and the Resident reported that she was not feeling good. The nurse noted continued warmth and redness to the left lower extremity. At 1:05 PM, Resident #51 had a temperature of 100.4 degrees and the physician ordered a hospital transfer. There was no note or assessment of the pressure ulcers to determine if they could be the source of the infection prior to the ER transfer. According to the Nursing Home to Hospital Transfer Form dated 12/5/19 and signed at 1:52 PM as completed by the DON, the form was left blank under the section of risk alerts for pressure ulcers and blank under the area for skin/wound care for pressure ulcers (stages, location, appearance, treatments). There was no indication documented for the emergency room (ER) that Resident #51 had two pressure ulcers. During an interview and record review on 12/5/19 at 4:20 PM, the DON provided copies of Resident #51's medical records. The DON stated that Resident #51 admitted to the facility with two Stage 2 pressures ulcers. This surveyor asked to review the weekly wound assessments and measurements and the DON stated that the facility did not have any and was not able to provide them before the exit of this survey. When asked if there was a care plan for the pressure ulcers, the DON stated there wasn't any. On 12/5/19 at 2:50 PM, this Surveyor, (accompanied by another Surveyor) went to the ER attached to this facility, to see Resident #51. The emergency room (ER) nurse assigned stated that Resident #51 was sent over approximately 40 minutes prior and when the initial assessment was completed the ER nurse stated Resident #51 had an open area on her bottom. In the presence of two Surveyors, the ER nurse turned Resident #51 to her right side and measured the wound. The wound measured 9.0 cm x 9.0 cm with an open area in the center that measured 1.0 cm x 0.5 cm x 0.2 cm. The wound covered the entire sacrum, dark red in color, and did not have a dressing covering it when the nurse received Resident #51 in the ER, only a brief. Resident #33 Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE] revealed Resident #33 admitted to the facility on [DATE], with a readmission date of [DATE]. Brief Interview for Mental Status (BIMS), reflected a score of 11 out of 15 which represents Resident #33 had moderate cognitive impairment. During an interview and observation on 12/4/19 at 4:45 PM, this surveyor observed Nurse FF provide a dressing change to Resident #33's pressure ulcer to the right heel. There was an opened area to the right heel with eschar and slough to the wound bed. A progress note dated 10/22/19 at 4:31 PM, authored by CCC R, reflected the development of a new stage 2 pressure ulcer (2 weeks after readmission) that measured 0.4 cm x 0.5 cm. The progress note reflected, Note left for provider. The weekly wound measurements were requested for review and reflect the following measurements and assessments were located within the providers note: -10/25/19 at 3:36 PM, Resident #33's pressure ulcer measured 0.5 cm x 1.2 cm x 0.2 cm and documented that the pressure ulcer was now a stage 3 (evolved from stage 2 on 10/22/19). -11/4/19 at 4:44 PM, Resident #33's pressure ulcer measured 2.0 cm x 1.5 cm x 0.1 cm and had an eschar cap. This assessment was 13 days after the first and revealed a larger measurement. -12/2/19 at 2:34 PM (4 weeks since the last assessment), Resident #33's pressure ulcer measured 2.0 cm x 1.5 cm x 0.1 cm and had increased drainage from the ulcer. The provider started [MEDICATION NAME] (an antibiotic) to treat the wound infection. The facility failed to assess and monitor the wound weekly which resulted in a wound infection. During an interview on 12/4/19 at 3:23 PM, the Clinical Care Coordinator R stated that she expected the nurses to do weekly skin checks, notify the doctor, Nurse Practitioner and the CCC of any new skin issues. For the wound assessments she expected the nurses to include a measurement, description of the wound bed, and surrounding tissue, odor and then notify the doctors and obtain treatment orders, start a short-term care plan for pressure ulcers, and implement the doctor's orders. CCC R checked the short-term care plan binder and the electronic medical record and stated there was no care plan initiated for Resident #33's stage 3 pressure ulcer that developed on 10/22/19 (after his readmission on 10/8/19). There was an incomplete short-term care plan dated 12/2/19 for wound and skin but it did not reflect what and where the wound was located only that it had become infected and antibiotic treatment started on 12/2/19. When asked if the pressure ulcer was avoidable or unavoidable, CCC R stated, Avoidable, we could have done more with positioning and elevating to avoid it. When asked how staff notified the physician of the significant change in condition for Resident #33's new pressure ulcer, the CCC R stated that the providers come Monday through Friday and she left them a note. During an interview on 12/5/19 at 11:15 AM, after reviewing the initial note dated 10/22/19 and the providers note dated 10/25/19, the DON stated, I can't speak to why she did that (wrote it in the book instead of calling and notifying the physician). The DON stated that she expected the nurses to call the doctor with anything new such as a pressure ulcer and then write it in the book for the doctor to see on the next visit day. The progress notes reflected a skin assessment dated [DATE] and not again until 10/22/19 (13 days later), the day the pressure ulcer was noted. The DON stated that she expected nurses to do weekly head to toe skin checks and document a complete narrative under skin assessments, in the progress notes. According to the October, November, and (MONTH) 2019 Treatment Administration Record (TAR) an order was initiated on 10/25/19 (3 days after the pressure ulcer developed) for an off-loading boot to be worn to the right foot while in bed. During an observation on 12/5/19 at 9:00 AM, this surveyor asked to observe Resident #33's off-loading boot. Resident #33 was lying in his bed when this surveyor and RN Q entered the room. RN Q pulled the blanket off the right foot and we observed Resident #33's heel had a dressing on and a grip sock. Resident #33's heel was lying directly on the mattress and no off-loading boot was in sight. RN Q searched every closet and drawer in the room and was unable to find the off-loading boot. When asked how the CNA's would know to apply the off-loading boot, RN Q stated, It should say it on the ADL (activities of daily living) care plan. RN Q opened the closet door to review the care plan. There was no intervention listed to apply the boot. When asked to review the pressure ulcer care plan, RN Q checked the computer and the short-term care plan book and stated, There isn't one. When asked how the care givers would know that Resident #33 has a Stage 3 pressure ulcer to his right heel, RN Q stated, I only know because there is a treatment on the TAR for it. During an interview on 12/5/19 at 9:10 AM, when asked if Resident #33 had a care plan for the Stage 3 pressure ulcer to the right heel, RN CCC R stated, No, not yet. Resident #220 According to the Minimum Data Set (MDS) assessment, dated 9/21/19, Resident #220 had multiple [DIAGNOSES REDACTED]. This same assessment indicated Resident #220 required extensive assistance of two staff members to move in bed, transferring, dressing, and other hygiene needs including bathroom needs. Staff assessed Resident #220 as having severe cognitive impairment. According to the admission MDS assessment, dated 8/16/19, Resident #220 was admitted to the facility with two pressure ulcers. The pressure ulcer on the right buttock measured 1 cm (centimeters) x 1 cm x 0.1 cm and staff coded this pressure ulcers as a Stage 2. The pressure ulcer on the coccyx measured 2 cm x 1 cm x 0.1 cm, staff coded this pressure ulcer as a Stage 2. Resident #220 care planned interventions for skin, revised 8/19/19, read, Assist with repositioning with use of draw sheet as needed to prevent friction/shear, bridge heels in bed if indicated (DC if contraindicated) to protect heels, Consult RD/CDM (Registered Dietician/Certified Dietary Manager) prn (as needed) to evaluation nutritional approaches i.e., enhanced foods vitamin or protein supplements, measure open areas upon admission, weekly, prn, skin inspections with am/pm care and showering report abnormal to the charge nurse. There were no specific interventions such as turn schedules to limit pressure to bony prominences. The facility provided Wound Tracking documentation indicating the last time facility staff measured Resident #220's wounds were on 11/5/19 (a month ago). The following measurements were documented: Left Buttock (not present upon admission): 3.5 cm x 3 cm x 3 cm deep. This wound was described as a deep tissue injury and had tunneling measuring at least 3 cm in three different areas of the wound. Right Buttock: 3 cm x 4.5 cm (no depth was documented). This wound was described as a deep tissue injury and was covered with a layer of eschar (dead tissue). Most current physician notes, dated 12/9/19, revealed Resident #220's wounds were measured: Left Buttock: 2.6 cm x 3 cm x 2.5 cm deep. This wound was categorized as a Stage 4 with fat tissue exposed, undermining measuring 5.2 cm and the wound bed contained necrotic tissue. Right Buttock: 5 cm x 3 cm, x 1.5 cm deep and is unstageable. This wound contained a large amount of necrotic tissue. Left posterior lower leg (not present on admission): 2 cm x 0.8 cm x 0.1 cm. This wound contained a large amount of eschar. During an interview on 12/11/19 at 08:44 AM, Nurse Practitioner CC stated that Resident #220 did not have a bone infection at this time but because the wound was infected, Resident #220 was treated with antibiotics to prevent a bone infection. The facility was notified of Immediate Jeopardy (IJ) at F-686 on 12/5/19 at 12:40 PM and 5:31 PM, was identified on 12/5/19 and began on 10/22/19, due to the facility's failure to ensure complete and accurate weekly skin assessments, necessary assessments, treatments and interventions to prevent the development of and promote the healing of pressure ulcers, resulting in pressure ulcer development and worsening of pressures ulcers that became infected with the potential for serious injury and/or death for Resident #51 and #33. This deficient practice placed all facility residents, who were identified by the facility as at risk for skin integrity, at risk for serious harm, injury, and/or death. Immediacy was removed on 12/6/19 when the facility had the following in place for Residents #51 and #33: The facility response: This serves as response to the Immediate Jeopardy citation received by (Name of Facility) on 12/5/19 at 12:40 PM for Resident #33 and 5:31 PM for Resident #51. The facility Quality Assurance Committee immediately met with ad hoc to resolve the alleged ulcers increased in size for Resident #51. The Quality Assurance Committee implemented the following abatement procedure. F-686 Element #1: Action Taken: On 12/5/19 Resident #33 had a comprehensive review of documentation, nutritional status, treatment orders, and risk for impaired skin integrity. This assessment was utilized to update interventions and treatment for [REDACTED]. The wound has improved since 12/2/19. Resident #51 is not currently in the facility. Element #2: Identification of Other Residents: Each resident residing in the facility present varying degrees of risk for the development of pressure sores. On 12/5/19 a head to toe skin assessment was completed for each resident residing at (name of facility) to validate the status of skin integrity and the effectiveness of current interventions. Each resident had a review of their skin at risk plan of care to evaluate the interventions, health care practitioner orders if applicable, treatment orders, and care planned interventions to limit the potential for avoidable impairments to skin integrity. Beginning 12/6/19 a thorough skin and wound assessment per standards of care were started on residents at risk for impaired skin integrity. Element #3 Measures Taken: The facility will provide education to Nursing Staff on 12/5/19 and the education will continue shift-to-shift until each member of the nursing staff has received it. The educational agenda will include a review of application of Standards of Practice for interventions for skin observations which include: An Admission Assessment of skin impairment; prompt intervention to limit worsening of impaired skin integrity; prompt notification to the health care practitioner for orders; weekly assessments and measurement of impaired skin integrity with notification to the health practitioner if indicated; Certified Nursing Assistant Inspection of skin with Activity of Daily Living assistance and incontinence care; Certified Nursing Assistant report to the licensed nurse for narrative measurement and description of identified impaired skin integrity; Licensed Nurse implementing orders for identified impaired skin integrity. The care plans for skin at risk were individually reviewed for each resident to promote the continued prevention of unavoidable ulcers for each resident. Element #4: Monitoring: On 12/5/19 the Director of Health Care Services and/or designees initiated an audit to conduct rounds 5-7 times per week for 4 weeks on varying shifts to evaluate the education provided and inspect for the implementation of measures to prevent unavoidable ulcers. The audit will include verbal and demonstrative staff participation to evaluate understanding and provide validation of the interventions and documentation to prevent avoidable pressure ulcers. The Director of Health Care Service will compile a report of this audit for review and recommendation by the Quality Assurance Performance Improvement Committee monthly X 1 and periodically thereafter. The Director of Health Care Services will assume responsibility for sustained compliance. Although the Immediate Jeopardy (IJ) was removed on 12/6/19, the facility remained out of compliance at a scope of isolated and a severity of Actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to all staff had not been in-serviced on the corrective action implemented to remove the immediacy and sustained compliance has not been verified by the state agency.

