Every finding on record at Majestic Care of Battle Creek

Based on observation, interview and record review, the facility failed to ensure Advance Directives were accurately completed for four (R8, R9, R39 and R52) of four reviewed. Findings include:Resident #8 (R8) Review of the medical record revealed R8 was admitted to the facility [DATE] with diagnoses that included chronic respiratory failure, diabetes mellitus, chronic obstructive pulmonary disease (COPD), morbid (severe) obesity, tracheostomy, gastro-esophageal reflux, dependence on supplemental oxygen, depression, heart failure, hypertension, bipolar disorder, dysphagia (difficulty swallowing), visual blindness bilaterally, schizophrenia, celiac disease (an autoimmune disorder where gluten damages the small intestine), and atrial fibrillation. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R8 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on [DATE] at 12:32 p.m. R8 was observed lying in bed. R8 explained that she had been a resident at the facility since 2023. Review of R8's Michigan Do-Not-Resuscitation Order document, revealed R8 had signed the document on [DATE] which stated I have discussed my health status with my physician, (name of physician), and I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. Review of physician order entered [DATE] revealed an order Full Code (meaning resuscitation would be started if R8's heart and breathing were stop). On [DATE] at 09:31 a.m. Director of Nursing (DON) B explained that the facility nursing staff completed the Michigan Do-Not-Resuscitation Order document with the residents. DON B explained that the nursing staff would make sure that the document is accurate and then would obtain an appropriate physician order for DNR (Do not Resuscitate). DON B was asked to review R8's Michigan Do-Not-Resuscitation Order form and confirmed that R8 had signed the document on [DATE] that she did not want resuscitation to be conducted if her heart and breathing were to stop. DON B could not explain why R8's physician orders did not accurately reflect R8's wishes to not have resuscitation performed, as documented on her Michigan Do-Not-Resuscitation Order document. Resident #39 (R39) Review of the medical record revealed R39 was admitted to the facility [DATE]/2025 with diagnoses that included severe protein-calorie malnutrition, cachexia (a severe complex metabolic condition causing involuntary and significant loss of muscle mass and fat), hypertension, congestive heart failure (CHF), depression, chronic obstructive pulmonary disease, dysphagia (difficulty swallowing), dependence on supplemental oxygen, idiopathic pulmonary fibrosis (disease causing irreversible scarring in the lungs), heroin poisoning, alcohol abuse, chronic viral hepatitis C, insomnia, and anxiety. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R39 had a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15. During observation and interview on [DATE] at 09:51 a.m. R39 was observed lying down in bed. R39 explained that he had been a resident at the facility since august of 2025. Review of R39's Michigan Do-Not-Resuscitation Order document, dated [DATE], did not have dates for the two witness signatures. In an interview on [DATE] at 09:15 a.m. Social Worker (SW) E explained that she was responsible to review all resident Michigan Do-Not-Resuscitation Order documents. SW E explained that she would review the documents to ensure that they are completed accurately. SW E confirmed that R39's Michigan Do-Not-Resuscitation Order document did not contain dates that the witnesses had signed the document. SW E could not explain why the signatures did not contain dates of signature on the witness line of the document. Resident # 52 (R52) Review of the medical record revealed R52 was admitted to the facility [DATE] with diagnoses that included traumatic subdural hemorrhage (brain bleed), Alzheimer's disease, cerebral infarction (stroke), gastro-esophageal reflux, depression, hyperlipidemia (high fat content in blood), and hypotension. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed R52 had a Brief Interview for Mental Status (BIMS) of 05 (severe cognitive impairment) out of 15. During observation and interview on [DATE] at 11:10 a.m. R52 was observed sitting in her wheelchair, in the dining room. R52 could not explain how long she had been a resident at the facility. Review of R52's Michigan Do-Not-Resuscitation Order document, dated [DATE], did not have dates for the two witness signatures. In an interview on [DATE] at 09:24 a.m. Social Worker (SW) E confirmed that R52's Michigan Do-Not-Resuscitation Order document did not have dates for the two witness signatures. SW E could not explain why the document had not been completed accurately. In an interview on [DATE] at 09:31 a.m. Director of Nursing (DON) B confirmed that R52's Michigan Do-Not-Resuscitation Order document did not have dates for the two witness signatures. DON B could not explain why the document had not been completed accurately. R9: Review of the medical record reflected R9 admitted to the facility on [DATE], with diagnoses that included bipolar type schizoaffective disorder and dementia. The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], reflected R9 scored seven out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On [DATE] at 9:22 AM, R9 was observed lying awake, in bed. R9's medical record reflected a Do-Not-Resuscitate document (DNR-no cardiopulmonary resuscitation/CPR in the event of cardiac or respiratory arrest), which was signed by a Responsible Party on [DATE] and the Physician on [DATE]. The two witness signatures on the document were undated. In an interview on [DATE] at 9:15 AM, Social Worker (SW) E acknowledged that the witness signatures on R9's DNR document were undated. SW E indicated the significance of witness signatures was to ensure the decision was theirs (person signing DNR document) and nobody else's. In an interview on [DATE] at 9:31 AM, Director of Nursing (DON) B reviewed R9's DNR document and reported the witness signatures were undated. DON B reported their expectation was for witness signatures on a DNR document to be dated.

Based on observation, interview and record review, the facility failed to ensure staff utilized appropriate personal protective equipment (PPE) for two residents (R6 and R31) of two reviewed for Transmission-Based Precautions.Findings include: R6:Review of the medical record revealed R6 was admitted into the facility on 2/25/25 with diagnoses that included: vascular dementia, severe, with psychotic disturbance, major depressive disorder, and cerebral infarction (stroke). According to the Minimum Data Set (MDS) assessment dated [DATE], R6 scored 4/15 on the Brief Interview for Mental Status exam (which indicated severely impaired cognition). A review of R6's progress notes revealed, on 1/8/26 Resident tested positive for covid today. On 1/14/26 at approximately 12pm, a droplet precaution sign was observed on the exterior of R6's room door. Social services director (SSD) E was observed entering R6's room with only a surgical mask on and without performing any hand hygiene. In an interview on 1/16/26 at 2:37 pm, SSD E reported being aware of the droplet precautions in place for R6 and that she should have slowed down and read it (the precautions signage on the door). R31: Review of the medical record reflected R31 admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD). The Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/25, reflected R31 scored 12 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). According to the medical record, R31 returned from the hospital on 1/13/26 and was positive for COVID-19. On 01/14/2026 at 1:15 PM, a droplet precaution sign was observed on the exterior of R31's room door, which reflected everyone must clean their hands before entering and when leaving the room and make sure their eyes, nose and mouth were fully covered before room entry. Housekeeper D was observed in R31's room, wearing a gown, gloves, surgical mask and face shield. When asked if they knew why the droplet precaution sign was on R31's room door, Housekeeper D reported R31 had COVID-19. When asked what type of mask they were supposed to wear in R31's room, Housekeeper D stated they believed they were to wear an N95 mask. Housekeeper D acknowledged they were not wearing an N95 mask and could not state why. In an interview on 01/16/2026 at 2:29 PM, Director of Nursing (DON) B reported the expectation was to wear a gown, gloves, N95 mask and face shield for contact with COVID-19 positive residents.

Based on observation, interview and record review, the facility failed to 1) document clinical rationale for duplicate psychotropic medication therapy for one (R23) of five reviewed; and 2) ensure appropriate monitoring of antipsychotic medication use for one (R41) of five reviewed.Findings include:R23: Review of the medical record reflected R23 admitted to the facility on [DATE], with diagnoses that included fracture of lower end of right femur and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/25, reflected R23 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded as receiving antidepressant medication. On 01/16/2026 at 9:14 AM, R23 was observed seated in a wheelchair, in their room, combing their hair. A Physician's Order, dated 12/16/25, reflected R23 was prescribed 75 milligrams (mg) of Amitriptyline Hydrochloride (HCl) (antidepressant medication) by mouth, at bedtime, for depression. A Physician's Order, dated 12/16/25, reflected R23 was prescribed 150 mg of Venlafaxine HCl Extended Release (ER) (antidepressant medication) by mouth, daily, for depression. The list of diagnoses in R23's medical record did not include depression. In an interview on 01/15/2026 at 11:13 AM, regarding duplicate psychotropic medication therapy, Director of Nursing (DON) B reported the facility continued R23's medications from the hospital, and she did not see a diagnosis of depression in R23's diagnoses list. Regarding the expectation for documentation pertaining to duplicate psychotropic medication therapy, DON B reported they would expect to see the diagnosis listed, but some residents had a couple of medications in the same drug class that had been in their regimen for years. During the interview, documentation pertaining to clinical rationale for duplicate antidepressant therapy was requested. On 01/15/2026 at 12:35 PM, DON B reported anxiety and depression were listed in the Nurse Practitioner's Progress Note for 12/18/25. DON B acknowledged the diagnoses were listed as part of the medication orders that were referenced within the Progress Note. R41: Review of the medical record reflected R41 admitted to the facility on [DATE], with diagnoses that included hyperglycemia (high blood sugar), dementia with anxiety; depression, anxiety disorder, dysthymic disorder, obsessive compulsive disorder and altered mental status. The Quarterly/5-day Medicare MDS, with an ARD of 10/30/25, reflected R41 scored four out of 15 (severe cognitive impairment) on the BIMS and received antipsychotic medication. On 01/14/2026 at 2:45 PM, R41 was observed walking in their room, without an assistive device. A Physician's Order, dated 12/22/25, reflected R41 was to receive 12.5 mg of Quetiapine Fumarate (Seroquel-an antipsychotic medication), by mouth, at bedtime. On 01/16/2026 at 10:24 AM, review of R41's medical record reflected their most recent laboratory blood tests were a complete blood count (CBC) and comprehensive metabolic panel (CMP) on 7/9/25. In an interview on 01/16/2026 at 11:18 AM, DON B reported the most recent laboratory blood tests she saw for R41 were the CBC and CMP for July 2025. DON B stated she could ask the facility's pharmacy if there were any recommended laboratory tests for a resident receiving Quetiapine. On 01/16/2026 at 12:13 PM, DON B reported the facility's Pharmacist stated a hemoglobin A1c (a blood test that measures the average amount of sugar in the blood over the past few months) should be monitored within six months of starting Seroquel (Quetiapine) and every six months after.