Based on record review, the facility failed to update care plans for two Residents (#27 and #217) out of 40 residents reviewed for updated care plans. This deficient practice resulted in inaccurate care planning for actual skin integrity impairments, lack of updated and individualized interventions, lack of updated and measurable goals, and infections leading to worsening pressure ulcers. Findings include: Resident #27 According to the Minimum Data Set (MDS) assessment, dated 10/8/19, Resident #27 had multiple [DIAGNOSES REDACTED]. The Skin Condition section revealed Resident #27 had a Stage four pressure ulcer and an infection of the foot. The MDS assessment revealed, Resident #27 required assistance of one staff member to move in bed and for transferring. Staff had assessed Resident #27 as severely cognitively impaired. A Physician note, dated 9/27/19, describes Resident #27's wounds as having a grey wound bed and was odorous. The written physician plan was to continue with the antibiotic to treat the wound infection. The physician did not document wound measurements. A progress note, dated 9/25/19, revealed the wound on Resident #27's right heel measured 3.3 cm by 1.8 cm by 1.0 cm deep. Undermining was identified. Staff did not document other wound descriptions such as color of wound bed, drainage or odor. Another progress note, dated 12/6/19, revealed Resident #27's right heel was 2.4 cm by 2.0 cm by 0.5 cm deep, no further wound description was documented. Review of progress notes disclosed Resident #27 would frequently refuse wound care. Progress notes read: On 11/2/19 Resident refused dressing change, On 11/3/19 refused foot tx (treatment), On 11/4/19 refused dressing change, On 11/8/19 refused, On 11/9/19 res. (resident) refusing all cares and treatments, On 11/10/19 foot tx refused, On 11/11/19 refused several times, On 11/12/19 refused, and similar documented entries were noted on 11/13/19, 11/14/19, 11/15/19, 11/16/19, 11/17/19, 11/18/19, 11/19/19, 11/21/19, 11/22/19, 11/23/19, 11/26/19, 11/27/19 and 12/1/19. Review of Resident #27's Impaired Skin Integrity care plan, initiated 1/8/19, revealed a goal of (name of Resident #27) will show improvement of impaired skin integrity as evidence by no S/S (signs or symptoms) of infection and decreased measurements and/or prevention of avoidable impaired skin integrity will be achieved, there were no specific, measurable goals identified nor was there evidence that this goal was achieved, partially met, or not met. Staff last revised these goals on 12/2/19. At the time of this revision, the care plan did not reflect resident refusal of cares nor did it reflect Resident #27's current wound infection. The listed interventions on the Impaired Skin Integrity care plan, all initiated on 1/8/19, were not updated on 12/2/19 to include resident refusals nor were there interventions to identify resident barriers to care. A progress note, dated 12/2/19, revealed new orders for Resident #27 to begin an antibiotic for a foot ulcer with infection. Resident #27's care plan revisions on 12/2/19 did not reflect this change in resident condition. Resident #27's progress note, dated 12/5/19, read, Care plans reviewed and updated to include (name of resident) occasional declination with personal cares. The care plan had no interventions or indication Resident #27 had an infected wound. Resident #217 According to the Minimum Data Set (MDS) assessment, dated 9/27/19, Resident #217 had multiple [DIAGNOSES REDACTED]. Resident #217 required extensive assistance of two staff members for bed mobility, transferring, dressing and other activities of daily living including toileting needs. Staff assessed Resident #217 as having moderate cognitive impairment. This same assessment revealed Resident #217 had a stage four pressure ulcer present upon re-admission on 7/30/19. Review of Resident #217's care plan revealed on 10/25/18 the facility initiated a Potential risk for impaired skin integrity related to poor nutritional intake, impaired functional mobility, and or incontinence care plan, this care plan was not updated to reflect current wounds. Staff revised the care plan goals on 10/7/19 which read, will show improvement of impaired skin integrity as evidence by no s/s (signs and symptoms) of infections and decreased measurements and/or prevention of avoidable impaired skin integrity will be achieved. Staff did not identify specific measurable goals on the care plan. There were no care plan intervention updates for impaired skin integrity since 10/25/18 (over a year prior). The care plan did not identify Resident #217 had actual skin impairment.

Based on observation, interview and record review, the facility failed to accurately and consistently assess a resident's skin integrity and implement interventions to prevent pressure ulcers in 2 of 3 residents (Residents #5 and 10) who were reviewed for pressure ulcers, in a total sample of 15 residents, resulting in Resident #5 developing a stage IV pressure ulcer to the coccyx (tailbone) with complaints of pain to the buttock and Resident #10 developing a stage II pressure ulcer. Findings Include: The facility provided the following reference as policy/procedure for preventing pressure ulcers, Lippincott Procedure - skin assessment and pressure ulcer management, long-term care with a review date of 4/30/15. The reference reflected, The Joint Commission requires all long-term care facilities to assess residents at the time of admission using a validated risk assessment tool, such as the Braden Scale or Norton Scale. Both Tools screen residents for the presence of risk factors linked to skin breakdown and pressure ulcer development. Complete subsequent risk assessments weekly and with any change or deterioration of the resident's condition .Incomplete or inadequate skin assessment decreases the opportunities for the health care team to implement measures that can reduce skin breakdown and pressure ulcer development in long-term care residents. As a result, the recovery of long-term care residents is compromised because of greater potential for development of sequelae, such as geriatri[DIAGNOSES REDACTED]s. Additionally, residents experience increased rates of morbidity and mortality and increased lengths of stay and cost burden .Document interventions used to prevent pressure ulcers and the resident's response. If a pressure ulcer develops, note changes in the condition or size of the pressure ulcer and elevations of skin temperature. Document when you notified the practitioner of pertinent abnormal observations. Record the resident's temperature daily on the graphic sheet to allow easy assessment of body temperature patterns. Document resident and family teaching and their comprehension of your teaching .Documentation: Document the size, location, depth and stage of the pressure ulcer .Document wound care provided and the resident's response to your interventions. Review of the Face Sheet and Minimum Data Set (MDS), dated [DATE] reflected Resident #5 was an [AGE] year old male who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS reflected that Resident #1 was cognitively intact and required extensive staff assistance with all activities of daily living. During an observation of a dressing change to Resident #5's coccyx with Registered Nurse (RN) R on 5/13/15 at 10:10 AM, Resident #5 was observed with a wound to the coccyx that involved full-thickness tissue loss with exposed muscle with undermining (tunneling). This is a stage IV pressure ulcer. According to the admission assessment dated [DATE] Resident #5 had a dime size open area to the right mid buttock and the coccyx had redness. According to the nurses notes on 12/29/14 at 4:17 PM Resident #5's right mid buttock wound measured 0.7 x 0.5 cm (no depth noted). The note did not contain an assessment of the coccyx and redness (noted on 12/28/14). The nurses notes dated on 12/31/15 at 8:59 AM reflected, coccyx has open area. The note at 12:22 PM reflected, Skin breakdown noted on clients coccyx. Large circular pink area that does not blanche to the touch. Pink small blister noted with additional two small dark spots. Care manager notified of situation. Maintenance contacted for pressure relieving mattress in room (air mattress) Nursing order to monitor coccyx. The note does not reflect measurements of the coccyx wound, the wound care provided nor that the physician was notified of a new pressure ulcer development. The nurses notes dated 1/5/15 at 9:48 PM reflected, Staff was changing brief of client and noticed that there was a wound over coccyx area that was open. Area appeared reddened, but there was no drainage present. The note does not reflect measurements of the coccyx wound, wound care provided nor that the physician was notified of a new pressure ulcer development. According to the nurses notes dated 1/7/15 at 4:30 the coccyx wound measured 4.0 x 1.0 x. 0.3 cm the physician was notified and a treatment order was obtained for the coccyx wound (7 days after the discovery of the open coccyx wound). In an interview and record review on 5/13/15 at 2:00 PM, RN Care Manager K stated that Resident #5 was admitted on [DATE] for rehabilitation after a hospital stay. RN Care Manager K stated that the Certified Nurse Assistants (CNA's) were suppose to do a daily skin check and report any abnormalities to the nurse, the nurse will assess and chart it, the nurse will notify the manager and it will be measured weekly and the physician will be notified to obtain treatment orders. On 5/14/15 at 4:15 PM, RN Care Manager K stated that she was not able to locate the CNA skin assessment documentation from 12/28/14 - 1/27/14. RN Care Manager K stated that the facility completes a variance/incident form for all unexpected problems identified (such as a new pressure ulcer) but there was not one completed for the stage IV pressure ulcer to the coccyx. RN Care Manager K stated there was not a care plan originated on admission (12/28/14) to address the pressure ulcer to the right mid buttock and that a care plan was developed on 1/9/15 (12 days after admission and 9 days after the open coccyx wound was noted). RN Care Manager K stated that Resident #5's coccyx wound progressed to the following measurement on 1/23/15 of 1.5 X 2.2 X 0.4 cm and a foul odor was noted, so an antibiotic was ordered. RN Care Manager K stated that the coccyx wound measured 4.0 X 4.0 X 2.5 cm on 1/26/15 and the antibiotic was changed but subsequently transferred to the hospital on [DATE] for treatment of [REDACTED]. RN Care Manager K stated that Resident #5 was readmitted from the hospital on [DATE] with a wound vac (device that facilitates drainage and healing wound). RN Care Manager K stated that the right mid buttock pressure ulcer had recently healed but the most recent measurement of the coccyx wound dated 5/11/15 was 3.0 X 3.0 X 2.5 with tunneling of 1.0 cm at 11 o'clock, and 1.8 cm at 12 o'clock. According to the facility policy/procedure for Variance Reporting dated 8/29/14, last revised 8/14/14 reflected, Purpose: To provide a mechanism for timely documentation and reporting of variances in patient care and visitor events, adverse events and near misses. Reporting will be utilized for investigation, intervention, quality/safety review, and process improvement including the reduction of morbidity and mortality .Root Cause Analysis: A systematic process that uses information gathered during an investigation to determine the underlying reasons or causal factors for the unexpected clinical event to diminish the potential of occurrence of a subsequent or similar event. According to the facility policy/procedure for care planning dated 7/1986 last revised on 8/2014 reflected, Care plans address the specific needs of each individual resident and insure the facility provides for the best possible patient/resident outcome through identification of problems, planning, implementing interventions, and monitoring effectiveness the following temporary care plans are initiated in the electronic documentation system by the admitting nurse as required and are updated as permanent care plans after interdisciplinary team assessments are complete .Skin, Falls, Pain, Anticoagulation therapy, incontinence, and elopement. ( See also F 279) (# ) According to the face sheet, dated 5/14/15, Resident #10 was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) (a tool used to assess a resident and help determine the amount/level of care they need), dated 4/3/15, Resident #10 had multiple [DIAGNOSES REDACTED]. In addition, the MDS indicated Resident #10 was admitted to the facility with a stage 2 pressure ulcer (a shallow open pressure ulcer with a red or pink wound bed). According to the admission skin assessment, dated 3/27/15, Resident #10 was admitted to the facility with a stage 2 pressure ulcer to the coccyx (tailbone). According to the pressure ulcer documentation, dated 3/27/15 to 5/15/15, the following measurements were conducted for Resident #10's coccyx pressure ulcer: 4/2/15 (6 days after admission)- 1 cm (centimeter) x (by) 0.3 cm x 0.2 cm 4/9/15- 1 cm x 0.2 cm x 0.1 cm 4/21/15 - 1 cm x 0.2 cm x 0.1 cm (12 days after previous measurement) 4/28/15- 1 cm x 0.2 cm x 0.1 cm 5/6/15- 1 cm x 0.2 cm x 0.1 cm (9 days prior to this surveyor's review) On 5/15/15 at 10:00 a.m., after obtaining verbal permission from Resident #10, this surveyor observed the dressing change performed by registered nurse (RN) A. During this observation, this surveyor verified that Resident #10 had a pressure ulcer to the coccyx. RN A stated that CM L does the wound measurements. I know she's supposed to do them at least once a week. During an interview on 5/15/15 at 10:30 a.m., case manager (CM) L stated, When he (Resident #10) came in (was admitted ) he was on Medicare, so I didn't do his initial measurements. CM L stated Resident #10 was on another unit when he first arrived to the facility and Resident #10 was not admitted to her unit until around 4/14/15. CM L stated, I didn't get him until around 4/14/15 and then I did his (Resident #10's) measurements (wound). (Name of CM K) would have done his (Resident #10's) measurements until I got him. This surveyor reviewed Resident #10's pressure ulcer documentation with CM L. During the review, CM L stated, He (Resident #10) came in on 3/27/15 and she (CM K) did a follow-up assessment on 4/2/15. I don't see any measurement charting before that (4/2/15), so she (CM K) may have actually done the initial measurement on 4/2/15 and just clicked the wrong button (documented the wrong assessment type in the computer). CM L was asked how often does she do wound assessments and measurements. CM L stated, I do them weekly. We have a week after they're (the resident) admitted to do an initial measurement. I don't always do the measurements on the same day of the week every week. CM L stated that since Resident #10's wound was measured within a week of admission, then it was acceptable according to the facility's policy on frequency of wound measurements. During an interview on 5/15/15 at 10:45 a.m., CM K stated Resident #10 was not a resident on her unit when he was admitted and has not changed rooms since admission. He (Resident #10) came initially into (number of Resident #10's current room) and has been there the whole time. I know (name of CM L) was gone (off work) and she asked me to follow-up on her wounds on 4/2/15. That's why I did a measurement on 4/2/15. She (CM L) should have done the initial measurement. I do my initial measurements the day after the resident is admitted or the next business day if it's a weekend- on Monday. According to Perry and Potter (Clinical Nursing Skills and Techniques- 7 th edition), dated 2010, An important assessment before initiating wound therapy is a thorough assessment of the wound and the periwound (area surrounding the wound) skin. Data from this assessment assist in planning the appropriate care for a patient (resident) with a pressure ulcer (p. 474). A thorough assessment of the wound would include initial measurements of the wound on admission to determine if the wound is improving or getting worse. In addition, routinely assess the ulcer (pressure) to determine progress toward healing. Base interventions to support healing upon the assessment (p. 468). The facility provided the following reference as policy/procedure for preventing pressure ulcers, Lippincott Procedure - skin assessment, long-term care with a review date of 4/30/15. The reference reflected, The Joint Commission requires all long-term care facilities to assess residents at the time of admission using a validated risk assessment tool, such as the Braden Scale or Norton Scale. Both Tools screen residents for the presence of risk factors linked to skin breakdown and pressure ulcer development. Complete subsequent risk assessments weekly and with any change or deterioration of the resident's condition .Incomplete or inadequate skin assessment decreases the opportunities for the health care team to implement measures that can reduce skin breakdown and pressure ulcer development in long-term care residents. As a result, the recovery of long-term care residents is compromised because of greater potential for development of sequelae, such as geriatri[DIAGNOSES REDACTED]s. Additionally, residents experience increased rates of morbidity and mortality and increased lengths of stay and cost burden. ( )