Based on observation, interview and record review, the facility failed to obtain consent for psychotropic medication use for one (R23) of five reviewed. Findings include: Review of the medical record reflected R23 admitted to the facility on [DATE], with diagnoses that included fracture of lower end of right femur and chronic obstructive pulmonary disease (COPD). The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/25, reflected R23 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded as receiving antianxiety medication. On 01/16/2026 at 9:14 AM, R23 was observed seated in a wheelchair, in their room, combing their hair. A Physician's Order, dated 12/16/25, reflected R23 was to receive 15 milligrams (mg) of buspirone (antianxiety medication) three times daily for anxiety. The medical record did not reflect a consent for buspirone. In an interview on 01/15/2026 at 11:13 AM, Director of Nursing (DON) B reported if consents were needed, the nurse generally obtained them upon admission. DON B reported antianxiety medications were a classification of medication they would obtain consent for. In an interview on 01/15/2026 at 12:35 PM, DON B reported R23's buspirone consent had been missed.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5% when 2 of 25 medications were not administered in accordance with physician's orders for 1 (R40) of 4, resulting in a medication error rate of 8%.Findings include: Review of the medical record revealed R40 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes. Review of the Physician's Order dated 1/2/26 revealed an order for insulin aspart (rapid acting insulin) FlexPen 100 units/mL (milliliter) inject 10 units subcutaneously three times daily before meals for diabetes mellitus. Review of the Physician's Order dated 1/2/26 revealed an order for Metformin HCl 500 milligrams (mg) give 1 tablet by mouth one time a day for diabetes. During an observation on 01/15/2026 at 8:24 AM, Licensed Practical Nurse (LPN) G removed R40's insulin aspart FlexPen from the medication cart, dialed the pen to 5 units and pushed the injection button. When asked to describe the process, LPN G reported they primed the insulin pen with 5 units as they always do. LPN G did not have a needle on the insulin pen during priming. When entering R40's room, it was noted R40 had already finished breakfast and no longer had a breakfast tray in their room. LPN G administered 10 units of insulin aspart and metformin 1000 mg to R40. The insulin pen was primed incorrectly and administered after breakfast instead of before. The incorrect dose of Metformin was administered. On 01/16/2026 at 8:22 AM, an observation of the medication cart with Unit Manager (UM) H confirmed R40 only had Metformin 1000 mg available. In an interview on 01/16/2026 at 8:24 AM, Director of Nursing (DON) B reported a needle should be applied to the insulin pen before priming to ensure the insulin gets through the needle. According to the Cleveland Clinic, to prime an insulin pen, Attach a new pen needle to the insulin pen. To attach the pen needle, pull the paper tab off the pen needle, screw the new needle onto the pen, and remove the outer cap of the needle. You'll need the outer cap to remove the needle from the pen when you're done with the injection. Remove the inner cap. Prime the insulin pen. Priming means removing air bubbles from the needle. It ensures that the needle is open and working. You must prime the pen before each injection. To prime the insulin pen, turn the dosage knob to the 2 units indicator. With the pen pointing upward, push the knob all the way. At least one drop of insulin should appear. You may need to repeat this step until a drop appears. (https://my.clevelandclinic.org/health/treatments/17923-insulin-pen-injections)

Based on observation, interview and record review, the facility failed to provide timely routine and emergency dental services for two (R4 and R6) of four reviewed for dental services. Findings include:Resident #6On 1/14/26 at 1:05 pm, R6 was observed asleep, sitting up in a wheelchair. R6 did not arouse when greeted. Review of the clinical record revealed R6 was admitted into the facility on 2/25/25 with diagnoses that included: vascular dementia, severe, with psychotic disturbance, major depressive disorder, and cerebral infarction (stroke). According to the Minimum Data Set (MDS) assessment dated [DATE], R6 scored 4/15 on the Brief Interview for Mental Status exam (which indicated severely impaired cognition). In a telephone interview on 1/14/26 at 2:36 pm, with Family Member (FM) R, it was reported that R6 had not been seen for dental services in approximately 2 years and had not had a pair of dentures in a year and a half. A review of R6's physician orders revealed three orders stating May be seen by Podiatrist, Dentist, Optometrist, Audiologist, Psychiatrist/Psychologist, dated 2/25/25, 7/25/25 and 10 /24/25. A review of the clinical record revealed a consent for dental services with 360 Care, signed by R6's responsible party on 2/27/25. Despite a consent for services and an active physician order for dental services, no record of R6 receiving dental services was found. In an interview on 1/15/26 at 2:13 PM, Social Service Director (SSD) E reported that based on his admission date and a valid consent for services, that she would have expected that R6 would have been seen by Dental services already. SSD E denied any knowledge of R6 needing dentures and was unable to provide any documentation of R6 having received dental services. A review of the facilities policy titled Dental Services updated 11/25, documented in part All residents/patients will have access to dental services as part of comprehensive care.Emergency dental care must be arranged promptly when clinically indicated. Resident #4 (R4) Review of the medical record revealed R4 was admitted to the facility 09/19/2025 with diagnoses that included osteomyelitis (inflammation or infection of the bone) of left ankle and foot, hypertension, osteomyelitis, type 2 diabetes, muscle weakness, lack of coordination, non-pressure chronic ulcer of left foot, depression, diabetic foot ulcer, and absence of left toes. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/24/2025, revealed R4 had a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 01/14/2026 at 02:05 p.m. R4 was observed sitting on the side of his bed. R4 explained that he had occasional dental pain but had not seen a dentist at the facility. R4 also explained that he had not been offered the option of being provided with dental services. Review of R4's medical record did not reveal a consent for dental services. R4's medical record did reveal a physician order, entered 09/19/2025, which stated: may be seen by Podiatrist, Dentist, Optometrist, Audiologist, Psychiatrist, and Psychologist. R4's medical record did not demonstrate any documentation that he had been provided with dental services since date of admission. In an interview on 01/15/2026 at 02:13 p.m. Social Worker (SW) E explained that residents are offered dental services upon admission. SW E explained that residents would sign a consent for ancillary services and that the consent would be placed in the residents medical record. SW E explained that the resident would then be seen during the next dental visit. SW E could not locate a consent for dental services in R4's medical record. In an interview on 01/15/2026 at 03:18 p.m. Social Worker (SW) E provided a document entitled Attending Physician Request for Services/Consultation was signed on 1/07/2026. The dental section of the document revealed a x in the box entitled mouth pain. SW E confirmed that this document was a request for service but was not a consent to be provided dental services. SW E explained that dental services had not been provided for R4's dental pain, as to date.

Based on observation, interview and record review, the facility failed to ensure a Binding Arbitration Agreement was explained to the resident in a form and manner they understood for one (R23) of three reviewed.Findings include:Review of the medical record revealed R23 was admitted to the facility on [DATE] with diagnoses that included anxiety and depression. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/25 revealed R23 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). R23 was their own decision maker. R23 signed the Arbitration Agreement on 12/19/25 and Director of Marketing and Admissions (DOMA) F signed as the authorized facility representative. On 01/16/2026 at 9:26 AM, R23 was observed sitting in a wheelchair in their room. R23 reported they did not recall discussing or signing an Arbitration Agreement. When explained that the Arbitration Agreement included giving up their right to litigation in a court proceeding and using the arbitration process instead, R23 reported they would not have signed that. In an interview on 01/16/2026 at 9:29 AM, DOMA F reported the Arbitration Agreement was part of the main admission agreement. When asked how arbitration was explained, DOMA F reported they explain to the resident/representative that if they were ever unhappy with anything and can't come to an agreement with the facility, then a third party was invited in. DOMA F reported they also explain the agreement is voluntary. DOMA F reported they do not explain anything about giving up the right to litigation in a court proceeding. In an interview on 01/16/2026 at 10:32 AM, Nursing Home Administrator (NHA) A reported the Arbitration Agreement was optional. When asked if it was expected for staff to explain that the agreement waives their right to a court proceeding, NHA A reported they believed it was written in the agreement. NHA A reported the Arbitration Agreement was more of a legal thing and they would not expect a nursing home employee to understand all of it.

This citation pertains to intake number 2610947.Based on observation, interview, and record review the facility failed to ensure for two out of four residents (Residents #1 and 3) care plans were revised as care needs changed. Resident #1 (R1):Per the facility face sheet R1 was admitted to the facility on [DATE]. Diagnoses included a stage III pressure ulcer of the sacrum (butt bone).Review of a Skin Condition Evaluation form dated 6/9/2025, revealed R1 had a wound to the right inner thigh documented to be unstageable, a pressure wound to the gluteal fold (the crease in the buttocks) that was documented at a stage II, another wound on the right gluteal fold that was a stage II, a pressure ulcer to the left great toe, and a pressure ulcer to the left heel. Review of a Skin Condition Evaluation dated 6/16/2025, revealed R1 had a sacral pressure ulcer that measured 12 X 9 X 0.3 cm (centimeters) and was a stage III. The assessment did not mention the two gluteal fold stage II pressure ulcers (in this area two gluteal ulcers may merge into one large wound in the sacral area).Review of a Skin Condition Evaluation dated 6/30/2025, revealed R1's sacral pressure wound was a stage III that now measured 15.0 X 14.0 X 0.3 cm. Review of a Skin Condition Evaluation dated 7/7/2025, revealed R1's sacral pressure wound was a stage III that now measured 19.5 X 9.0 X 1.0 cm. Review of a Skin Condition Evaluation dated 7/14/2025, revealed R1's sacral pressure wound was a stage III that now measured 22.5 X 9.5 X 1.0 cm.Review of a Skin Condition Evaluation dated 7/7/2025, revealed R1's sacral pressure wound had a dept of 2.5 cm.Review of a care plan that was active revealed R1 had impaired skin integrity that included the sacral wound stage III pressure ulcer, however the care plan also had the two gluteal stage II pressure ulcers documented under the Focus also. This care plan had the date that it was initiated on as 6/10/2025, and a revision date of 7/1/2025. All of the interventions list on the care plan were dated 6/10/2025, and despite with worsening of R1's sacral pressure ulcer no new interventions were added to R1's plan of care to promote healing. All of the interventions were the same interventions that were put into place on R1's admission. Resident #3 (R3):Per the facility face sheet R3 was admitted on [DATE].Review of an admission assessment dated [DATE] revealed R3 did not have any pressure ulcers at the time of admission.Review of R3's progress notes dated 8/26/2025 revealed R3 had a fall which resulted in an abrasion to his back at the mid thoracic area (chest area but in the back). Another progress note dated 9/1/2025 revealed R3's abrasion had tuned into a stage III pressure ulcer.Review of R3's care plans revealed a care plan was in place with a Focus of (R3) is at Risk for skin breakdown due to impaired mobility and scattered bruising mid thoracic spine PI (pressure injury). and was dated 8/12/2025. The care plan was updated but not until 9/11/2025. However, none of the interventions were updated that revealed R3 had actual skin breakdown, and a stage III pressure ulcer and had. All the interventions were dated 8/12/2025.In an interview on 9/18/2025 at 3:01 PM, Licensed Practical Nurse (LPN) C stated R3's care plan for his wounds should have been updated with new interventions based on the changes with the abrasion.In an observation on 9/18/2025 at 2:55 PM, of R3's stage 3 on his spine revealed a stage 3, clean, no drainage, and no odor.In an interview on 9/22/2025 at 10:55 AM, Director of Nursing (DON) B stated that every morning when the team meets care plan review is discussed if needed, and any updates to the care plans are done right then, by the LPN C or the Minimum Data Set or MDS nurse, and stated that was her expectation. DON B said she did not know why R1 and R3's care plans were not updated.

This citation pertains to intake MI00148919. Based on observation, interview and record review, the facility failed to notify the provider of a change in condition for one (Resident #1) of two reviewed. Findings include: Review of the medical record reflected Resident #1 (R1) admitted to the facility on [DATE], with diagnoses that included unspecified severe protein-calorie malnutrition, degenerative disease of the nervous system and quadriplegia. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/1/24, reflected R1 was rarely/never understood and received nutrition via feeding tube. On 1/3/25 at 2:20 PM, R1 was observed lying in bed, awake. R1 did not verbally respond when spoke to. A bottle of Jevity 1.5 calorie tube feeding formula was infusing at a rate of 55 milliliters (mL) per hour. A bag of water was observed hanging, set for a flush rate of 50 mL every eight hours. On 1/6/25 at 8:59 AM, R1 was observed lying in bed, with their eyes closed. A bottle of Jevity 1.5 calorie tube feeding formula was infusing at a rate of 55 mL per hour. A bag of water was observed hanging, set for a flush rate of 50 mL every eight hours. On 1/6/25 at 3:47 PM, R1 was observed lying in bed with a tube feeding and water flush infusing via Percutaneous endoscopic gastrostomy (PEG tube/an endoscopic medical procedure in which a PEG tube is placed into the stomach, through the abdominal wall, and can be used to provide nutrition and hydration). R1's medical record reflected they were not to receive anything by mouth, thus required hydration, nutrition and medication to be administered via PEG tube. A Progress Note for 12/8/24 at 2:36 PM reflected R1's PEG tube was found dislodged, lying on their abdomen. According to the note, the nurse inserted an 18 French (foley/urinary) catheter with a 10 mL balloon in place of the PEG tube. R1's medical record reflected they were sent to the emergency room (ER) on 12/11/24 (three days later) to have their PEG tube replaced. During a phone interview on 1/6/25 at 11:38 AM, Physician D reported if someone were to call the on-call provider, a verbal order could have been given by phone that may not have been documented by the provider. Physician D stated the nursing notes would say who was contacted. Physician D indicated a provider should have been notified of the situation (R1's PEG tube dislodgment) and a request made for recommendations, even if the notification was made the following day. During a phone interview on 1/6/25 at 2:13 PM, Registered Nurse (RN) C reported they inserted a foley catheter tube in place of R1's PEG tube when it became dislodged. RN C reported Director of Nursing (DON) B was notified of the PEG tube being dislodged, but they could not recall if a text notification had been sent to a provider. RN C reported it was a common thing to happen, and they were not used to notifying the provider of such an occurrence. During an interview on 1/6/25 at 2:24 PM, DON B reported if a PEG tube became dislodged, the expectation was that the nurse would notify the physician and document it. DON B reported being notified that the tube became dislodged and was told the on-call provider had been notified that a foley catheter would be placed. R1's medical record did not reflect that a provider had been notified when the PEG tube became dislodged on 12/8/24, nor any orders pertaining to how to proceed with care. According to the facility's Change in Condition/Physician Notification policy, dated 1/2/24, .When a change in condition is discovered, the nurse will evaluate the resident and notify the resident's physician/NP/PA with pertinent information to discuss care for the resident .The nurse will notify the physician/NP/PA and the resident/resident representative when: .Need to alter medications or treatment .A significant change in the resident's physical, mental, or psychosocial status . According to the facility's Enteral Feeding policy, dated 1/2/24, .It is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible .Feeding tubes will be utilized according to physician orders .Only tubes designed or intended for enteral feeding will be utilized, except under extenuating circumstances and for the shortest time possible .Direction for staff regarding the conditions and circumstances under which a tube is to be changed will be provided: .When to replace and/or change a feeding tube (generally as ordered/scheduled by the physician, when a long-term feeding tube comes out unexpectedly .) .Instances when a tube can be replaced within the facility and by whom .Instances when a tube must be replaced in another setting .Notification of the practitioner when the need for a tube change arises unexpectedly .

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen. Findings include: During an initial tour of the kitchen, at 9:12 AM on 10/27/24, observation of the two door Delfield refrigeration unit found the following items: a container of hot dogs dated 10/24 to 11/7, an open container of sliced smoked ham with no date, a saran wrapped chunk of ham with no date, an open container of strawberry sauce dated 10/13 to 10/19, a ziplock bag of bratwurst dated 10/18 to 11/18, and a bag of shredded lettuce dated 10/26 to 11/1 with a manufacture best by date of 10/28/24. An interview with [NAME] F, at 9:15 AM on 10/27/24, asking how many days are usually given to items like brats and hot dogs, [NAME] F stated it should be seven days, I would throw them away. According to the 2017 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . According to the 2017 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) . During an initial tour of the kitchen, at 9:29 AM on 10/27/24, it was observed that a bottle of lemon juice, dated open on 9/10/24, was found sitting on a dry storage shelf above the microwave. Further observation of the lemon juice found that it was milky white in coloration and the manufactures directions state Refrigerate After Opening. According to the 2017 FDA Food Code section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57C (135F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54C (130F) or above; or (2) At 5C (41F) or less. During the initial tour of the kitchen, at 9:34 AM on 10/27/24, observation of the mechanical scoops clean utensil bin on the cook line, found a small puddle of water inside the container from scoops being put away wet. Further observation found one scoop with stuck on food debris and an accumulation of crumb debris inside the container of scoops. During an initial tour of the kitchen, at 9:36 AM on 10/27/24, observation of the clean pots and pans storage rack found three six inch deep quarter pans stacked wet. Further observation found two of the wet quarter pans had stuck on white food debris on the inside of the containers. During a tour of the dining room, at 9:49 AM on 10/27/24, it was observed that the dispensing spout on the ice machine was found with excess accumulation of white and black dried crusted debris. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During a tour of the dish machine area, at 9:38 AM on 10/27/24, observed Dietary Aide G washing dishes at the dish machine by himself. It was observed that Dietary Aide G went from racking dirty dishes and putting away clean dishes multiple times without using the hand sink or changing gloves in between changing tasks. An interview with Dietary Aide G found that he doesn't normally wash the dishes. Further observation found that Dietary Aide G started to make some coffee in-between doing the dishes. No hand sink observations from Dietary Aide G were made while going from dirty to clean to food preparation. According to the 2017 FDA Food Code section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and:(A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. During an observation of the dish machine area, at 9:52 AM on 10/27/24, an increased accumulation of debris was found under the dish machine leading into the back corner of the unit. Further observation found that the back underside wall was deteriorating around the perimeter of the stainless-steel shield. Observation of pitting and open holes near the floor was observed where the stainless steel meets the wall and the floor. During an observation under the cook line and cold hold equipment, at 9:59 AM on 10/27/24, it was observed that an accumulation of debris, crumbs, a bread roll, cardboard, and dirt was present. According to the 2017 FDA Food Code section 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. According to the 2017 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A)PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean . During a tour of the ice machine, at 9:50 AM on 10/27/24, it was observed that the air gap for the ice machine was sunk into the waste drain and not allowing for a physical air gap of the unit. The set up should be installed in a manner that there is a physical gap that exists between the drain for the ice machine and the drain leading to the sewer. According to the 2017 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 . During a tour of the kitchen mop sink closet, at 9:54 AM on 10/27/24, it was observed that the mop sink faucet was left in the on position with a Y valve on the spout of the faucet. The faucet was found connected to a chemical pre-dispense system so that staff could push a button and dispense chemicals. This set up puts undue back pressure on the faucets internal vacuum breaker, of which it is not rated to handle. It was also observed that the hot water valve was missing its handle, so that it could not be turned off at this time. A wasting tee or sidekick device should be installed to alleviate any back pressure on the vacuum breaker and maintain its working integrity. According to the 2017 FDA Food According to the 2017 FDA Food Code section 5-205.15 System Maintained in Good Repair. A PLUMBING SYSTEM shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.