This citation pertains to MI# 206 Based on observation, interview and record review the facility failed to prevent an accident in 1 (#1) of 3 total sampled residents resulting in Resident #1 who had a history of [REDACTED]. Findings include: Record review of facility 'Fall Prevention and Post Fall follow up' policy dated 2013, revealed: The facility ensures that resident safety is maintained while they reside in the facility. Supervision is provided to minimize the risk of falls and other accidents as much as possible. The environment will remain free of accident-causing hazards. The policy included: 'All alarm controls are to be placed out of reach of residents whether in wheelchairs, beds, etc....., whenever possible...' Record review of facility 'Alarms, Personal' policy dated 2013 revealed: (The facility) uses a variety of devices to minimize the risk of potential injury or harm to residents. Procedure: 1.) Secure the alarm to the resident's bed or chair. Keep alarm control boxes out of reach of resident as appropriate. Record review of the facility's 5 day report revealed that on 3/17/14 at 5:45 AM Certified Nurse Assistant (CNA) 'D' heard a noise come from Resident #1's room. CNA "D" entered Resident #1's room and observed the resident on the floor at the foot of her bed in her room. Resident #1 was assisted with a gait belt into her wheelchair and complained of immediate pain to her ribs and back area. The 5 day report identified that the pressure alarm was not sounding at 5:45 AM when the resident was observed on the floor. The alarm was in working condition when checked after the incident, but that Resident #1 stated that she shut the alarm off when she got out of bed. RN "E" stated that the alarm box at the time of the fall was located on the black plastic storage bin with drawers and that it was directly within her reach, so she could shut it off. RN "E" stated that he was not sure if the alarm was moved or not. Record review of facility post fall investigation dated 3/17/14 at 5:45 AM revealed an unwitnessed fall in the resident's room. Resident #1 was attempting to get socks out of a drawer at the time of the fall, and that the resident required supervision. The fall investigation noted resident statement, "..was trying to get her socks from her drawer and just fell " and "she turned alarm off when she got out of bed". The fall investigation noted Resident #1's behaviors/cognition to be the following: Tries to stand, transfer or walk alone unsafely, has impaired mobility and increase in behaviors or change in mental status in the last 90 days. Safety interventions in use at the time were pressure pad alarm that did not sound due to resident turned it off. Observation on 3/27/14 at 9:15 AM at the beginning of the abbreviated survey in Resident #1's room revealed 5 (drawer) black and clear plastic drawer storage chest/bin approximately 4 foot tall next to the resident's bed with the bed alarm box hung/clipped to a drawer beside the resident's bed within reach of resident #1. Record review of Resident #1's Minimum Data Set ((MDS) dated [DATE] revealed an [AGE] year old female with Brief Interview of Mental status (BIMs) score of 3 severe cognitive impairment skills. The MDS noted no behaviors by the resident and active [DIAGNOSES REDACTED]. Record review of Resident #1's radiology report dated 3/17/14 revealed reason for x-ray was rib pain and trauma from a fall. Findings included acute, non-displaced fracture of the posterior right eighth rib. An interview on 3/27/14 at 9:50 AM with Certified Nurse Assistant (CNA) 'D' revealed that she came on duty 3/17/14 at 5:00 AM, had done a walking report with the off going shift and noted Resident #1 was in bed covered up and seemed to be sleeping. CNA "D" stated she went up the hall to the walkaroo to look up her daily resident cares, showers, weights and vital signs, then she went to the clean linen room to get the vital machine, went down the 100 hall to start her vitals in rooms 107 through 111. CNA "D" stated that she was in room 108 getting vitals on a resident when she heard a weird noise like a thump of the closet door and was pretty sure that someone had fallen. CNA "D" stated that she did not finish the vitals in room 108 but went into the hallway and noticed Resident #1 on the floor at the end of her bed. CNA "D" stated that Resident #1 had been in the top drawer of her vanity, because she had socks in her hands, laying on her right side with her shoulder and hip on the floor. CNA "D" stated that she called for Registered Nurse (RN) "E" to come to the room. CNA "D" stated that there was a bed pressure alarm, but that no alarm was sounding and that Resident #1 has a history of shutting off her alarm. CNA "D" stated that the alarm box was on the bedside plastic storage/dresser drawer right next to her bed. CNA "D" stated that Resident #1 gets up, shuts off the alarm and moves about; she pushes the button that resets/silences the alarm. CNA "D" stated that Resident #1 used to shut off the alarm a lot a year ago, but the last 4 months she has declined and has not been shutting off the alarm as much, but still does shut it off. CNA "D" stated that around lunch time that day she was talking to CNA "F" about the fall and the CNA's decided to move the alarm box out of the resident's reach which is at the foot of the bed. CNA "D" stated that she had a few days off and when she came back the alarm box was again at the head of the bed whichw as within reach. Today (3/27/14) the alarm box was hanging at the head of the bed on the plastic dresser drawer within reach of the resident. CNA "D" stated, "Yes it was hanging at the head of the bed this morning" and at 9:45 AM (after the state surveyor observed the alarm hanging within reach of the resident) the unit manager RN "C" moved it again to the foot of the bed. In an interview on 3/27/14 at 11:25 AM with sampled resident #2, roommate to Resident #1, who is alert and oriented with a BIMs of 15, revealed that Resident #1 would shut off her alarm, Resident #2 stated that she has heard Resident #1 shut off the alarm and that it hangs on Resident #1's plastic dresser where she can reach it. Resident #2 stated that Resident #1 has been shutting off her alarm for a long time, since before Christmas and even before that. Resident #2 stated that she did not hear the alarm sound when Resident #1 fell . She explained the alarm is loud and that she hears it and people in the hallways hear it, but not that time. An interview on 3/25/14 at 12:15 PM with CNA "F" who worked the 100 hall, revealed that she had seen Resident #1 shut off her alarms before. The alarm would be attached to the plastic storage drawers and that Resident #1 would sit up and automatically shut it off. CNA "F" stated that the CNA's had told the nurse's and unit manager that Resident #1 was shutting off her alarms. CNA "F" stated that she has seen Resident #1's daughter hang the alarm box on the plastic storage drawers. CNA "F" stated that after the fall a motion sensor alarm was added to the resident's bed. An interview on 3/27/14 at 2:38 PM with Registered Nurse (RN) "E" revealed that he was called to Resident #1's room and when he walked into the room Resident #1 was on the floor. RN "E" stated that there was no alarm sounding and that CNA "D" had said that she heard the resident fall, but no alarm. RN "E" stated that he asked Resident #1 what she was doing. The resident stated getting socks since her feet were cold. RN "E" asked Resident #1 about the alarm and that Resident #1 told him that she shut off the alarm. Record review of Resident #1's care plans dated 1/22/14 prior to fall on 3/17/14 revealed that the resident was noncompliant with alarms, turns alarms off. Interventions included letting resident verbalize noncompliance, but did not identify placement of alarms out of reach of resident or educating the family member on alarm safety. It was unclear how the facility addressed Resident #2's habit of shutting the alarm since the alarm was still part of the care plan which proved to be ineffective. (# ) ( )

Based on observation, interview and record review, the facility failed to educate and supervise 1 resident (Resident #6) out of 8 residents reviewed for falls from a total sample of 17 residents resulting in a potential for ongoing falls Findings include: According to a facility face sheet dated 9/19/13 at 8:31 AM, Resident #6 was an [AGE] year old female admitted to the facility on [DATE] with the cumulative Diagnoses: [REDACTED]. During an interview on 9/19/13 at 10:52 AM with (Minimum Data Set) MDS RN "T", in her office, MDS RN "T" stated that Resident #6 experienced the following falls: 1. 3/7/13 Rolled out of bed, no injury, not witnessed. Intervention: Pressure alarm 2. 3/22/13 Alarm sounding, sitting on floor by bed. Wheels to bed not locked. Intervention: bed moved so one side against the wall, wheel guards to the bed and wedge cushion while in bed. 3. 5/10/13 Sitting on floor, unwitnessed, no injury. Alarm was not sounding, cord was broken at the clip. Intervention: replace cord. MDS RN "T" confirmed that alarm function is checked every shift. 4. 5/31/13 Certified Nurses Aid (CNA) assist to floor. Intervention: assist to bathroom with 2 staff members. 5. 5/27/13 On leave of absence with husband, fall outside off of facility grounds. Intervention: Husband was instructed to take his cell phone with the facility phone number programmed in. 6. 6/4/13 Resident #6 was with her husband in her room, coming in from out of doors. As husband hung up coat, resident turned and hit the door jam resulting in a laceration to her forehead. Intervention: Medication review by the physician. 7. 7/27/13 Resident #6 was ambulating in the hall and walked into Hoyer lift in the hall. MDS RN "T" confirmed resident was walking independently, no supervision. During review of the MDS Significant Change Assessment, 7/19/13, the MDS reflected Resident #6 required limited assistance, with one person assist during ambulation in Resident #6's room and in the hallway. Resident #6's MDS dated [DATE] also reflected balance during transitions and walking were: Moving from seated to standing position: Not steady, only able to stabilize with staff assistance. Walking (with assistive device if used): Not steady, but able to stabilize without staff assistance. Turning around and facing the opposite direction while walking: Activity did not occur. Moving on and off toilet: Activity did not occur. Surface to surface transfer (transfer in between bed and chair or wheelchair): Not steady, only able to stabilize with staff assistance. Review of a facility policy titled, "Transfers/Equipment Adaptation" revised 7/2010 reflected "Gait Belts: ...apply belt around patient's/resident's waist while in a seated position, stand as close to the patient/resident as possible, maintaining a broad base of support. To ambulate: assist patient/resident to a standing position by grasping the belt at the waist from underneath, stand on either side to the patient/resident and assist/encourage ambulation. When transfer is complete, remove belt". An observation and an interview were conducted on 9/18/13 at 1:25 PM with Resident #6's husband in the hall as he was ambulating Resident #6. He was noted holding her right hand and standing next to her. Resident #6's husband stated that he visited daily for lunch and took her for a walk mostly in the facility. Resident #6's husband denied staff instructing him on the need for a gait belt around his wife during ambulation. Resident #6's husband confirmed he does not see a gait belt on his wife nor use a gait belt for his wife when Resident #6 is ambulating. During an interview with MDS RN "T" in the conference room, MDS RN "T" confirmed that Resident #6's husband had not been educated on the need for a gait belt for his wife during ambulation MDS RN "T" agreed that a resident that is required to have limited assistance, with one person assist during ambulation, should have a gait belt on during ambulation. During review of a facility sheet titled "CNA Care Plan Information" dated 9/18/13 at 4:42 PM reflected, "Always use gait belts." An observation of Resident #6 on 9/19/13 at 2:45 PM in the hall, Resident #6 was observed to be walking with her husband on her right holding her hand and a middle age man to her left holding her hand. Resident #6 was not observed to have had a gait belt on. ( )