Based on observation, interview, and record review the facility failed to provide hot liquids at a palatable temperature to 5 of 8 residents in a group interview and one of two residents (R30) surveyed. This deficient practice has the potential to result in decreased hydration consumption and potential for decreased satisfaction of living. On 10/28/24 at 1:00 pm during the confidential group meeting , 5 of 8 group participants reported being frustrated with the temperatures of beverages, stating coffee and tea are always cold and water for hot cocoa was always too cold resulting in the cocoa packet not getting dissolved and left clumpy. Resident #30 Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] Resident # 30 (R30) was admitted to the facility on [DATE] with diagnoses that included, major depression, hemipelaigia and hemiparesis. Review of the MDS reflected R30 scored 15 out of 15 (cognitively intact) on the Brief Interview Mental Status (BIMS), further review of the MDS reveled R30 had clear speech and adequate hearing. On 10/28/24 09:36 AM, during an interview with R30 it was reported coffee was not good because it was always cold therefore even though coffee was the preferred beverage it was no longer requested to be served due to the temperature. R30 further reported their spouse brings coffee in from local restaurants which has steam coming off it and was delicious. R30 voiced irritation that this could not be provided by the facility. R30 stated it was brought to managements attention and a grievance form filed but no changes were made. When queried if there had been an assessment for hot liquid or the need for an adaptive cup for hot liquid R30 stated no. Nursing progress notes dated 10/23/24 revealed . requested hot cocoa during Coffee and Chronicles pass. Beverage was temped just prior to delivering to [name redacted]. Temp was confirmed to be 145 degrees. He stated, it could be hotter. He has been informed of the safe and required temp range, and that 145 degrees does fall within that range. Review of R30's grievance filed on 10/14/24 for coffee temperature being too cold, the facility response was dated 10/15 and was coffee temp range was to be 120 - 140. 38905 During a tour of the kitchen, at 1:02 PM on 10/29/24, an interview with Dietary Manager E found that the kitchen keeps a temperature log for maintaining hot liquid temperatures between 120F and 140F. When asked where the policy or concern for hot liquid temperatures arose, Dietary Manager E was unsure and stated he had only been here a month. Dietary Aide I, stated that he remembers an issue with a resident getting burned awhile back and thought the policy started around that time. An interview with the Nursing Home Administrator and the Director of Nursing regarding the facilities Hot Liquid Policy, at 1:10 PM on 10/29/24, found that they were both newer to the facility and would need to look up the policy to be sure. A record review of documentation provided by the facility, found an incident form, dated 11/9/23, where a resident was assessed for burns due to hot liquids. A further review of the incident form found that a plan of correction for Element 2 (Identification of residents who may be affected) found that All residents who are identified at risk will be audited for completion of a hot liquid evaluation . A review of the facilities policy entitled Safety of Hot Liquids, revised October 2014, states Residents who prefer hot beverages with meals (i.e., coffee, tea, soups, etc.) will not be restricted from these options. Instead, staff will conduct regular Hot Liquids Safety Evaluations as indicated and document the risk factors for scalding and bums in the care plan. Once risk factors for injury from hot liquids are identified, appropriate interventions will be implemented to minimize the risk from burns. Such interventions may include: a. Maintaining a hot liquids serving temperature of not more than 180 degrees Fahrenheit; b. Serving hot beverages in a cup with a lid; c. Encouraging residents to sit at a table while drinking or eating hot liquids; d. Providing protective lap covering or clothing to protect skin from accidental spills; and e. Staff supervision or assistance with hot beverages.

Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing and failed to protect clean and sanitary supplies from possible wastewater contamination. This deficient practice has the potential for the growth and transmission of Legionella in the circulating water of the building and the spread of Legionella infections, and potential contamination of clean supplies, affecting all residents. Findings include: During a tour of the facility, at 10:10 AM on 10/27/24, an observation of the small shower room found a shower fixture on the wall with no direct spigot or faucet found to dispense the water. Upon momentarily turning on the handle, water could be heard coming out of a fixture in the wall. During an interview with Maintenance Director (MD) H,at 11:08 AM on 10/27/24, it was found that he flushes all empty rooms on a weekly basis. During a tour of the nourishment room behind the nurse's station, at 11:10 AM on 10/27/24, it was observed that two water lines were coming out of the wall. Neither water line was connected to a fixture in order to be easily flushed. During an interview with MD H, at 11:30 AM on 10/29/24, it was found that the small shower room wall fixture used to be for the tub that was installed in the room. MD H was able to pull off a boarded up section of wall to find the old tub spigot. When asked about the water running in this area, MD H stated that its not a fixture he has been flushing. During a tour of the basement medical supply room, at 11:45 PM on 10/29/24, it was observed that that a shower was present in the storage closet. When asked if he was aware whether the shower was hooked up to water, MD H was unsure. During a tour of the central supply room, at 11:55 AM on 10/29/24, it was observed that a large double compartment utility sink was present on the back right wall. Observation of the sink found it dry with dust and debris in the basin. When asked if the sink gets used. MD H stated that its not used or one that is flushed. Further review of the sink found a momentary flow of brown and discolored water that came out of both hot and cold-water lines. Next to the two compartment sink was an eye wash station observed, when asked if this station gets flushed, MD H stated he doesn't get to it often because it doesn't have a drain. Observation found that the eye wash station doesn't have a wastewater line and just drops water onto the floor of the central supply and doesn't gravitate towards the floor drain roughly eight feet away. During an interview with MD H regarding the facilities water management plan, at 12:25 PM on 10/29/24, found that MD H has monthly meetings between the maintenance group, but not too much in house. When asked if there was currently any sampling the facility did, MD H stated no. During a review of the facilities Water Management Program, approved 12/12/23, found that The water management team will consist of at least the following personnel: a. The infection preventions; B. The administrator; c. The medical director (or designee); d. The director of maintenance; and e. The director of environmental services. A Further review of the plan found that The water management program includes the following elements: a. An interdisciplinary water management team; . d. The identification of situations that can lead to Legionella growth, such as: 7. Water stagnation; and 8. Inadequate disinfection. e. Specific measures used to control the introduction and/or spread of legionella ( e.g., temperature, disinfectants); f. The control limits or parameters that are acceptable and that are monitored; g. A diagram of where control measures are applied; h. A system to monitor control limits and the effectiveness of control measures; 1. A plan for when control limits are not met and/or control measures are not effective; and J. Documentation of the program . Through interview and record review of the Water Management Plan, No listed active and ongoing control measures and control limits were found to be documented and in place at this time. Observation of the basement central supply room, at 11:58 AM on 10/29/24, found that a large wastewater line extends from the right side of the ceiling to the left side, and down the left side storage rack (against the wall). Items under the wastewater line were found to be clean and sanitary nursing items used for resident care.

This Citation Pertains to Intake #M00145852 Based on observation, interview and record review the facility failed to provide consistent and accurate activity calendars and failed to provide meaningful, diverse and engaging activity programs for one resident (#30) of three residents reviewed and 6 of 8 residents from confidential group meeting. Resident #30 Review of the clinical record including the Minimum Data Set (MDS) dated [DATE] Resident # 30 (R30) was admitted to the facility on [DATE] with diagnoses that included, major depression, hemipelaigia and hemiparesis. Review of the MDS reflected R30 scored 15 out of 15 (cognitively intact) on the Brief Interview Mental Status (BIMS), further review of the MDS reveled R30 had clear speech and adequate hearing. On 10/27/24 at 11:23 AM, during a bedside interview R30 was observed in bed and reported he was bored as the facility offers little to no activities, R30 reported there had been no Activity Director or Activity Aid in a month and they were employed at the facility for only a short time. R30 reported with the exclusion of bingo there was nothing to do at the facility. R30 elaborated that the activity calendar that is posted in resident rooms was different than the large activity calendar posted in the hallway, which increased confusion as to what if anything was happening on any given day. R30 then stated it was not that big of an issue because most activities on both calendars get canceled anyway. Review of the large activity calendar posted on the main hallway reflected Bingo was to occur on 10/27/24 at 12:00 pm, lunch occurred at 12:00 pm and Bingo was observed at 2:00 pm. On 10/28/24 at approximately 09:30 AM during an interview with Nursing Home Administrator ( NHA) A she reported the facility currently had no activity staff and the Certified Nursing Assistants were filling in. Review of grievances reflected R30 filed a grievance on 7/3/24 that he was not notified of the facility cookout and wasn't given the opportunity to participate. ( There was no resolution documented on form). R30 filed a grievance on 7/13/24 R30 complained scheduled activities over the weekend music and exercise did not happen. R30 filed a grievance on 7/16/24 which reveled an outdoor activity in the afternoon (due R30's medical condition and pain issues being up in a wheelchair needs to be done in short intervals, therefore R30 stayed in bed in the morning and opted to get up in the afternoon to attend the activity and get some fresh air. ) When R30 went to attempt the afternoon outdoor activity, R30 was informed it was held in the morning due to weather. R30 filed a grievance on 7/23, that they were not asked to go on outing - on the findings portion of the form it reflected R30 was not asked to go due to lack of space . R30 filed a grievance on 9/3 that the activity calendar are not followed and not adjusted to reflect any changes that were made. On 10/28/24 at 1:00 pm during the confidential group meeting , 6 of 8 group participants reported being bored with the lack of activities and frustrated with the large wall calendar posted in the hall and the activity calendar handed out to them being different and altered with no notification of changes made. On 10/29/24 at 02:52 PM during an interview with Certified Nursing Assistant (CNA) M she reported being employed at the facility for approximately 2 months and that she works periodically in activities. CNA M stated she was assigned to activities on Sunday (10/27) and again today. CNA M stated there was one CNA assigned to activities daily as there wasn't any activity staff. CNA M acknowledged the activity calendar changes without notice , CNA M elaborated and gave an example such as Men's Program or Cardio Crushers , CNA M stated she didn't know what to do for a lot the activities listed on the calendar so she would substitute things with coloring or ask someone else what to do. CNA M stated she had no training in activities but did not fully understand any of the calendars and was doing the best she could. Further review of the Activity calendar reflected Coffee and Chronicles was to start on 10/29 at 9:00 am, however CNA M's shift does not start until 10:00 am, CNA M reported Coffee and Chronicles didn't start until after 10:00 am when queried how residents were informed of the change in start time, CNA M stated she did not know. Of note, Cardio Crushers was scheduled for 10/29 at 10:00 am , which was when CNA M started her shift and did Coffee and Chronicles, which consisted of going room to room passing out coffee and a chronicle. On 10/29/24 at 03:35 PM, during an interview with NHA A she reported working at the facility for two months and the activity director at that time started a week prior and that the activity assistant was new as well, NHA A reported neither were no longer employed at the facility and reiterated that CNA's were trying to fill the void, NHA A offered no explanation for why the large activity calendar posted in the hall listed different activities and times as the activity calendars that were provided and posted in resident rooms or why either calendar had not been followed.

Based on observation, interview and record review the facility failed to have an emergency tracheostomy readily available for 1 (R9) of 1 resident reviewed for tracheostomy care, resulting in the potential for a delay in needed action in the event of an emergency tracheostomy dislodgement. Findings include: On 10/27/24 at 10:42 AM R9 was observed resting in bed with a relaxed facial expression and breathing quietly through a tracheostomy which appeared intact and clean. Review of the electronic medical record (EMR) revealed R9 had an original admitted [DATE] and a last admitted [DATE]. R9 had the following pertinent diagnoses: Chronic Respiratory Failure with Hypercapnia (breathing difficulty due to a high level of carbon dioxide) and Tracheostomy status (dated 2023). (A tracheostomy is a surgically created opening in the neck for access to the windpipe) On 10/28/24 at 9:25 AM during observation of tracheostomy care and after completion of care, Licensed Practical Nurse (LPN) J searched for the emergency tracheostomy. LPN J searched through the equipment on R9's table at the end of the bed and through drawers below. After 3 minutes of searching the package containing a sterile outer and inner cannula was found. The package did not contain an obturator (a curved rod that helps guide the tracheostomy into the airway). On 10/28/24 at 9:45 AM during interview with LPN J and Director of Nursing (DON) B and Clinical Consultant K the question about the availability of an emergency tracheostomy was answered by the Clinical Consultant K: The emergency tracheostomy will be on the wall within quick reach. On 10/28/24 at approximately 10:15 AM LPN J displayed an orange sign to go up on the wall in R9's room on which the emergency tracheostomy would be taped. Review of the facility policy with a revision date of 1/2/24 and titled Tracheostomy Care states in part, General considerations include: . Maintain a suction machine, a supply of suction catheters, correctly sized cannulas, and an ambu bag easily accessible for immediate emergency care.

Based on interview and record review, the facility failed to revise timely, individualized care plans for one (Resident #25) of 13 residents reviewed for care planning, resulting in the potential for inadequate/inappropriate care and this resident not maintaining or achieving their highest practical physical well-being. Resident #25 (R25) Review of the medical record reflected R25 was an initial admission to the facility on [DATE] with a readmission on 01/08/24. Diagnoses of Diabetes Mellitus with foot ulcer, restless leg syndrome, non-pressure related ulcers of the right foot with necrosis, Peripheral Vascular Disease and Chronic Kidney Disease. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/30/2024, revealed R25 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R25 requires stand by assistance to independent with personal care. During an interview on 10/27/24 at 01:27 PM, R25 stated the facility nurses were not doing the wound vac dressing right. R25 also stated the nurses reported R25 didn't want the wound vac anymore, so the specialty clinic is now sending him to the wound clinic. Record review revealed R25 was receiving care for his diabetic ulcers through the wound clinic, vascular surgeon and Primary Care Provider (PCP). Specialty clinic placed an order for the wound vac to be placed on R25's foot on 06/21/24. Record review did not reveal that this order was implemented. During an interview on 10/29/24 at 09:20 AM, R25 stated that he had the wound vac on this last time for about 2 weeks. R25 stated he had never refused to have the wound vac on or have the dressing changes completed. During an interview and observation on 10/29/24 at 09:43 AM, Registered Nurse (RN) Q performing wound care to R25's right foot. RN Q gowned for enhanced precautions, had the dressing supplies gathered. RN Q cleaned scissor's prior to removing the soiled dressing, softened dressing stuck on the open areas. RN Q stated the wound care provided would be documented under treatment administration record (TAR) section of the orders. Writer asked where the wound vac dressing changes would be documented. RN Q stated when an order was put in the electronic medical record (EMR), it would generate a task to be completed, and new orders show up on medication administer record (MAR) or TAR. Writer could not find the record of performing wound vac dressing changes. RN Q explained the current dressing change process, cleaned with wound cleaner, a dressing that absorbs exudate placed on wound bed, covered with thick absorbent dressing and wrapped with rolled gauze. RN Q used clean technique, hand hygiene completed after removal of soiled dressing, prior to applying the new dressing and finishing the dressing change. Removed PPE appropriately and disposed of trash from the room. During an interview on 10/29/24 at 10:13 AM, RN Q stated R25 was on the wound vac for a short time as she was looking for dates. R25 was on wound vac on 11/20/23-12/08/23, 02/19/24 for 1 day. RN Q stated there was a recent wound vac order from vascular on 09/13/24 to 09/23/24. RN Q was unable to find orders for the wound vac. RN Q went to the DON's office for assistance locating the wound vac orders. PCP saw R25 on 09/23/24 and discontinued the wound vac. DON B also stated R25 was non-compliant with the use of the wound vac to his right foot. Writer asked to see the interventions that were used to work with R25 on his dressings of the right foot. DON B stated they just talked to him. Writer asked if R25 had any updated interventions on the care plan. DON B stated no. During an interview on 10/29/24 at 11:57 AM, R25 stated he had not refused treatment, R25 stated he had been outside and his dressing on the right foot get wet, R25 also stated he may have gotten his dressing wet a time or two but not because he was dragging his foot in the snow or rainwater. R25 stated he was in his wheelchair when he went outside and used the footrest on the wheelchair. R25 stated he doesn't go outside with his walker, as he cannot walk well, working with physical therapy. R25 stated he has had to walk into the bathroom because he didn't have a choice, had to go to the bathroom. During an interview on 10/30/24 at 08:00 AM, Nurse Practitioner (NP) S stated has been concerned about this resident, as she had ordered the wound vac and the facility staff have reasons to not put it on him. NP S stated that she had run into these problems for over a year and his wounds are not healing. NP S stated she felt in the middle because R25 deserves the care he needed, but there was always a reason that the treatment she ordered was not followed, due to the facility coming up with reasons or excuses. NP S stated her orders were not followed or implemented. NP S also stated that R25 can make his own medical decisions on his care, and he had voiced a desire to get better so he can go back to his home. NP S also stated that she was trying to advocate for him but running into barriers. NP S stated there were interventions that could be put in place to assist him, such as a bag over right foot when he goes outside in the rain or snow. NP S stated she was not giving up on him, and she would continue to advocate for him. During an interview on 10/30/24 at 09:58 AM, RN Q stated she did tell the vascular office about his non-compliance. RN Q stated the wound vac was placed on his right foot, but he cannot walk on it. RN Q stated R25 would drag it outside and they would have to change it daily. Writer asked RN Q what interventions they had used to address this concern. RN Q stated she did not document what she educates him on as it was daily, so it wasn't documented with interventions. During an interview on 10/30/24 at 10:11 AM, DON B stated they had educated him on autonomy and do not always document it. DON B stated R25 usually had the socks on over the dressing and didn't allow anything else. Writer asked if they had tried any new or updated interventions to work with R25 on the wound care concerns. DON B stated they had talked to him but didn't write it down. Record review of R25's care plan revealed R25 had not had any new or updated interventions regarding his impaired skin integrity to his right foot since the date of 03/30/23 and was revised during the annual survey dated on 10/29/24.