This citation pertains to Revisit #Y3TH12 and Annual #5CZ212 Based on observation, interview and record review, the facility failed to provide functioning safety device and device checks to prevent a fall in 1 (#14) of 11 residents, from a total sample of 11, resulting in Resident #14 being found on the floor with no alarm sounding resulting in emergency room visit due to laceration to the back of the head requiring staples. Findings include: Revisit #Y3TH12 'Providers Plan of Correction' dated 8/30/13 revealed under citation F-323 element #3. Education to nursing staff on the use of alarms........the proper functioning of the alarms.....Element #4. Managers to audit functionality of alarms........ Revisit annual #5CZ212 'Providers Plan of Correction' dated 11/14/13 revealed under citation F-323 related to education related to falls. On 11/19/13 at the beginning of the re-visit survey the state surveyor requested all variance reports (accident/incident reports) for residents who had sustained a fall. Resident #14 was not included with the received variance reports at that time. Observation on 11/22/13 at 8:25 AM of the main dining room breakfast meal revealed that the state surveyor was flagged down by Resident #14, who was concerned that she had fallen earlier in the week and that there were staples to the back of her head and that they were going to do something to them but she did not know what. Observation of the back of Resident #14's head revealed that there were metal staples to her head. Observation of Resident #14 while sitting at the dining table with two other female residents revealed that there was no chair alarm in place. The resident did have oxygen at 2 liter via nasal cannula noted and was able to self-propel with her feet or arms. Resident #14 stated that since her fall earlier in the week that she has not been able to walk because her hip hurt when she stood. Resident #14 stated that x-rays were taken the day prior but that she did not know the results. Observation and record review on 11/22/13 at 9:30 AM in room #201 of Resident #14's closet door Certified Nurse Assistant (CNA) care plan last revision date 11/17/13 revealed 'Pressure alarm to bed and wheelchair'. There was no alarm noted for the recliner located within the room that was observed with a tab alarm attached to the right upper corner of the recliner. Observation of Resident #14 at that time whom was sitting up in her wheelchair in the room, revealed there to be no alarm in place. Observation of the recliner located in the room revealed there to be a tab alarm attached to the recliner that was not in use. An interview with nursing student "E" and Resident #14 revealed that Resident #14 was sitting up in her wheelchair with no alarm in place and the student and Registered Nurse (RN) "D" had just removed the staples to the residents head and placed steri strips to the area. The state surveyor pointed out that there was no alarm in place per care plan and the student quickly placed the tab alarm from the recliner to the resident's wheelchair. The nurse student stated that RN "D" had assisted in removing the staples while the resident was in the wheelchair. In an interview while in room #201, Resident #14 stated again that "Yes, it hurt, I fell . I went to the hospital for my head, I got hurt. I was doing pretty good at walking; now I don't walk. I use my wheelchair, my hip hurts and I'm waiting for my x-ray (results)". Record review of Resident #14's 'Variance Report' dated 10/9/13 at 3:50 PM revealed that the resident sustained [REDACTED]. The report noted that the resident had an alarm in place and that it sounded, but the resident did not use her call light or call for assistance. The department manager follow-up noted that care plans were reviewed and updated. Alarm on wheelchair to a pull tab, continued pressure alarm to bed and recliner. Record review of Resident #14's November 2013 monthly physician orders [REDACTED]. Record review of Resident #14's 'Variance Report' dated 11/17/13 at 3:04 AM revealed an un-witnessed fall when staff heard Resident #14 calling out for help. Resident #14 was found on the floor, supine at the foot of the bed, bleeding from her head. Range of Motion was normal for resident and the resident was lifted with gait belt with assist of two staff into wheelchair. Bleeding ceased and the resident was sent to ER (emergency room ). The resident returned with a laceration to left occipital scalp with 5 staples in place and elbow laceration with steri strips. The department manager follow up noted staff noted that the pressure alarm cord was not securely plugged into the alarm box, thus it did not sound when resident attempted to get oob (out of bed) unassisted. Call light within reach but not used. The supervisor checked alarm after cord plugged properly and functioned properly. CNA did not remember if it was that was when she put the resident into bed during the night.....CNA was instructed that the "alarm check every two hours" means to check them even if not use, and to check for the function and integrity of the whole unit. Both CNA and the supervisor signed the education acknowledgement. Record review of a hand written note attached to Resident #14's variance report dated 11/17/13 at 5:30 AM revealed 'CNA educated on checking function of alarm and checking alarm integrity every two hours, even if not in use'. The hand written note was signed by a registered nurse and certified nurse assistant. Record review of Resident #14's hand written 'Post Fall Investigation' report dated 11/17/13 at 3:04 AM revealed that the resident fell in her room and that the fall was not witnessed. The post fall report noted that the resident had fallen one time prior in the past 31-180 days on 10/9/13. The post fall report noted that Resident #14 was injured with a laceration to the back of left side of head and laceration to left elbow. At the bottom of the form under safety interventions revealed that there was a pressure alarm in place to the bed, but that the pressure alarm did not sound. The report noted that 'Alarm cord was not firmly/completely plugged in the base (alarm box). Record review of CNA (Certified Nurse Assistant) documentation for Resident #14's "Alarm Checks/Close Observation" report from 11/16/13 through 11/22/13 revealed that on 10/22/13 alarm checks every 2 hours. Review of 11/17/13 date revealed there were blank or no alarm checks after 0:01 AM till 6:00 AM noted. All of the other time blocks on the form were noted to be initialed. In an interview on 11/22/13 at 11:00 AM with registered nurse (RN) "D" revealed that Resident #14 was calling for "Help" and was found on the floor at the foot of her bed in front of the doorway. RN "D" stated that Resident #14 had confusion and attempts to self-transfer and had intermittent call light use. RN "D" stated that the resident had an injury of laceration to head with bleeding, was on Plavix (inhibitor of platelet aggregation) and was sent to the ER. RN "D" stated that the alarm did not sound and that it was unplugged or had a loose connection, the plug was not completely in the socket (of alarm box). RN "D" stated that when the resident was set on the pressure alarm (getting into bed) it should peep and that should tell you it's working. Record review of Resident #14's 'Fall Risk' scoring tool dated 10/22/13 revealed a total fall risk score of 14-high risk. Record review of Resident #14's 'Potential for injury (falls)' care plan dated 11/17/13 related to: age >60, intermittent confusion, elimination with assist, confined to bed/chair, loss of balance standing, balance problem walking, decreased coordination, instability when turning, uses assistive device.....on 10/9/13 was observed on floor after attempting to transfer self from wheelchair to recliner, alarm to recliner changed to a pull tab alarm, observed on floor 11/17/13. Review of further care plans noted on 11/17/13 at 3:58 AM safety needs-Monitor frequently pressure alarm to bed and wheelchair. Record review of facility 'Fall Prevention and Post Fall follow up' policy reviewed date 2012, revealed under the heading 'Environment' noted the environment will be kept free of any hazards such as those listed below.....equipment is in good repair. Staff participation noted staffs are expected to maintain all alarms, motion detectors, sensors, and other safety interventions in the "on" position. Record review of facility 'Alarm, Personal' policy reviewed date 2012 revealed the facility uses a variety of devices to minimize the risk of potential injury or harm to residents. Procedure #1. All alarms in use are to remain activated. Proper alarm function and/or motion detector is checked each shift or more frequently as needed. ( # )

This citation pertains to MI# 535 and MI# 727 Based on observation, interview and record review, the facility failed to ensure that the residents environment remain as free of accidents as is possible and had assistive devices to prevent accidents and falls in 2 (#103, #104) of 4 sampled residents reviewed for falls, from a total sample of 4, resulting in resident #103 who had an alarm in place, but did not sound, being found by staff on the floor and sent to the hospital and Resident #104 slipping from his wheelchair during care resulting in fractures. Findings include: Record review of facility 'Safety and Supervision of Patient/residents' policy dated 9/2012, revealed the facility strives to make the environment as free from accident hazards as possible. Patient/resident safety and supervision and assistance to prevent accidents are facility wide priorities. Record review of facility 'Fall Prevention and Post Fall follow up' policy dated 11/1/11, reviewed 2012, revealed supervision is provided to minimize the risk of falls and other accidents as much as possible. The policy noted under staff participation that staff is expected to maintain all alarms, motion detectors, sensors, and other safety interventions......... Resident #103 Record review of Resident #103's Minimum Data Set ((MDS) dated [DATE] revealed a [AGE] year old male with brief interview of mental status (BIMs) score of 9, moderately impaired with [DIAGNOSES REDACTED]. Record review of resident #103's 'Fall Assessment' dated 5/16/13 revealed the resident had intermittent confusion with balance problems and scored as high risk. Record review of Resident #103's 'Potential for Trauma-Falls' care plan dated 5/18/13 revealed interventions dated 6/2/13 included pressure alarms to bed and wheelchair or Geri chair. Bed in locked position. Pressure alarm to bed and wheelchair, tab alarm to foot when in bed to alert staff to the resident putting his legs over the side of the bed........... Record review of Resident #103's June 2013 physician orders [REDACTED]. Record review of Resident #103's variance report dated 6/21/13 at 4:30 PM revealed a [AGE] year old male with confusion/disoriented intermittent had a not observed fall from bed. Resident #103 was noted to have a history of falls. Preventive devices where noted that a bed alert was on but not working. The variance report noted that no injury resulted from the fall. Narrative notes revealed: 'He was observed on the floor (stated he was trying to get up and he had co (complained of) pain and was sent to ER (emergency room ). When he returned from ER he has no fractures noted. Neuro's WNL (within Normal limits) no bruising or skin tears noted. Had co (complained of) pain and states does not feel well. Tylenol was given and he was sent assisted to bed. He was sleeping soon after went to bed. Alarm did not sound, was functioning correctly when checked. Pull tab to foot was working throughout the day, did not sound at this time. Battery was noted to have come loose'. There was no mention of why the bed pressure alarm did not sound. Record review of Resident #103's 'Post Fall Investigation' form dated 6/21/13 at 4:30 PM revealed that the resident had climbed out of bed with the bed in a semi-low position and fall not witnessed. The form noted that EMS (emergency medical services) was called due to fall unseen and complaint of head hurting. Behavior/cognition was noted as restless. Environmental safety interventions in use at the time were noted as pull tab and pressure. Hand written notes at the bottom of the form were: 'Prior to being on floor alarms not sounding at times. No back on pull tab so battery was loose, pressure pad worked all day. Record review of the facility 'Unusual Occurrence' form dated 6/21/13 at 4:30 PM written by certified nurse assistant (CNA) #10 revealed that Resident #103 was trying to get up in wheelchair and slipped and fell on floor. CNA #10 noted that the resident had an alarm, bit was not sounding and that the resident did not have socks/grippy socks or shoes on. Record review of Resident #103's 'Alarm check/close observation' record dated 6/19/13 through 6/23/13 revealed that on 6/21/13 the resident #103 was on every 2 hour alarm checks. The first close observation checks every 30 minutes were documented at 5:00 PM on 6/21/13. In an interview on 7/24 13 at 10:35 AM with certified nurse assistant (CNA) #10 revealed that she came out of another residents room and saw Resident #103 laying on the floor with no alarms sounding. CNA #10 stated, "No, no alarms sounded......told the unit manager that no alarm sounded. He was just on the floor....I was surprised to see him on the floor". In an interview on 7/24/13 at 11:15 AM with the registered nurse Unit Manager (UM) #3 revealed that Resident #103 had a tab alarm hooked to his sock and he had to physically move his foot to pull the tab alarm string. UM #3 stated that Resident #103 was found by staff on the floor with his socks on with the tab alarm attached to the sock, but no alarm sounded. UM #3 stated that she looked at the alarm box and that the back door of the battery compartment was loose and that the slide in 9 volt battery holder was loose. UM #3 stated that the resident had a history of [REDACTED]. UM #3 stated that the Resident #103 had an un-witnessed found on the floor with complaint of hip pain and was sent to the emergency room for evaluation and came back with x-ray results of ninth rib fracture. The unit manager did not know why the bed pressure alarm did not sound. Observation on 7/24/13 at 9:55 AM during an interview with Resident #103 revealed the resident to be reclining in a Geri chair with a pressure pad alarm in place. In an interview on 7/24/13 at 9:55 AM with Resident #103 revealed that he did recall falling and that his ribs were sore, and that x-rays were done, but that the doctor told him that no surgery would help it sand that it would get better with time. Resident #103 stated that he did not recall an alarm sounding when he fell . Record review of Resident #103's x-ray results dated 6/21/13 revealed reason for exam was rib pain post trauma with impression of potential non-displaced right ninth rib fracture. Record review of facility 'Alarms, Personal' policy dated 3/2012 revealed the facility used a variety of devices to minimize the risk of potential injury to residents. Procedure included securing the alarm to the resident's bed or chair, keeping alarm control box out of reach of resident as appropriate. All alarms in use are to remain activated. Proper alarm function and or motion detector is checked each shift or more frequently as needed...... Resident #104 Observation on 7/24/13 during a tour of the resident living areas or the facility was done at the beginning of the unannounced onsite investigation revealed that Resident #104 no longer lived at the facility. Record review of facility 5 day report revealed that on 7/1/13 revealed that Resident #104 [DIAGNOSES REDACTED]. Resident #104 was in the bathroom completeing his AM care and once he was done he was noted to start to wheel himself out of the bathroom backwards into hi room. Certified