Based on interview and record review the facility failed to ensure baseline care plans were developed within 48 hours of admission for one of 13 residents (Resident #41) resulting in the potential for unmet care needs. Findings included: Per the facility R41 was admitted to the facility on [DATE]. Diagnoses included dyskinesia (disorder of the esophagus) and dysphasia (difficulty in swallowing). Record review of R41's nutrition care plan revealed that it wasn't until 10/1/2024, six days after R41 was admitted , that a plan of care was put into place. R41's nutritional care plan revealed, presents with potential for nutritional risk related to acute metabolic encephalopathy (brain disease), UTI (urinary tract infection) chronic dysphasia. DX: MDD (diagnosis major depression disorder), anxiety, seizures, CKD (kidney disease) HLD increase lipids), chronic gastritis, vit D deficiency, hypothyroidism, sarcopenia (loss of muscle/strength). Mechanically altered diet affecting her oral intake. Date Initiated: 10/01/2024. R41's care plan was very specific to her nutritional care needs. Record review of R41's Physician orders revealed R41 was ordered to take: ARIPiprazole Oral Tablet 10 MG (Aripiprazole) Give 1 tablet by mouth one time a day for Depression, dated 9/24/2024. Celexa 1 mg one time a day for depression, ordered on 9/24/2024. RisperiDONE Oral Tablet 1 MG (Risperidone) Give 1 tablet by mouth one time a day for Bipolar affective disorder, dated 9/25/2024. QUEtiapine Fumarate Oral Tablet 100 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for Bipolar affective disorder, dated 9/24/2024. Review of R41's care plans revealed that a plan of care was not developed and implemented until 10/7/2024 regarding R41's psychotropic, antianxiety, nor antidepressant medications that were ordered for R41 to take on a daily basis. The care plan that was developed on 10/72024 revealed R41 received psychotropic (or psychotropic like medication) and was at risk for adverse side effects antianxiety, antidepressant, antipsychotic Date Initiated: 10/07/2024. Review of R41's Medication Administration Record (MAR) for the month of September 2024 revealed R41 did received the ordered doses of Celexa, Aripiprazole, Seroquel, Risperidone, and Klonopin, starting on 9/24/2024, and therefore would have had a need for a plan of care starting 9/24/2024. In an interview on 10/29/2024 at 9:20 AM, Director of Nursing (DON) B stated that within 24 hours of a resident being newly admitted baseline care plans were to be developed and the resident or the resident representative were to receive a copy. Requested DON B to provide documentation or a copy that R41 had baseline care plans developed and implemented within 48 hours of admission on 9/24/2024, and that R41's guardian received a copy. In another interview on 10/29/2024 at 11:56 AM, DON B stated that she was not able to find any documentation or copies that baseline care plans were developed or provided to R41's guardian.

Based on interview and record review, the facility failed to ensure the Preadmission Screening (PAS)/ Annual Resident Review (ARR) form for Mental Illness (MI)/ Intellectual Disability (ID)/ Related Conditions Identification (DCH-3877) document was timely completed and sent to the local state agency for an evaluation for a Level II determination for one residents (R18) of one residents reviewed for PASARRs. Findings include: Findings include: On 10/28/24 at 10:30 AM R18 was observed sitting in a wheelchair in the hallway; greeting staff and residents by name as they came by. Review of the Electronic Medical Record (EMR) revealed R18 had an original admitted [DATE]. R18 had the following diagnoses: Quadriplegia (a paralysis that affects all limbs), Schizoaffective Disorder; Bipolar Type (a psychotic condition which causes fluctuation of mood), Major Depressive Disorder, Anxiety Disorder, and Dementia (a chronic condition that causes a decline in mental abilities). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/5/24 revealed R18 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). EMR review further revealed that R18 had a care plan addressing episodes of disturbing behavior - sexually explicit and angry comments and reactions. On 10/25/24 a Behavior Management Review was completed with documentation that R18's behavioral/mood symptoms were worsening. On 10/28/24 04:34 PM during interview with the Social Worker (SW) D and Assistant Director of Nursing (ADON) C the Level I PASARR completed in 2023 was discussed which documented the mental illness and dementia diagnosis. Based on the diagnoses the Level II PASRR was excluded. When asked if there had been a reevaluation the ADON C explained R18 did not have a guardian which was being worked on and would be needed. On 10/29/24 1:10 PM the Nursing Home Administrator (NHA) A said that the Behavioral Health team had scheduled an appointment for 10/30/24 to perform a reassessment of R18's dementia diagnosis. On 10/30/24 08:19 AM Social Worker (SW) D was interviewed and said Prior to today it is true he didn't get a reassessment of his dementia. He has a BIMS of 15. We know that. He has consistent behaviors. Social Worker (SW) D also added, Maybe we've just been going along with motions of what was determined last year and now he isn't there anymore. We need to look at where he is today. According to an online article posted by the Department of Human Services titled Level II Mental Health Preadmission and Resident Review Basics states in part that significant changes trigger a resident review such as . a decrease or clearing of dementia or delirium which may allow the person to benefit from mental health services.

Based on observation, interview and record review the facility failed to provide a written copy to one (Resident #20) of two residents reviewed for bed hold notification in a language that was understandable, resulting in potential for lack of understanding and knowledge for and what the bed hold policy entailed. Findings include: Resident #20 (R20) Review of the medical record reflected R20 was an initial admission to the facility on [DATE] with a readmission on 01/24/24. Diagnoses of Parkinsons Disease, Diabetes Mellitus, Dementia, Cardiac Arrhythmias, Anxiety, Chronic Pain and weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2024, revealed R20 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R20 requires minimal assistance with personal care. During an interview on 10/27/24 at 12:27 PM, R20 stated the last time she was in the hospital, she was admitted with a urinary tract infection (UTI), and the other time she fell and was hospitalized . Record review revealed R20 was hospitalized for UTI and Hypoxic (low oxygen in her system). Facility staff documented she was more lethargic and less talkative than usual. Writer could not find a hospital discharge/transfer notice for this hospitalization in her medical record. Record review also revealed R20 was sent out to the hospital after she was found diaphoretic (excessive sweating) and unresponsive. R20 was admitted and treated for metabolic encephalopathy (lack of oxygen or glucose sugar in her blood) related to UTI. Writer could not find a hospital discharge/transfer notice for this hospitalization in her medical record. During an interview on 10/29/24 at 02:35 PM via email, writer requested the bed hold/transfer/discharge for hospitalization for both March/April 2024 hospitalization . On 10/29/24 at 03:00 PM, writer received via email a bed hold/transfer/discharge with R20 demographic information, with no date or signature on the form. This form was not part of the medical record prior to asking for it. During an interview and observation on 10/29/24 at 03:31 PM, R20, she stated she had never seen that form before. R20 also stated she was not given any forms when she went in to the hospital in March 2024 and April 2024.

Based on observation, interview and record review the facility failed to provide a written copy to one (Residents #20) of two residents of the reason for transfer/discharge to the hospital in a language that was understandable, resulting in potential for lack of understanding and knowledge. Findings Include: Resident #20 (R20) Review of the medical record reflected R20 was an initial admission to the facility on [DATE] with a readmission on 01/24/24. Diagnoses of Parkinsons Disease, Diabetes Mellitus, Dementia, Cardiac Arrhythmias, Anxiety, Chronic Pain and weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2024, revealed R20 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R20 requires minimal assistance with personal care. During an interview on 10/27/24 at 12:27 PM, R20 stated the last time she was in the hospital, she was admitted with a urinary tract infection (UTI), and the other time she fell and was hospitalized . Record review revealed R20 was hospitalized for UTI and Hypoxic (low oxygen in her system). Facility staff documented she was more lethargic and less talkative than usual. Writer could not find a hospital discharge/transfer notice for this hospitalization in her medical record. Record review also revealed R20 was sent out to the hospital after she was found diaphoretic (excessive sweating) and unresponsive. R20 was admitted and treated for metabolic encephalopathy (lack of oxygen or glucose sugar in her blood) related to UTI. Writer could not find a hospital discharge/transfer notice for this hospitalization in her medical record. During an interview on 10/29/24 at 02:35 PM via email, writer requested the bed hold/transfer/discharge for hospitalization for both March/April 2024 hospitalization . On 10/29/24 at 03:00 PM, writer received via email a bed hold/transfer/discharge with R20 demographic information, with no date or signature on the form. This form was not part of the medical record prior to asking for it. During an interview and observation on 10/29/24 at 03:31 PM, R20, she stated she had never seen that form before. R20 also stated she was not given any forms when she went in to the hospital in March 2024 and April 2024.

Based on observation, interview and record review the facility failed to ensure required transfer and discharge documentation was completed for one (Resident #20) of two residents reviewed for discharge. Resulting in the potential for ineffective or mismanaged continued care, as care plan goals were omitted from the transfer paperwork. Findings include: Resident #20 (R20) Review of the medical record reflected R20 was an initial admission to the facility on [DATE] with a readmission on 01/24/24. Diagnoses of Parkinsons Disease, Diabetes Mellitus, Dementia, Cardiac Arrhythmias, Anxiety, Chronic Pain and weakness. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/12/2024, revealed R20 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R20 requires minimal assistance with personal care. During an interview on 10/27/24 at 12:27 PM, R20 stated the last time she was in the hospital, she was admitted with a urinary tract infection (UTI), and the other time she fell and was hospitalized . Record review revealed R20 was hospitalized for UTI and Hypoxic (low oxygen in her system). Facility staff documented she was more lethargic and less talkative than usual. Writer could not find a hospital discharge/transfer notice for this hospitalization in her medical record. Record review also revealed R20 was sent out to the hospital after she was found diaphoretic (excessive sweating) and unresponsive. R20 was admitted and treated for metabolic encephalopathy (lack of oxygen or glucose sugar in her blood) related to UTI. Writer could not find a hospital discharge/transfer notice for this hospitalization in her medical record. During an interview on 10/29/24 at 02:35 PM via email, writer requested the bed hold/transfer/discharge for hospitalization for both March/April 2024 hospitalization . On 10/29/24 at 03:00 PM, writer received via email a bed hold/transfer/discharge with R20 demographic information, with no date or signature on the form. This form was not part of the medical record prior to asking for it. During an interview and observation on 10/29/24 at 03:31 PM, R20, she stated she had never seen that form before. R20 also stated she was not given any forms when she went in to the hospital in March 2024 and April 2024.