Nursing Assistant (CNA) #9 came to assist the resident by pulling on the wheelchair from behind him to get him through the door. While assisting Resident #104 he slid from the wheelchair. Resident #104 was noted to complain of ache to his back. Physician was notified on 7/2/13 of right hip non-displaced fracture through the base of the greater trochanter of the right hip. Record review of Resident #104's variance report dated 7/1/13 at 6:20 AM revealed that the resident was alert and oriented and sustained an observed fall from wheelchair. Pre-fall factors included that the dialysis Hoyer sling was under the resident. Narrative notes on the form noted that Certified Nurse Assistant (CNA) #9 was assisting Resident #104 out of the bathroom and the resident slid out of wheelchair. Observation and interview on 7/24/13 at 3:30 PM of the blue dialysis Hoyer sling of a current resident living in the facility with Certified Nurse Assistant (CNA) #21 who had worked with Resident #104 during his stay at the facility revealed that the staff placed blue dialysis sling in the wheelchairs of dialysis residents on dialysis day. CNA #21 revealed that the facility used a green nylon Hoyer sling that is compatible with facility lifts and that residents are lifted from the beds or chairs with the green slings into wheelchairs with the blue slings already lined with the dialysis slings. CNA #21 stated that she would remove the green nylon sling by pulling it out from under the resident once he was placed in the wheelchair. In an interview on 7/25/13 at 9:04 AM with Certified Nurse Assistant (CNA) #9 revealed that it was about 6:00 AM when Resident #104 was in the bathroom doing his hair and brushing his teeth getting ready for dialysis. CNA #9 stated that she was walking back past Resident #104's room when he was trying to maneuver himself out of the bathroom. CNA #9 stated that Resident #104 had a wider bariatric wheelchair and that he was wedged in the bathroom doorway and that the resident wasn't at the edge of the wheelchair but that he had one hip twisted in the wheelchair looking back. CNA #9 stated that the resident almost had the back of the wheelchair aligned to the bathroom door. CNA #9 stated that she grabbed the (wheelchair) handles on the back of the wheelchair and was looking down at the wheels on the bottom to get the chair out of the door frame when she gave a tug and Resident #104 slid out of the wheelchair on to the floor. CNA #9 stated that Resident #104 was a large man and that she couldn't grab him when he went forward from the chair and landed on his bottom. CNA #9 stated that the dialysis sling was in the wheelchair with the green nylon facility Hoyer sling on top of the dialysis sling. CNA #9 stated that in Resident #104's wheelchair there was the bottom of the wheelchair seat with a dycem (non-skid piece) with a wheelchair cushion (about 2-4 inches thick) with a blue sling (dialysis Hoyer sling) with a green nylon facility Hoyer sling on top of that all under the resident when he slipped out of the wheelchair. On 7/25/13 State surveyor requested policy and educational material for the use of Hoyer slings and dialysis Hoyer slings. The Director of Nursing (DON) #2 stated that there was no policy for the use of Hoyer slings and that no educational material on the use of the green nylon slings was avaliable for the surveyor to review. Record review of the manufactureer manuals for mechanical lifts revealed that there was a sling used, but that there was no instructions on how to use the slings. Interviews on 7/25/13 during the investigation survey with 5 current working certified nursing assistants (CNA's) on the use of Hoyer lifts and slings, revealed that they had an inservice a while ago, but could not remember the date on hoyer lifts and that they all stated that they remove the green nylon sling from under the resident once they are placed in the chair or bed. Record review of facility 'Transfers/Equipment Adaptations' policy dated 7/2010 and reviewed 2012, revealed that the the facility used a hoyer lift and a sit to stand lift. The last line on the policy revealed to remove buckles and sling and move lift away from residents. #

This citation pertains to Revisit #Y3TH12 and Annual #5CZ212 Based on observation, interview and record review, the facility failed to provide functioning safety device and device checks to prevent a fall in 1 (#14) of 11 residents, from a total sample of 11, resulting in Resident #14 being found on the floor with no alarm sounding resulting in emergency room visit due to laceration to the back of the head requiring staples. Findings include: Revisit #Y3TH12 'Providers Plan of Correction' dated 8/30/13 revealed under citation F-323 element #3. Education to nursing staff on the use of alarms........the proper functioning of the alarms.....Element #4. Managers to audit functionality of alarms........ Revisit annual #5CZ212 'Providers Plan of Correction' dated 11/14/13 revealed under citation F-323 related to education related to falls. On 11/19/13 at the beginning of the re-visit survey the state surveyor requested all variance reports (accident/incident reports) for residents who had sustained a fall. Resident #14 was not included with the received variance reports at that time. Observation on 11/22/13 at 8:25 AM of the main dining room breakfast meal revealed that the state surveyor was flagged down by Resident #14, who was concerned that she had fallen earlier in the week and that there were staples to the back of her head and that they were going to do something to them but she did not know what. Observation of the back of Resident #14's head revealed that there were metal staples to her head. Observation of Resident #14 while sitting at the dining table with two other female residents revealed that there was no chair alarm in place. The resident did have oxygen at 2 liter via nasal cannula noted and was able to self-propel with her feet or arms. Resident #14 stated that since her fall earlier in the week that she has not been able to walk because her hip hurt when she stood. Resident #14 stated that x-rays were taken the day prior but that she did not know the results. Observation and record review on 11/22/13 at 9:30 AM in room #201 of Resident #14's closet door Certified Nurse Assistant (CNA) care plan last revision date 11/17/13 revealed 'Pressure alarm to bed and wheelchair'. There was no alarm noted for the recliner located within the room that was observed with a tab alarm attached to the right upper corner of the recliner. Observation of Resident #14 at that time whom was sitting up in her wheelchair in the room, revealed there to be no alarm in place. Observation of the recliner located in the room revealed there to be a tab alarm attached to the recliner that was not in use. An interview with nursing student "E" and Resident #14 revealed that Resident #14 was sitting up in her wheelchair with no alarm in place and the student and Registered Nurse (RN) "D" had just removed the staples to the residents head and placed steri strips to the area. The state surveyor pointed out that there was no alarm in place per care plan and the student quickly placed the tab alarm from the recliner to the resident's wheelchair. The nurse student stated that RN "D" had assisted in removing the staples while the resident was in the wheelchair. In an interview while in room #201, Resident #14 stated again that "Yes, it hurt, I fell . I went to the hospital for my head, I got hurt. I was doing pretty good at walking; now I don't walk. I use my wheelchair, my hip hurts and I'm waiting for my x-ray (results)". Record review of Resident #14's 'Variance Report' dated 10/9/13 at 3:50 PM revealed that the resident sustained [REDACTED]. The report noted that the resident had an alarm in place and that it sounded, but the resident did not use her call light or call for assistance. The department manager follow-up noted that care plans were reviewed and updated. Alarm on wheelchair to a pull tab, continued pressure alarm to bed and recliner. Record review of Resident #14's November 2013 monthly physician orders [REDACTED]. Record review of Resident #14's 'Variance Report' dated 11/17/13 at 3:04 AM revealed an un-witnessed fall when staff heard Resident #14 calling out for help. Resident #14 was found on the floor, supine at the foot of the bed, bleeding from her head. Range of Motion was normal for resident and the resident was lifted with gait belt with assist of two staff into wheelchair. Bleeding ceased and the resident was sent to ER (emergency room ). The resident returned with a laceration to left occipital scalp with 5 staples in place and elbow laceration with steri strips. The department manager follow up noted staff noted that the pressure alarm cord was not securely plugged into the alarm box, thus it did not sound when resident attempted to get oob (out of bed) unassisted. Call light within reach but not used. The supervisor checked alarm after cord plugged properly and functioned properly. CNA did not remember if it was that was when she put the resident into bed during the night.....CNA was instructed that the "alarm check every two hours" means to check them even if not use, and to check for the function and integrity of the whole unit. Both CNA and the supervisor signed the education acknowledgement. Record review of a hand written note attached to Resident #14's variance report dated 11/17/13 at 5:30 AM revealed 'CNA educated on checking function of alarm and checking alarm integrity every two hours, even if not in use'. The hand written note was signed by a registered nurse and certified nurse assistant. Record review of Resident #14's hand written 'Post Fall Investigation' report dated 11/17/13 at 3:04 AM revealed that the resident fell in her room and that the fall was not witnessed. The post fall report noted that the resident had fallen one time prior in the past 31-180 days on 10/9/13. The post fall report noted that Resident #14 was injured with a laceration to the back of left side of head and laceration to left elbow. At the bottom of the form under safety interventions revealed that there was a pressure alarm in place to the bed, but that the pressure alarm did not sound. The report noted that 'Alarm cord was not firmly/completely plugged in the base (alarm box)'. Record review of CNA (Certified Nurse Assistant) documentation for Resident #14's "Alarm Checks/Close Observation" report from 11/16/13 through 11/22/13 revealed that on 10/22/13 alarm checks every 2 hours. Review of 11/17/13 date revealed there were blank or no alarm checks after 0:01 AM till 6:00 AM noted. All of the other time blocks on the form were noted to be initialed. In an interview on 11/22/13 at 11:00 AM with registered nurse (RN) "D" revealed that Resident #14 was calling for "Help" and was found on the floor at the foot of her bed in front of the doorway. RN "D" stated that Resident #14 had confusion and attempts to self-transfer and had intermittent call light use. RN "D" stated that the resident had an injury of laceration to head with bleeding, was on Plavix (inhibitor of platelet aggregation) and was sent to the ER. RN "D" stated that the alarm did not sound and that it was unplugged or had a loose connection, the plug was not completely in the socket (of alarm box). RN "D" stated that when the resident was set on the pressure alarm (getting into bed) it should peep and that should tell you it's working. Record review of Resident #14's 'Fall Risk' scoring tool dated 10/22/13 revealed a total fall risk score of 14-high risk. Record review of Resident #14's 'Potential for injury (falls)' care plan dated 11/17/13 related to: age >60, intermittent confusion, elimination with assist, confined to bed/chair, loss of balance standing, balance problem walking, decreased coordination, instability when turning, uses assistive device.....on 10/9/13 was observed on floor after attempting to transfer self from wheelchair to recliner, alarm to recliner changed to a pull tab alarm, observed on floor 11/17/13. Review of further care plans noted on 11/17/13 at 3:58 AM safety needs-Monitor frequently pressure alarm to bed and wheelchair. Record review of facility 'Fall Prevention and Post Fall follow up' policy reviewed date 2012, revealed under the heading 'Environment' noted the environment will be kept free of any hazards such as those listed below.....equipment is in good repair. Staff participation noted staffs are expected to maintain all alarms, motion detectors, sensors, and other safety interventions in the "on" position. Record review of facility 'Alarm, Personal' policy reviewed date 2012 revealed the facility uses a variety of devices to minimize the risk of potential injury or harm to residents. Procedure #1. All alarms in use are to remain activated. Proper alarm function and/or motion detector is checked each shift or more frequently as needed. (# )

This citation pertains to MI# 928 Based on observation, interview, and record review, the facility failed to provide necessary care post fall of a resident on [MEDICATION NAME] (anticoagulant) for 1 (#101) of 3 sampled residents, of a total of 3 sampled residents, resulting in Resident #101 experiencing: 1) a delay in treatment for [REDACTED]. Findings included: Record review of the facility incident summary report fax dated 12/29/11 revealed that on 12/24/11 at approximately 7:05 PM, resident #101 was found on the floor laying on her right side. Resident #101 was found with no foot rest on her wheelchair and her alarmed seat belt was turned off. Resident #101's husband, and roommate (Resident #102), had a known history of turning off Resident #101's alarms and/or taking her safety devices off. According to the incident summary, staff responded to resident #102's chair alarm sounding and found him standing over resident #101 looking down at her. The incident summary revealed that staff responded and that slight discoloration to Resident #101's right cheek was noted. The report noted that Resident #101's alarmed seat belt did not sound and that it had been turned off. Observation on 1/19/12 between 8:20 AM and 9:00 AM during the entrance tour at the beginning of the investigation revealed that the resident #101 was up in wheelchair with a buckle style seat belt latched, with no alarm, and no tab alarm while seated in the dining room for breakfast. Resident #101 was noted to say single word "Boy" in response to questions asked of her. Resident #101 was noted to have post stroke symptoms of the right side paralysis with the wheelchair having a leg rest to the right side and a right side arm board. Record review of resident #101's minimum data set ((MDS) dated [DATE] revealed a [AGE] year old female with cognitive skills for daily decision making as severely impaired never or rarely making decisions. The MDS revealed that the resident had unclear speech with slurred or mumbled words and could rarely or never make her self understood, and had rarely or never understood others. Resident #101's MDS reflected that she had functional limitation in range of motion in both the upper and lower extremity. Active [DIAGNOSES REDACTED]. The MDS reflected that the resident #101 had a history of [REDACTED]. Record review of resident #101's care fall care plan dated 12/22/11 revealed that the alarm box on wheelchair was to be moved where resident's husband can not visualize to turn it off. Record review of resident #101's nurse narrative notes dated 12/24/11 through 12/25/11 reflected that nurse #6 documented an occurrence on 12/24/11 at 8:09 PM that resident #101 had an occurrence at 7:13 PM (did not state what type of occurrence) where resident #101's wheelchair alarm (seat) belt was unleashed and belt alarm was in the off position. The nurse noted no apparent injury and no first aid was given. Possible cause was noted removed restraint, slid from chair, incident unobserved. Vital signs: blood pressure 119/64, pulse 60, respirations 16, temperature 97.2, neuro checks: N/A (not applicable). Actions were noted as chair alarm was placed on lower bar of wheelchair out of sight. Resident #101 was placed into bed after the incident. Nurse note dated 12/25/11 at 0:59 AM noted that the physician was notified via physician book. In an interview on 1/19/12 at 10:38 AM, certified nurse assistant (CNA) #3 revealed that she was at the nursing station and heard an alarm going off, went to resident #101's room and resident #101 was on the floor and that the resident #101's face was on the floor and that the resident was holding her face. In an interview on 1/19/12 at 12:35 PM, CNA #4 stated that she responded to resident #102's alarm that was sounding and that resident #101 was on the floor laying on her right side with her face on the floor. CNA #4 stated that the Licensed Practical Nurse (LPN) #6 had her turn resident #101 over so that she could assess her. CNA #4 turned over resident #101 and there was blood in the crack of the resident's mouth. CNA #4 stated that CNA #5 had a flash light and offered it to Licensed Practical Nurse (LPN) #6 to check the resident's mouth but she could not determine where the blood was coming from. CNA #4 stated that LPN #6 asked resident #101 if she had any pain and resident #101 stated "Boy". CNA #4 stated that resident #101 was nonverbal except for the word "Boy". CNA #4 declined to move resident #101 when LPN #6 told her to pick up the resident. CNA #4 told LPN #6 to ask nurse LPN #7 to come and assess. LPN #6 came back into the room and told CNA #4 that no body saw the fall so that we can't assume resident #101 hit her head. CNA #4 stated that she told LPN #6 that no body saw her fall so we can't assume she did not hit her head. The CNA's were told to pick up resident #101 and put her in bed. CNA #4 stated that resident #101 did not seem fine, that resident #101 had puffiness to the right side of her face, and that the resident #101 reached across with her left hand because of the right side was affected by a stroke and held her right side of her face, appeared in pain with facial grimacing. CNA #4 stated that CNA #5 took resident #101's vital signs and that she CNA #4 wrote an unusual occurrence report. In an interview on 1/19/12 at 2:30 PM, CNA #5 stated that the fall occurred at shift change and that the resident's seat belt alarm did not sound. CNA #5 stated Resident #101 was face down laying on her right side. CNA #5 stated that LPN #6 had the CNA's flip resident #101 over and then she told them to pick resident #101 up. CNA #5 stated that LPN #6 kept saying "I don't know what to do; I don't know what to do". CNA #5 stated that LPN #6 kept taking her four fingers tips and poking/pressing on resident #101's face and asked does it hurt. CNA #5 said that she told LPN #6 that resident #101 only says the word "Boy", CNA #5 told LPN #6 that resident #101 was not verbal. CNA #5 stated that resident #101's face started to swell. CNA #5 stated that she put a pillow under resident #101's face while on the floor and that there was blood on the pillow. CNA #5 gave LPN #6 a flashlight and asked if she wanted to check resident #101. CNA #5 stated that LPN #6 looked into the Resident #101's mouth. Resident #101 was put to bed and LPN #6 stated that staff didn't see resident hit her head and not to assume that she did. CNA #5 stated that resident #101's face started to bruise and swell. CNA #5 stated that she asked LPN #7 to go and look at resident #101's face. CNA #5 stated that around 12:30 AM resident #101 woke up very agitated, crying and holding her face. CNA #5 calmed the resident down and got the nurse to look at Resident #101. CNA #5 stated that Resident #101 was agitated/upset told LPN #6 to call for a 1:1 (increased supervision) but that LPN #6 told her to put resident #101 into her wheelchair with a tab alarm, seat belt and leg rest in place. CNA #5 stated that resident #101 self propelled in her wheelchair from 1:30 AM till 3:30 AM. CNA #5 stated that at 3:30 AM she took resident #101 to the bathroom and that LPN #7 assisted her to get the resident on the toilet. CNA #5 stated that resident #101 had a diarrhea bowel movement and that she turned around to get a brief and when she turned back around resident #101 had blood coming from her mouth and nose. CNA #5 stated that she pulled the bathroom call light cord repeatedly and went to the door and yelled down the hall for help. CNA #5 stated that LPN #6 came into the room and asked resident #101 if she picked her nose and did this. CNA #5 stated that when the bleeding started that she used the blue brief to catch the blood and that it was filling up. CNA #5 stated again that LPN #6 stated "I don't know what to do". CNA #5 stated that LPN #7 and CNA #8 came to the room and decided that resident #101 needed to go to emergency room . CNA #5 stated that she and CNA #8 pushed resident #101 in her wheelchair over to the emergency room because resident #101 was starting to gurgle and blood was pouring out. CNA #5 stated that LPN #6 did not apply an ice bag to resident #101's face nor did LPN #6 order x-rays. Record review of resident #101's physician monthly orders dated 12/1/11 through 12/31/11 reflected that resident #101 was ordered aspirin 81 milligrams every day for cerebral [MEDICAL CONDITION] (blood clot) prevention and [MEDICATION NAME] (anticoagulant-blood thinner) 5 mg tab once weekly on Thursdays and [MEDICATION NAME] (anticoagulant) 4 mg tab once daily 6 times a week. Record review of resident #101's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of nurse note dated 12/25/11 at 4:51 AM revealed that at 3:50 AM nurse was called to resident #101's room do to the resident was sitting on the toilet after having a bowel movement and the resident was bleeding profusely from her nose and mouth do to unknown reason at that time. Resident was noted to be transferred over to the emergency room for evaluation. It was noted at this time that the nurse documented level of consciousness, but did not document a level or pupil size. Further review of nurse notes for resident #101 revealed that on 12/25/11 at 7:04 AM nurse #6 documented speaking with the hospital at 5:00 AM regarding resident #101 and that nurse #6 was informed that resident #101 had multiple fractures and was sent to a larger hospital. Further review of nurse notes for resident #101 revealed that on 12/25/11 at 7:11 AM nurse #6 did a late entry documentation post bleeding incident of: 'Late entry 7:15 PM through 3:50 AM, level of consciousness: oriented to self, normal limit for resident, left hand grasp firm, right hand grasp weak, wnl (within normal limits), foot pushes firm to left and weak to right, wnl. Pupils equal, round and react to light. Record review of resident #101's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #101 did not receive any pain medication post fall. The MAR/TAR did not have any neuro checks post fall for the date of 12/24/11 through 12/25/11 performed by LPN #6. In an interview on 1/19/12 at 11:00 AM, Director of Nursing (DON) #2 revealed that Emergency Medical Services (EMS) should have been called when Resident #101 was found with her face on the floor. DON #2 stated Resident #101's fall was unwitnessed and Resident #101 was on [MEDICATION NAME] anticoagulation therapy. DON #2 stated that the nurse (LPN #6) palpated Resident #101's face and that Resident #101 was put to bed. Record review of the U.S. National Library of Medicine web site www.ncbi.nlm.nih.gov/pubmedhealth/PMH 34/?report consumer medication information dated 9/1/10 revealed that [MEDICATION NAME]/[MEDICATION NAME] (anticoagulant) warnings included to tell your physician if you have a fall or serious injury, and bleeding is more likely during treatment of [REDACTED]. Review of the U.S. Department of Health and Human Services 'Blood Thinner Pills: Your Guide to Using Then Safely' dated 8/10 revealed that products that contain aspirin may increase bleeding risk. The guide noted possible side effects to notify physician of serious fall or bump on the head. Record review of Mosby Drug Guide for Nurses, 7th edition, copyright 2007, located at the nurses station at the facility, page 976-977, [MEDICATION NAME] ([MEDICATION NAME]) noted the action as the medication interferes with clotting and complications included hemorrhage. Record review of the facility 'Anticoagulant Therapy' policy and procedure dated 6/09, reflected that the facility nurses were to document assessment by the nurse to include signs and symptoms of bleeding, reporting and treatment of [REDACTED]. Record review of resident #101's anticoagulant/bleeding care plan dated 12/8/11 reflected that nurses were to monitor for intracranial bleed. Record review of the facility 'Vital signs' policy and procedure dated 1/3/06, reflected that neurological checks post fall, or suspected head injury and post un-witnessed fall, should have been done every 15 minutes for one hour, every hour for 4 hours, and every 8 hours until 72 hours had been reached. The nurse was to check level of consciousness (LOC), pupil reaction, both eyes. Check grip strength, both hands. Check for extremity movement, ability to follow commands and pain response. The nurse was to document on the Neurological Assessment Flow sheet in the computer. On 1/19/12 at 11:50 AM the state surveyor requested a copy of the Neurological Assessment Flow sheet in the computer from DON #2. The state surveyor was notified by DON #2 that there were no Neurological Assessment Flow sheets in the computer because there was a charting alarm to alert nurses to check neuros and chart them, but the neuro charting alarm system was removed from the computer system before resident #101's fall on 12/24/11. DON #2 stated that there were no neuro checks found in the computer other than those in the nurse narrative. #

This citation pertains to MI# 928 Based on observation, interview, and record review, the facility failed to prevent a fall for 1 (#101) of 3 sampled residents, from a total sample of 3 residents, resulting in Resident #101 sustaining multiple facial fractures which required surgical intervention and hospitalization . Findings include: Record review of the facility incident summary report fax dated 12/29/11 revealed that on 12/24/11 at approximately 7:05 PM, resident #101 was found on the floor laying on her right side. Resident #101 was found with no foot rest on her wheelchair and her alarmed seat belt was turned off. Resident #101's husband, and roommate (Resident #102), had a known history of turning off Resident #101's alarms and/or taking her safety devices off. According to the incident summary, staff responded to resident #102's chair alarm sounding and that he was found standing over resident #101 looking down at her. The incident summary revealed that staff responded and that slight discoloration to right cheek was noted. The report noted that the resident #101's alarmed seat belt did not sound and that it was turned off. Record review of facility Alarms/personal policy and procedure dated 3/11, reflected to keep alarm control boxes out of reach of person (resident) and that alarms are to be in the "on" position at all times. Record review of resident #101's minimum data set ((MDS) dated [DATE] revealed a [AGE] year old female with cognitive skills for daily decision making as severely impaired never or rarely making decisions. The MDS revealed that the resident had unclear speech with slurred or mumbled words and could rarely or never make her self understood, and had rarely or never understood others. Resident #101's MDS reflected that she had functional limitation in range of motion in both the upper and lower extremity. Active [DIAGNOSES REDACTED]. The MDS reflected that the resident #101 had a history of [REDACTED]. Observation on 1/19/12 between 8:20 AM and 9:00 AM during the entrance tour at the beginning of the investigation revealed that the resident #101 was up in a wheelchair with a buckle style seat belt latched, with no alarm, and no tab alarm while seated in the dining room for breakfast. Resident #101 was noted to say single word "Boy" in response to questions asked of her. Resident #101 was noted to have post stroke symptoms of right sided paralysis with the wheelchair having a leg rest to the right side and a right side arm board. Record review of Resident #101's fall assessment dated [DATE] revealed that Resident #101 was at high risk for falls. Record review of Resident #101's care fall care plan dated 12/22/11 revealed that the alarm box on her wheelchair was to be moved where Resident 101's husband could not visualize it and turn it off. Record review of Resident #101's certified nurse assistant (CNA) flow sheet form dated 12/24/11 thru 12/31/11 revealed that alarm checks were to be done every hour. On 12/24/11 at 7:00 PM the alarm check was left blank. In an interview on 1/19/12 at 10:38 AM, CNA #3 revealed that she was at the nursing station and heard an alarm going off, went to Resident #101's room and found Resident #101 on the floor. CNA #3 stated that Resident #101's face was on the floor and that Resident #101 was holding her face. In an interview on 1/19/12 at 12:35 PM, CNA #4 stated that she responded to resident #102's alarm that was sounding and that resident #101 was on the floor laying on her right side with her face on the floor. CNA #4 stated that Licensed Practical Nurse (LPN) #6 had the CNA turn resident #101 over so that she could assess her. CNA #4 turned Resident #101 over and there was blood in the crack of Resident #101's mouth. CNA #4 stated that CNA #5 had a flash light and offered it to LPN #6 to check Resident #101's mouth but she could not determine where the blood was coming from. CNA #4 stated that LPN #6 asked Resident #101 if she had any pain and Resident #101 stated "Boy". CNA #4 stated that Resident #101 was nonverbal except for the word "Boy". CNA #4 declined to move resident #101 when LPN #6 told her to pick up Resident #101. CNA #4 told LPN #6 to ask nurse LPN #7 to come and assess Resident #101. LPN #6 came back into the room and told CNA #4 that no body saw the fall so they couldn't assume Resident #101 hit her head. CNA #4 stated that she told LPN #6 that no body had seen Resident #101 fall so they couldn't assume that Resident #101 did not hit her head. The CNA's were told to pick up Resident #101 and put her in bed. CNA #4 stated that Resident #101 did not seem fine, that Resident #101 had puffiness to the right side of