This citation pertains to complaint #MI00132727. Based on observation, interview and record review, the facility failed to follow physician's orders and perform a wound vacuum (vac) dressing change within standards of practice for two out of three residents, resident's #22 and #3 (R22 and R3), failed to identify, provide timely treatment and appropriate care and services to meet the needs of one resident out of one resident (R#22). Resident 3 (R3) Review of the medical record reflected R3 was an initial admission to the facility on [DATE], readmitted on [DATE] with diagnoses of non-pressure chronic ulcer of unspecified part of the right lower leg with unspecified severity and venous insufficiency and unspecified intellectual disability. During an interview on 05/16/23 at 08:17 AM, Wound Clinic Program Director (WCPD) M stated that R3 would come to his appointments at the wound clinic and his wound vac dressing would have not been changed as ordered, wound vac canister was full and backed up into the tubing. R3's wound vac dressing was stuck to the wound bed due to not following the orders and instructions for cutting the black foam smaller than the actual wound size. WCPD M stated that the facility nurses were not using the correct type of dressing, added the facility nurses were not following their doctors' orders, and had called the facility and discussed this with the nursing management team multiple times. During an interview on 05/16/23 at 08:25 AM, Wound Clinic RN Case Manager (WCRNCM) L stated that R3 would come into the wound clinic, the dressing was not applied appropriately, the black sponge was overlapping the healthy skin, the drape/clear adhesive dressing was too tight. Also stated the facility nurses did not change the wound vac canister timely and it was leaking out of the canister. R3 would report to WCRNCM L that on Monday when he needed the wound vac changed, that the facility nurse would tell him the dressing was already changed, however when he got to the wound clinic, he would have more than 2 days drainage on the dressing, wound drainage down into R3's shoes. WCRNCM L called the DON B regarding these concerns. Things got better for about a week then back to the old pattern. Review of the complaint information revealed a new wound due to wound vac dressing changes not completed correctly, the black sponge was overlapping the healthy tissue and breaking down. The clear adhesive dressing also known as a drape was on too tight, like a tourniquet, not applied correctly. The 2-layer compression wrap was also too tight and created a pressure wound on his left leg interior to the original wound. Additionally, facility did not empty his canister timely, and drainage was leaking out of the cannister, tubing backed up, draining onto R3 clothes and into his shoes. The medication/treatment administration record (MAR) had blank holes in the monthly report reflecting missed wound care treatments with no explanation as to why they were not done. During an interview on 05/16/23 at 01:45 PM, DON B stated R3 wanted to stop going to the wound clinic, and no longer wanted the wound vac, so he switched to the Wound Nurse Practitioner that comes to the facility. DON B denied having any conversations with the wound clinic staff regarding R3's wound vac dressing changes being a concern or dressing applied not being what the wound clinic ordered. Record review of the treatment administration record (TAR) revealed R3 did not have his wound vac dressing changed on 10/14/22, 10/28/22, 12/7/22 by the facility nurses. During an interview and observation on 05/16/23 at 03:56 PM, R3 stated that he likes to remove the dressing on his left leg himself because he was used to the pain from dressing removal, and that pain makes his right leg shake. Also stated it took him up to a half hour to remove the dressing because it stuck to the wound and cause bleeding. R3 stated he had been removing his own wound care dressing for years. Writer asked him if the nursing staff showed him how to remove it without causing it to bleed or take off new tissue growth, R3 stated no. R3 observed not moistening the wound dressing prior to removing dressing which caused bleeding and removal of healthy tissue. R3 observed wearing gloves to remove the dressing but would touch his feet and arm and then touched the wound bed. During observation, R3 did not follow basic wound care infection control measures. During an interview on 05/17/23 at 08:45 AM, LPN K stated she was not wound care certified. Writer asked if any of the nurses in the facility were wound certified and she stated no. Writer asked who taught the facility nurses to do wound care and wound vac dressing changes, LPN K stated she taught the stronger nurses, and they taught each other. Writer asked why R3 wound vac was discontinued, LPN K stated it was because the wound increased in size. Also stated it was because the black sponge was not being cut small than the actual wound size, overlapped on the healthy tissue and breaking down any new granulation. During an interview on 05/17/23 at 02:30 PM, previous Assisting Director of Nursing (ADON) N, stated she used to make rounds with the wound NP and assist with dressing changes, adding whatever the NP wanted for dressing changes, she would apply it. LPN N stated it was her job to put in the wound care orders. When asked about competencies of the floor nurses to do wound care according to the facility policies, LPN N stated the floor nurses would teach each other to do dressing changes. Writer asked if she was wound certified, she stated no. Writer asked if anyone in the building was wound certified, she stated no, not that she knew of. Resident 22 (R22) Review of the medical record reflected R22 was an initial admission to the facility on [DATE] with diagnoses of Type 1 Diabetes Mellitus with Foot Ulcer, Type 1 Diabetes Mellitus with Diabetic Neuropathic Arthropathy and Charcot's Joint right ankle and foot. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/13/2023, revealed R22 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. Observation and interview on 05/18/23 at 09:15 AM NP J and LPN K provided wound care and wound vac change for R22. Writer noted a strong odor entering the resident's room walking toward the residents' bed. Observation of white 4x4 gauze dressing taped over the wound vac dressing at the wound vac suction disc placement. R22 stated he had covered it himself yesterday due to the foul smell coming from the wound. Also stated the nurse yesterday did not think it was bad enough to complete a wound care dressing change. R22 also stated the nurses are not doing the dressing appropriately. NP J removed the soiled dressings and threw them in the trash at bedside. Writer was overcome by the strong malodorous smell from the dressing and wound. NP J cleansed the wound with a normal saline wound wash, then used Dakin's solution (Dakin's solution is a strong topical antiseptic wound wash used to clean infected wounds, ulcers or burns) to clean the wound, then cleaned with normal saline again. R22 had a hard time holding his right leg up to complete the dressing change so he rested his right foot on the bedframe at bottom of the bed. No barrier was used between the bed and the resident's foot. LPN K had to go back and forth to the treatment cart to gather gloves and wound care supplies to be used, did not have needed items brought into the room initially. During observation NP J and LPN K was not observed performing hand hygiene between glove changes. NP J measured the length and width, but not the depth of the wound. Observation of dry flaky skin on the bottom of his foot surrounding the wound. LPN K used the soiled scissors that NP pulled from his lab coat pocket not cleaned from last dressing change, to cut the clear adhesive dressing/drape for the first layer over the black foam sponge in the base of the wound bed. NP J did not use a skin barrier wipe around the outside of the wound to ensure the dressing would safely stick to the skin (barrier wipes are part the dressing change). NP J cut a small slit in the clear adhesive dressing over the black sponge to allow the suction/disc/ tubing to be placed directly over it. NP J then removed the canister from the wound vac machine, replaced it and threw the old one in the trash can. NP J set the canister apart from the machine on the floor trying to figure out how to get it back in the machine. LPN K assisted with replacement of the canister. NP J did not apply the second clear adhesive over the entire dressing on the wound to ensure the dressing was intact and securely in place (part of the wound vac dressing kit). R22 asked NP J to wrap something around the wound so when he got up to walk, he would not pull on the tubing attached to the wound vac. NP J wrapped a Kerlix dressing around the whole foot, blocking observation of the wound through the clear dressing. NP J put the soiled scissors back in his lab coat pocket. All remaining dressing that was not used, LPN K took back to the treatment cart and put them back in the drawer with the other new clean dressings. Discrepancies observed from observation of wound care and the policy on wound care. During an interview on 05/22/23 at 09:30 AM, R22 stated they did not change his wound vac dressing change on Saturday (05/20/23) like it was ordered. Writer asked if nursing had been in yet today to change it, R22 stated no. R22 stated he told the nurse he needed it change because it didn't get done on Saturday, and she told him it wasn't due to be changed on Monday. Day nurse printed off the wound vac dressing change schedule and gave it to R22. R22 stated he still requested it to be changed and the nurse would not change it. During an interview and observation on 05/22/23 at 11:16 AM, R22 stated the nursing staff did not send his wound vac dressing supplies with him to the wound clinic on 05/19/23. Wound Clinic Nurse O told R22 his wound should not smell like it did. R22 also stated the wound care nurse O had to wrap it up until he got back to the facility so the nurse could put the wound vac dressing back on, due to not having the needed supplies from the facility sent with him to his appointment. Record review of weekend calendar revealed Registered Nurse (RN) P worked on R22's hallway on Saturday (05/20/23) and the MAR under date of 05/20/23 it was documented to see nursing progress note, wound vac dressing change treatment was not provided. Record review of the treatment administration record (TAR) also revealed R22 did not get his wound vac dressing changed on 05/16/23, 05/18/23 or 05/20/23. During an interview on 05/23/23 at 08:30 AM, Unit Manager (UM) I stated R22 was sent to the hospital during the night per his request. Writer asked why he requested to go, UM I stated, apparently, he had a rash on his leg. Writer asked what the nurse reported about the rash. UM I stated, well I assume one of the nurses looked at it. Added she knew about it when she read the 24-hour report. Also stated she would look R22 up in epic (hospital's medical record) during their 09:00 AM morning rounds meeting. During an interview on 05/23/23 at 08:45 AM, DON B stated R22 was admitted to the hospital with cellulitis, treated with IV antibiotics, wound cultures were positive. Writer asked for a copy of the hospital admission record for R22. DON B also stated R22 told the night nurse that he had talked to the day nurse S and NP R on 05/22/23 about his rash and swelling on the right leg. During an interview on 05/23/23 at 11:20 AM, NP R stated she saw R22 on 05/22/23 and R22 told her he thought his leg was getting infected again, it was warm to the touch and had a rash. NP R also stated R22 denied chills, fever so recommended he have labs drawn. When asked why she did not look at his leg, she stated, He was like, hey my leg hurts, check it out, so vague. NP R stated she told DON B to have his labs drawn today. Writer asked again for clarification of bedside visit on 05/22/23, NP R stated she did not assess his right leg during this visit. R22 had to advocate for himself to seek treatment from the hospital. Record review revealed R22 did not have labs drawn on 05/22/23 when ordered. During an interview on 05/23/23 at 12:35 PM, LPN S stated she was the day nurse working on 05/22/23. R22 was upset because he wanted his wound vac dressing changed and today was not his scheduled day. LPN S printed off the schedule of when he got wound vac dressing changes and gave to him. LPN S stated, R22 told her he had blotches down his leg, and it was swollen, and he was concerned. LPN S also stated she looked at his right leg by his groin and it was swollen but she was not concerned. R22 told her he wanted to go to the hospital, so she notified the NP via tiger text (communication text), called DON B and sent him to the hospital. During an interview on 05/23/23 at 12:48 PM, Registered Nurse (RN) P stated she did not change the wound vac dressing on Saturday 05/20/23 as ordered because it was changed the day prior. Writer asked if she verified the orders for the wound vac dressing changes for Tuesday, Thursday and Saturday, RN P stated no, she received the information during shift change. Also added that she looked at the dressing and it was dry and intact. RN P did not follow physicians' orders to change the wound vac dressing on 05/20/23. Record review of the nursing progress notes did not reveal documentation from the day nurse S or NP R regarding R22's concern regarding his right leg concern. No documentation from NP P showing this visit.