her face, and that Resident #101 reached across with her left hand because the right side was affected by a stroke and held the right side of her face. CNA #4 stated Resident #101 appeared to be in pain with facial grimacing. CNA #4 stated that CNA #5 took resident #101's vital signs and that she (CNA #4) wrote an unusual occurrence report. Record review of CNA #4's unusual occurrence report dated 12/24/11 at 7:13 PM revealed that Resident #101 was noted to have pain on the right side of her face and that the residents alarm was not sounding. In an interview on 1/19/12 at 2:30 PM, CNA #5 stated that the fall occurred at shift change and that Resident #101's seat belt alarm did not sound. CNA #5 stated that Resident #101 was face down laying on her right side. CNA #5 stated that LPN #6 had the CNA's flip Resident #101 over and then she told them to pick resident #101 up. CNA #6 stated that LPN #6 kept saying "I don't know what to do; I don't know what to do". CNA #5 stated that LPN #6 kept taking her four finger tips and poking/pressing on resident #101's face and asked, 'does it hurt'. CNA #5 said that she told LPN #6 that Resident #101 only says the word "Boy". CNA #5 told LPN #6 that Resident #101 was not verbal. CNA #5 stated that Resident #101's face started to swell. CNA #5 stated that she put a pillow under Resident #101's face while on the floor and that there was blood on the pillow. CNA #5 gave LPN #6 a flashlight and asked if she wanted to check resident #101's mouth. CNA #5 stated that LPN #6 looked into the mouth of Resident #101. Resident #101 was put to bed and LPN #6 stated that staff didn't see Resident #101 hit her head and not to assume that she did. CNA #5 stated that Resident #101's face started to bruise and swell. CNA #5 stated that she asked another LPN (#7) to go and look at resident #101's face. CNA #5 stated that around 12:30 AM Resident #101 woke up very agitated, crying and holding her face. CNA #5 calmed the resident down and got the nurse to look at Resident#101. CNA #5 stated that Resident #101 was agitated/upset told LPN #6 to call for a 1:1 (increased supervision) but that LPN #6 told her to put Resident #101 into her wheelchair with a tab alarm, seat belt and leg rest in place. CNA #5 stated that Resident #101 self propelled in her wheelchair from 1:30 AM till 3:30 AM. CNA #5 stated that at 3:30 AM she took Resident #101 to the bathroom and that LPN #7 assisted her to get Resident #101 on the toilet. CNA #5 stated that Resident #101 had a diarrhea bowel movement and that she turned around to get a brief and when she turned back around, Resident #101 had blood coming from her mouth and nose. CNA #5 stated that she pulled the bathroom call light cord repeatedly and went to the door and yelled down the hall for help. CNA #5 stated that LPN #6 came into the room and asked Resident #101 if she picked her nose and did this. CNA #5 stated that when the bleeding started that she used the blue brief to catch the blood and that it was filling up. CNA #5 stated again that LPN #6 stated "I don't know what to do". CNA #5 stated that LPN #7 and CNA #8 came to the room and decided that resident #101 needed to go to the emergency room . CNA #5 stated that she and CNA #8 pushed Resident #101 in her wheelchair over to the emergency room because resident #101 was starting to gurgle and blood was pouring out. CNA #5 stated that LPN #6 did not apply an ice bag to Resident #101's face and did not order x-rays. Record review of resident #101's physician orders [REDACTED].#101 was prescribed Coumadin (anticoagulation therapy) for a heart condition. Record review of Resident #101's medication administration record (MAR)/treatment administration record (TAR) revealed that all of the Resident #101's 8:00 PM medications were not given. Resident #101 did not receive any pain medication post fall. The MAR/TAR did not have any neuro checks post fall for the date of 12/24/11 through 12/25/11 performed by LPN #6. In an interview on 1/19/12 at 11:00 AM, Director of Nursing (DON) #2 revealed that Emergency Medical Services (EMS) should have been called when Resident #101 was found with her face on the floor. DON #2 stated Resident #101's fall was unwitnessed and Resident #101 was on Coumadin anticoagulation therapy. DON #2 stated that the nurse (LPN #6) palpated Resident #101's face and that Resident #101 was put to bed. Record review of resident #101's nurse notes dated 12/9/11 at 6:14 PM noted that, at 10:15 AM, Resident #101 was observed by staff to be sitting on her blue (fall) mat in her room. The nurse note revealed that Resident #101 was alert and appeared to be wet with urine and attempting to get to the bathroom. No injury was noted at that time. Record review of resident #101's nurse note dated 12/12/11 at 2:54 AM noted that, at 2:15 AM, Resident #101 was noted to be sitting on blue mat next to her bed. Resident #101 was noted to be incontinent of stool and had pulled her tab alarm off and the tab alarm did not sound. Corrective actions were noted to continue to observe. Record review of a fall assessment done on 12/12/11 at 3:06 AM scored resident #101 with intermittent confusion, elimination with assistance, visual impairment, uses assistive devices for mobility, loss of gait rising from bed, and the use of diuretics, hypoglycemic agents and narcotic medications were noted. The fall assessment score reflected a total score of 15 with a 'high risk' notation. Record review of a fall assessment done on 12/16/11 at 3:00 PM scored Resident #101 with intermittent confusion, elimination with assistance, visual impairment, confined to bed or chair, uses assistive devices for mobility, loss of gait rising from bed, and the use of anti-seizure/antiepileptic, antihypertensive diuretics, hypoglycemic agents and narcotic medications were noted. The fall assessment score reflected 'high risk'. Record review of nurse notes dated 12/24/11 at 8:09 PM noted that Resident #101 had an occurrence at 7:13 PM (did not state what type of occurrence) where Resident #101's wheelchair alarm (seat) belt was unleashed and belt alarm was in the off position. The nurse noted no apparent injury and no first aid was given. The possible cause was noted as: removed restraint, slid from chair, incident unobserved. Actions were noted of chair alarm was placed on lower bar of wheelchair out of sight. Resident #101 was placed into bed after the incident. Record review of nurse note dated 12/25/11 at 4:51 AM revealed that, at 3:50 AM, LPN #6 was called to Resident #101's room due to Resident #101 sitting on the toilet after having a bowel movement and Resident #101 was bleeding profusely from her nose and mouth due to unknown reason at that time. Resident #101 was noted to be transferred to the emergency room for evaluation. Record review of social service notes dated 12/13/11 at 5:04 PM revealed that resident #101 was alert with confusion, had both short term and long term memory loss. Resident #101 was noted to have severely impaired daily decision making abilities and has limited responses. Resident #101's verbalizations are limited to the word "Boy". Social services noted that the Resident #101 did not use the call light consistently and was nonverbal with unclear speech. Record review of the emergency room record dated 12/25/11 revealed that Resident #101 was bleeding from her mouth and nose. The emergency room drew blood work including coagulation levels due to Resident #101 being on anticoagulation therapy and ordered a CT scan of the head. Record review of the hospital preliminary radiology report for a computerized tomography (CT) scan (x-ray that provides more detailed pictures of structures inside the body) dated 12/25/11 revealed Resident #101 had a fall, had a history of [REDACTED]. The CT report also indicated that Resident #101 was on Coumadin (anticoagulation therapy) and had a bloody nose. Finding: fracture of right zygomatic arch with fractures of medial wall right orbit, right orbital floor fracture, and fractures of anterior and lateral walls of the right maxillary sinus with hemorrhagic fluids within the right maxillary sinus. Record review of Resident #101's hospital 'Inter-Facility Patient Transfer' form dated 12/25/11 revealed that resident #101 was transferred to an acute trauma center for maxilla-facial surgical services due to multiple facial fractures. #

This citation pertains to MI 193 Based on observation, interview and record review, the facility failed to prevent a fall in 1 (#101) of 4 sampled residents, resulting in Resident #101 being found on the floor by staff, face down with a large hematoma (8 cm X 1 cm X 2 cm) to the left temporal area, and a abrasion to the lip. Findings include: Record review of the minimum data set ((MDS) dated [DATE] revealed Resident #101 was an [AGE] year old male with severely impaired cognitive skills for daily decision making and never or rarely made decisions. Resident #101 was noted to have unclear speech and was able to make himself understood sometimes. Resident #101 had [DIAGNOSES REDACTED]. Record review of the facility unusual occurrence form dated 11/21/11 at 2:10 PM revealed Resident #101 was in his room after lunch and fell over the arm of his Broda (tilt/recline chair) chair and landed on his left side with his left arm under him. Resident #101 was noted to have an open area on his head that was bleeding and a large Hematoma. Emergency Medical Services (EMS) were called to get him up off the floor and to take to the emergency room for evaluation and treatment. The unusual occurrence form noted that the Broda chair was not reclined. Record review of emergency room record dated 11/21/11 revealed that Resident #101 was seen for head injury from a fall from a seated position and a large hematoma of 8 centimeters (cm) X 1 cm X 2 cm and a laceration to the left lip area. Record review of the certified nurse assistant (CNA) care plan guide, located in the residents closet door, revealed Resident #101 was to eat sitting up in his Broda chair at 90 degrees and is to stay sitting up for at lest 1/2 hours (30 minutes) after meals and then tilt Broda chair at least to 45 degrees (recline). Observation on 21/8/11 at 9:55 AM with Registered Nurse (RN) #3 revealed a black egg crate style foam cushion that estimated to be 4-5 inches thick and 12 inches wide and 15-18 inches long, as identified by the RN #3 as the cushion that was in Resident #101's chair at the time of his fall that was brought in by a family member. The black cushion was not care planned, but RN #3 stated that the staff had been using it. Record review of the potential for trauma-falls care plan dated 10/18/11 revealed nurse aides were to tilt Resident #101's Broda chair when not eating to at least 45 degrees. Record review of the medication administration record (MAR) for November 2011, revealed that Resident #101 was on aspirin 81 milligrams daily and Plavix 75 milligrams daily, both medications can increase bleeding risk which can potentially be life threatening (www.Plavix.com) Record review of Resident #101's increased risk of bleeding and bruising related to anticoagulant therapy care plan dated 10/18/11 revealed an intervention to handle resident carefully when transferring, turning and positioning. An interview on 12/8/11 at 11:45 AM with certified nurse assistant (CNA) #8 revealed that there were 3 CNA's and 2 CNA orientees' assigned to the unit on 11/21/11. CNA #8 stated that she was the only CNA on the floor during the time of the fall. CNA #8 stated that the nurse for the unit was on lunch, CNA #7 and the CNA orientatee #5 assigned to her were on lunch, CNA #11 and the CNA orientate #6 were at the hospital with a resident getting x-rays, when the fall occurred. The CNA #8 stated that one of the orientatees had pushed Resident #101 to his room and did not recline the chair, stating that the chair was still pretty straight up, and that the fall happened right after lunch. CNA #8 stated that Resident #101 was out of the dining room around 1:45 PM and that she found Resident #101 on the floor at 2:10 PM. CNA #8 stated that she was at the in-wall charting station charting food acceptances from lunch meal when she heard a thump and a groan, and went to Resident #101's room and found him on the floor with his head bleeding and a large goose egg to the left temporal area. CNA #8 stated that she got help and emergency medical services (EMS) were called. CNA #8 stated Resident #101 had an extra cushion in his chair that his spouse had brought in, stating that the staff did not know about the cushion and that it wasn't care planned, but that staff had been using the extra cushion in the Broda chair when he was up in the chair for the last couple of weeks. In a telephone interview on 12/8/11 at 1:56 PM, CNA #5 revealed that she fed Resident #101 his lunch and that she did not take him back to his room. CNA #5 stated she was on orientation on the day of the fall and that she had fed Resident #101 with his chair straight up as care planned. CNA #5 stated that she pushed Resident #101 out into the hallway, when an alarm went off, she went to answer the alarm, and then she went to lunch leaving Resident #101 in the hallway. CNA #5 stated that the last time she saw resident #101 on the day of the fall he was sitting up in the hallway and that his chair was still in the straight up ward from eating for 30 minutes after his lunch. Record review of the 500 hall RN #3's investigation summary for Resident #101's fall dated 11/21/11 revealed: "This fall may have happened because resident leans forward in his chair, and he lost trunk control, the back of the chair was not fully reclined. It was leaned back one notch, and resident had been returned to his room after lunch at approximately 2 PM". An observation on 12/8/11 at 9:22 AM of Resident #10 while in his room in the Broda chair revealed a trigger latch with hydraulic/pump system to back of the Broda chair for positioning. One notch of positioning was very close to straight up, while multiple notches reclined the Broda chair. Record review of the facility fall prevention policy dated revision 5/11 revealed that the facility environment was to remain free of accident-causing hazards. The policy noted that continued or additional safety devices, as determined by the interdisciplinary team, will be posted for the staff on the care plans. There was no care plan intervention that included use of the black cushion brought into the facility by family member, or any physical therapy or occupational therapy of evaluation of Resident #101's use of the black cushion added to the chair prior to the fall on 11/21/11. Record review of the facility variance report dated 11/21/11 for Resident #101 revealed that "the patient was left unattended". The form noted Resident #101 was sitting up right in his Broda chair when nurse aide heard a sound and found resident lying face down on the floor. At the bottom of the variance form revealed: was this preventable? The facility checked "Yes- Resident was returned to his room at approximately 2 PM after lunch. His chair back was up right and is generally reclined. This resident may have leaned forward and lost trunk control that caused him to fall forward out of chair".

This citation pertains to intake number MI 113. Based on observation, interview, and record review, the facility: 1.) failed to provide supervision to prevent elopement in 1 of 9 sampled residents (Resident #101), from a total sample of 9 residents, resulting in an Immediate Jeopardy when Resident #101, who had been identified as an elopement risk, eloped from the facility on 10/8/11 at approximately 1:00 p.m., unbeknownst to facility staff, and was found at 1:30 p.m. in the front entrance between the set of double entry doors attempting to re-enter the facility. This deficient practice placed 15 additional residents, identified as elopement risks, at risk for serious harm, injury, and/or death. Findings include: Resident #101: Record review of a facility reported incident report, dated 10/13/11 (fax dated), revealed that on 10/8/11 Resident #101 was noted to wheel herself throughout the facility independently. Resident #101 was noted to be alert and oriented to self. Resident #101 was noted to have a wanderguard on and in working order. The facility report noted that Resident #101 followed another resident out the front door, which triggered the wanderguard door alarm at approximately 1:30 PM. Review of the face sheet and the minimum data set (MDS), dated [DATE], revealed Resident #101 was a [AGE] year old female with a cognitive brief interview for mental status (BIM's) score of 3 (0-7: severe impairment) and had a history of [REDACTED]. Resident #101 had a history of [REDACTED]. Resident #101 had diagnoses, which included: senile dementia, chronic obstructive pulmonary disease, congestive heart failure (weak heart), and chronic brai[DIAGNOSES REDACTED]. Record review of Resident #101's Elopement Risk Assessment, dated 8/31/10 and 10/9/11, revealed that Resident #101 had attempted to elope. Record review of the Wandering/Elopement Risk care plan, dated 8/27/10, revealed that on 6/14/11 the facility implemented placement of an ID bracelet (no location noted), wanderguard checks every shift, check for green ID band every shift, ensure green border is around picture outside of residents room, and to record episodes of wandering for Resident #101. Record review of the unusual occurrence report, dated 7/28/11, revealed that facility visitors opened a door for Resident #101 and she went outside to the sidewalk. The administrator observed the exit and followed Resident #101. The report indicated facility staff were in the parking lot and returned Resident #101 to building. Resident #101's activities prior to exiting the building were documented because Resident #101 was wheeling herself and wandering in her W/C (wheelchair) and propelling herself through the hallways. Corrective action to prevent further elopements were for Resident #101 to be on every 15 minute checks and that facility staff were to be aware of Resident #101's location when she was propelling herself in the wheelchair. Record review of the unusual occurrence report, dated 7/30/11, revealed that Resident #101 exited the building while following a family out the front lobby doors. Resident #101 got out into the parking lot and then was assisted back to the facility by a family member and a certified nurse assistant (CNA). Corrective action to prevent Resident #101's future elopement included that facility staff to be aware of Resident #101's location when she was self propelling in the wheelchair. Record review of Resident #101's unusual occurrence report, dated 10/8/11 at 1:30 PM, revealed the wanderguard alarm on the front lobby door was sounding. Licensed Practical Nurse (LPN) #3 responded to the alarm and turned it off when she saw Resident #105 (a different resident) leaving with her spouse. Record review of Resident #105's medication and treatment records for the month of October 2011 revealed Resident #105 did not have a wanderguard device and therefore the lobby door wanderguard alarm would not have sounded when she exited the facility on 10/8/11 at 1:15 PM (per sign out log) with her spouse. In interview on 10/18/11 at 9:25 AM, LPN #3 stated, "After lunch, around 1:00 PM, the front lobby alarms were sounding. I turned off/silenced the alarms, walked outside and saw ladies sitting under the porch cover visiting. I saw my own resident (#105) wheeling herself down the ramp to the parking lot, her spouse was bringing the car up to pick her up to go out for the day. I looked around the parking lot for residents, there were none beyond the porch area. I went back into the building and went back to work on 100 hall. I can remember Resident #102 and Resident #103 from the 200 hall sitting outside on the porch area at that time. There was 3-4 ladies outside". LPN #3 could not recall if Resident #101 was outside, because "she was not my resident". Record review of the facility investigation file revealed a written statement by CNA #7 that indicated CNA #7 heard the overhead pager alerting to "clear lobby door" and went to check it. CNA #7 documented she found that (Resident #101) was outside trying to get back in. CNA #7 brought Resident #101 back in and reported it to her nurse. Resident #101 was noted to be in between the outer and inner doors. An interview on 10/19/11 at 9:50 AM, CNA #7 stated, "On 10/8/11 at 1:30 PM, I heard an alarm going off. I heard the overhead alarm voice to check lobby doors. I went to the lobby, looked around the lobby, but didn't see any one. I looked outside (through glass doors). I went up to the doors and saw someone sitting in between the double entry doors. I kept looking outside for the alarm resident (the resident who may have set off the alarm) and then noted (Resident #101) between the doors trying to get back in. I thought it was funny. I know she has a wanderguard. I use to work 400/600 halls, so I know (Resident #101). Resident #101 had been outside; all I saw was her between the two doors". CNA #7 stated, "I let (Resident #101) back in, she took off down the hall. I went back to my unit (100 hallway). LPN #3 told me to call Resident #101's nurse (LPN #6) and tell her Resident #101 was outside". CNA #7 stated that Resident #105 who left for the day with her spouse did not have a wanderguard device. An observation on 10/18/11 at 10:00 AM with Maintenance Person #4 revealed that the cameras on the 200 hallway showed Resident #101 self propelling throughout the facility on 10/8/11. Maintenance Person #4 stated that the front lobby interior camera was not working/recording at the time of Resident #101's elopement on 10/8/11. In an interview on 10/18/11 at 11:15 AM, Resident #103 (identified by LPN #3 as being outdoors on 10/8/11) stated, "We just sat out under the porch covering. I said to (Resident #101) are you suppose to be out here? I kept waiting for staff to come and get her. It made me nervous that she was out there. She's (Resident #101) confused you know. (Resident #101) was outside and no one knew it. I tried to keep her under the porch area. I thought she would go into the parking lot. I tried to keep her occupied". In an interview on 10/18/11 at 11:20 AM, Resident #104 (identified by LPN #3 as being outdoors on 10/8/11) stated, "Yes, I was outside when (Resident #101) came out of the door. I don't believe she was supposed to be out there. She was out there a while, 15 minutes or so, we convinced her to go back inside". Record review of Resident #101's nurse notes, dated 10/8/11 at 3:55 PM, revealed a late entry for 1:30 PM that documented Resident #101 was noted between the double doors in lobby, per report by CNA. The alarm sounded and CNA responded to alarm to see Resident #101 "in between the double doors in the lobby attempting to open door to return into lobby, staff was able to direct resident back to her hallway to see nurse". Review of the facility white elopement risk binder on 10/18/11 at 12:35 PM, which was located at the 100 hall nurses' station, revealed there was a list of resident names that the facility identified as wandering residents with colored photographs of the residents for easy recognition. Also included in the elopement binder were the elopement/wandering/missing resident policy and search forms to assist staff in the case of a missing resident. Resident #101's photo was in the binder. An interview on 10/18/11 at 12:30 PM with LPN #3 revealed that she did not look in the facility elopement binder on 10/8/11. The LPN #3 stated that she knew that she should have, but she did not. An observation on 10/18/11 at 8:43 AM of Resident #101 while self propelling in her wheelchair revealed there was a wanderguard device attached to the wheelchair. Closer observation of the resident revealed that there was no wanderguard device attached to her body. Record review of Resident #101's medication and treatment record for the months of September and October 2011 revealed that beginning on 8/8/11, facility staff were to check for wanderguard placement on the right ankle twice daily, am shift and night shift. Review of the treatment records revealed that facility staff initialed the document to indicate they were checking Resident #101's right ankle for placement of the wanderguard (not the wheelchair as observed). During an interview and observation on 10/18/11 at 1:47 PM, CNA #10 confirmed during an observation of Resident #101's arms and legs that there was no wanderguard. CNA #10 stated "It's on her wheelchair, not her body. It's been on her wheelchair a long time". The Director of Nursing (DON) #2 was notified on 10/20/11 at 4:16 PM of the Immediate Jeopardy that was identified on 10/18/11 and began on 10/8/11 at 1:15 PM when Resident #101, who had been identified as an elopement risk, eloped from the facility, unbeknownst to facility staff, and was found at 1:30 p.m. in the front entrance between the set of double entry doors attempting to re-enter the facility. This deficient practice placed 15 additional residents, identified as an elopement risk, at risk for serious harm, injury, and/or death. On 10/21/11 at 1:00 PM, the surveyor confirmed that the facility implemented the following to remove the Immediate Jeopardy: 1. On 10/18/11, 16 residents at risk for elopement were assessed and had elopement risk assessments reviewed, validated that wanderguard's were in place and in an appropriate location, validated green ID bands were in place, validated the presence of the green background on pictures on room doors, order for checking wanderguard on each shift validated, and validated that physicians' order and care plans for wandering were in place. 2. On 10/20/11, elopement books were validated for accuracy and the list of risk for elopement updated. 3. On 10/18/11, the wandering care plan for Resident #101 was updated by the social worker to show manifestation of wandering. 4. On 10/21/11, 97 of 97 residents residing at the facility were re-assessed for elopement risk. 5. On 10/19/11, face to face education began with 8 out of 154 employees (including agency, full time, part time and casual) to review the elopement/wanderguard policy with a quiz to validate the education of employees. The quiz included who is responsible for the completion of an elopement risk assessment, what indicates a risk for elopement and the steps needed to take when a resident is at risk for elopement, what to do when a resident is discovered to be missing, how often doors are checked, who to contact when there is an elopement/missing resident and what to do after the resident is found. No employee will be allowed to work prior to being educated on the elopement/wandering policy with the quiz completed. 6. On 10/19/11, 16 of 16 residents identified as at risk for elopement had their elopement risk assessments reviewed for accuracy to ensure they were up to date. The elopement risk assessments are to be done upon admission, re-admission, quarterly, with significant change of condition, and as needed to ensure the safety of all residents. Elopement risk assessments are scheduled with the MDS calendar. Care plans were updated as needed according to the risk score and cognitive status of each resident according to elopement/wandering policy. 7. On 10/20/11, Resident #101's wandering care plan was updated by the social worker to include goals of safe wandering. 8. On 10/21/11 at 9:22 AM, Resident #101's wandering care plan was updated by the nurse manager to have nurses conduct 15 minute checks for location. 9. On 10/8/11, the facility continued wanderguard system checks 5 times a week and randomly, which are documented on a log. 10. On 10/20/11, 12 of 16 residents, who repeatedly wander off the unit, had their care plans reviewed to reflect a monitoring schedule to ensure resident safety. The bedside care plans were reviewed to ensure that 15 minute checks to determine the location of the resident were indicated. 11. On 10/21/11 at 8:46 AM, 16 of 16 wandering residents were added to the 15 minute checks list. 12. On 10/21/11 at 6:55 AM, a drill was conducted with the front door alarm being set off by the Director of Nursing. After two nurses and one CNA responded within 30 seconds, a search was conducted outside, a "code green" was paged and a head count was begun. All residents were accounted for at that time. A sign-in sheet was completed with a summary of the event. While the Immediate Jeopardy was removed on 10/21/11 at 1:00 p.m., the facility remained out of compliance at scope of pattern and a severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy due to not all staff have been in-serviced and sustained compliance has not been verified by the state agency.

This citation pertains to MI# 607 Based on observation, interview and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents in 1 of 6 (#101) sampled residents, resulting in resident #101 who sustained two falls with injury on 2/24/11, and 18 of 44 residents listed with alarms being audited to have issues with the alarm type, care plan or certified nursing care guide. Findings include: Record review of facility unusual occurrence report dated 2/24/11 at 6:00 AM revealed that the resident #101 was observed on the floor in the resident ' s room. Resident #101 was noted to be pleasantly confused. Injury noted of bruising, edema and redness to right face under eye. The resident was noted to complain of pain in left hip when moving leg. Corrective actions taken by the facility were to keep room free of clutter, neurological checks for 24 hours, rearrange room/furniture and observe for bruising. Record review of resident #101's nurse notes dated 2/24/11 at 7:47 AM revealed that the resident was observed on the floor, pleasantly confused and complained of pain to left hip when moving legs. Ice was applied to the resident ' s facial bones. Record review of further nurse notes dated 2/24/11 revealed that at 8:11 AM the resident complained of sharp pain while moving left leg. The resident went for x-rays and received Tylenol for pain. Record review of facility fall assessment for resident #101 dated 2/24/11 at 7:56 AM revealed a fall score of 10, placing the resident at moderate risk of falling. Record review of facility fall prevention & post-fall follow-up policy and procedure dated 12/10 revealed that a resident (fall) assessment score of 10 or greater indicates need for fall prevention protocols. Record review of facility unusual occurrence report dated 2/24/11 at 8:30 PM revealed resident #101 was observed on the floor in the resident ' s room. Actions taken were to place chair and bed alarms. Record review of resident #101's nurse notes revealed a late entry dated 2/25/11 at 5:24 AM of the residents fall. The resident was noted to have no apparent injury, but complained of pain from previous fall in the AM. The nurse noted chair and bed alarm were being put in place. Record review of the resident #101's MRI of pelvis dated 3/8/11 revealed fractures of the left sacrum, and fracture of the left symphysis pubis. Record review of resident #101's fall care plan revealed that on 2/25/11 interventions of alarms to bed, wheelchair and recliner were added. An interview on 3/14/11 at 3:45 PM with director of nursing revealed that there were no alarms applied on 2/24/11 after the 6:00 AM fall. The director of nursing acknowledged that the residents post fall assessment score was 10. The director of nursing could not explain why alarms were not applied at that time. Review of the second fall on 2/24/11 at 8:30 PM with the director of nursing revealed that alarms were applied to bed and chair, but no fall assessment was done at that time. During the investigation the state surveyor performed an alarm safety audit on 3/14/11 by asking the certified nursing assistants on duty which of their residents had alarms and walking with the CNA from room to room to observe the alarms. There were 30 resident observed to have alarms for falls in place. The director of nursing provided a list of 20 residents with fall precautions. There were multiple errors of the type of alarms residents were assessed for, care planned for, and the alarms in actual use. The director of nursing was notified by the state surveyor of more than the 20 residents listed being observed with alarms. An interview on 3/15/11 at 9:20 AM with the director of nursing revealed: "We did an audit after you left yesterday. Quite a few things needed to be fixed, would you like the list. Yes, care plans and orders were updated. 18 of 44 residents fall programs needed fixing. No one actually looked at the residents alarms until you did, then we discovered errors". Observations on 3/15/11 at 10:25 AM of resident #101 in her room revealed that the resident was sitting in her recliner with no alarm (pressure sensor) under her. Pressure alarm noted to be in wheelchair sitting next to her. There was no alarm sounding. At 10:28 AM the director of nursing was escorted by the state surveyor to resident #101's room to see resident sitting in recliner with no alarm under her or attached to her. The director of nursing stated that the alarm would have sounded if she would have self transferred, staff could have placed her in the recliner and turned it off. The director of nursing did not know why alarm was not in place. Observation on 3/15/11 of sampled resident #103, located across the hall from resident #102, revealed a pressure alarm to chair and bed. The closet door certified nurse assistant care plan guide noted a tab alarm to chair and bed. Observation on 3/15/11 of sampled resident #104 revealed the resident to be placed by staff in a recliner. There was no chair alarm noted under or attached to resident #104. The closet door certified nurse assistant care plan guide dated 3/14/11 revealed bed and chair alarms. The facility implemented a second audit of alarms. #