This citation pertains to intake numbers MI00132727 and MI00135356. Based on observation, interview, and record review the facility failed to ensure two out of four residents (Resident #3 and 18) received appropriate care and treatment for pressure ulcers (PU) resulting in the development of pressure ulcers. Findings Included: Resident #18 (R18): Per the facility face sheet R18 was admitted to the facility on [DATE]. Review of a Pressure Ulcer-Weekly Observation-V 2 assessment dated [DATE], revealed R18 had a pressure ulcer to his outer right ankle that measured 2.1 x 3 x 0 (length, width, and depth). The assessment revealed that the PU was acquired while R18 was a resident at the facility. The PU was documented to be unstageable (not able to visualize the bed of the wound due to slough, which is a white/yellow material in that can obstruct the view of the wound bed). The assessment revealed, under 5a, e, First Observation . of the wound, had no odor, but infection was suspected due to redness, swelling, and pain. Review of another Pressure Ulcer-Weekly Observation-V 2 assessment dated [DATE], revealed that the same wound, right outer ankle measured 2.5 x 3 x 0, was unstageable, had slough in the wound, necrotic tissue (dead blackened tissue), and was unchanged from the 4/20/2023 assessment. The assessment also revealed that 75% of R18's PU wound was covered with slough and/or necrotic tissue and had a foul odor. The documented treatment for R18's PU wound was, medihoney (used to remove dead tissue), calcium alginate (encourages wound healing), optilock (dressing for covering the wound), and kerlix (another dressing). Review of a Pressure Ulcer-Weekly Observation-V 2 assessment dated [DATE], revealed R18's PU wound measured 2.2 x 2.5 x 0, was facility acquired, unstageable, improving, had new tissue growth, and was not checked to have and slough or necrotic tissue. The assessment also revealed that R18's dressing treatment was changed from using Medihoney to Santyl (also used to remove slough or damaged tissue from the wound). Upon review of R18's Electronic Medical Record (EMR) no Pressure Ulcer-Weekly Observation-V 2 assessment was found for the week of 4/23 through 4/29/2023. Director of Nursing (DON) B was requested to provide all R18's skin assessments, in which DON B also provide all of R18's Pressure Ulcer-Weekly Observation-V 2 assessments. No assessment for the week of 4/23 through 4/19/2023 was provided. In an interview on 5/17/2023 at 3:08 PM, R18 stated that the wound on his outer right ankle was new approximately three weeks ago. R18 stated that the Velcro on his diabetic shoe was too tight. In an interview on 5/18/2023 at 10:23 AM, Nurse Practitioner (NP) J stated that he had observed R18's right outer ankle. NP J stated that he observed the wound to have slough, which covered 80% of the wound bed. NP J stated that R18's right outer ankle wound was unstageable, because if any slough was observed in the wound bed, then the wound was not stageable. NP J said he was not sure how R18 developed the right outer ankle PU. NP J then stated that the wound was probably a diabetic wound (not pressure related) but was on a bony prominence (area of bone that is close to the skin's surface and where pressure ulcers commonly develop). NP J said he was documenting R18's right outer ankle wound as a non-pressure ulcer. NP J was asked why the depth of the wound was not measured. NP J stated that the depth of the wound should be measured with the length and width measurements using a Q-tip. In an interview and observation on 05/16/23 at 09:45 AM, LPN T was observed to perform wound care on R18. LPN T used the same gauze to clean the both of R18's wounds. Furthermore, LPN T was observed to pick up the container of Santyl ointment which had fallen onto the floor, and place it back on the over the bed table where LPN T had a barrier with clean wound care supplies. During an observation and interview with NP J and Licensed Practical Nurse (LPN) K on 5/18/2023 at 8:30 AM of R18's weekly wound assessment, revealed R18 had an open wound to his right lateral ankle. The wound was observed to be measured at 2.5 x 2.0 by NP J however, NP J did not measure the depth of R18's would. Upon NP J removing the old dressing it was observed that the wound bed was visible with approximately 25% slough at the top right corner of the wound additionally, the wound was observed to have depth to it, and observed to be a stage 3 wound. LPN K stated that R18's wound was possibly caused from the shoe he wore and said R18 would take on and off his shoe himself and put the Velcro on to tight, but then stated that she did not know what caused the PU. During the same observation NP J was observed to pull scissors out of his lab coat, cut off dressing, and put soiled scissors back in this pocket. LPN K placed the dressing supplies on top of R18's over the bed table that was observed to also have R18's belongings. LPN K did not put a barrier down on the table to place the dressing supplies onto. NP J was observed to open a container of Santyl and place it on R18's bed but did not replace the cap on the container. NP J did not use hand sanitizing or cleanse hands between glove changes. It was also observed that left over dressings, that had been placed onto R18's over the bed table, were taken out of R18's room and put back into the treatment cart that was in the hallway. NP J was observed to used the same gauze pad to clean two different wounds R18 had. Record review of NP J's wound progress notes revealed that on 4/20, 5/4, and 5/11/2023, R18's right outer ankle was documented to be a chronic (been present a long time) non-pressure ulcer, however, was also documented to be unstageable. Review of R18's Treatment Administration Record (TAR) for the month of May revealed a treatment order for R18 right outer ankle wound dated 5/3/2023, Treatment to right lateral ankle: Cleanse with half strength dakins (sig) (used to clean wounds) solution (sig), pat dry, apply midhoney (sig) then calcium alginate Ag (a dressing that promotes healing) to fit wound bed, cover with optilock and wrap with kerlix. every day shift. The TAR revealed that on 5/4, 5/5, 5/6 and 5/10/2023 there were nurses initials that indicated the treatment was completed for R18's right outer ankle wound. Per the CMS's RAI (Resident Assessment Instrument) Version 3.0 Manual, page M-8, If the wound bed is only partially covered by eschar (a scab) or slough, and the anatomical depth of tissue damage can be visualized or palpated, numerically stage the ulcer, and do not code this as unstageable. 45135 Resident 3 (R3) Review of the medical record reflected R3 was an initial admission to the facility on [DATE], readmitted on [DATE] with diagnoses of non-pressure chronic ulcer of unspecified part of the right lower leg with unspecified severity and venous insufficiency and unspecified intellectual disability. During an interview on 05/16/23 at 08:17 AM, Wound Clinic Program Director (WCPD) M stated that R3 came to his appointments at the wound clinic and his wound vac dressing would have not been changed as ordered, wound vac canister was full and backed up into the tubing. R3's wound vac dressing was stuck to the wound bed due to not following the orders and instructions for cutting the black foam smaller than the actual wound size. (WCPD) M stated that the facility nurses were not using the correct type of dressing, adding the facility nurses were not following their doctors' orders, and had called the facility and discussed this with the nursing management team multiple times. During an interview on 05/16/23 at 08:25 AM, Wound Clinic RN Case Manager (WCRNCM) L stated that R3 came into the wound clinic, the dressing was not applied appropriately, the black sponge was overlapping the wound bed on to the healthy tissue, the drape/clear adhesive dressing was placed too tight. Also stated the facility nurses did not change the wound vac canister timely and it was leaking out of the canister. R3 would report to WCRNCM L that on Monday when he needed the wound vac changed, that the facility nurse would tell him the dressing was already changed, however when he got to the wound clinic, he would have more than 2 days drainage on the dressing, wound drainage down into R3's shoes. WCRNCM L called the DON B regarding these concerns. Things got better for about a week then back to the old pattern. WCRNCM L stated that once the facility got a wound nurse, R3 stopped coming to the wound clinic. During an interview on 05/16/23 at 01:45 PM, DON B stated R3 wanted to stop going to the wound clinic, and no longer wanted the wound vac on, so he switched to the wound Nurse Practitioner that comes to the facility. DON B denied having any conversations with the wound clinic staff regarding R3's wound vac dressing changes being a concern or dressing applied not being what the wound clinic ordered. Record review of the treatment administration record (TAR) revealed R3 did not have his wound vac dressing changed on 10/14/22, 10/28/22, 12/7/22 by the facility nurses. Wound clinic identified a new wound on 12/29/22 due to wound vac dressing changes not completed correctly, the black sponge was overlapping the healthy tissue breaking it down. The clear adhesive dressing also known as a drape was put on too tight, like a tourniquet, not applied correctly. The 2-layer compression wrap was also too tight and created a pressure wound on his left leg interior to the original wound. The medication/treatment administration record (MAR) had blank holes in the monthly report reflected missed wound care treatments with no explanation as to why they were not done.

This citation pertains to intake MI 147. This tag has two deficient practice statements. A. Based on interview and record review, the facility failed provide intravenous medication as ordered and respond to critical laboratory findings for 1 of 1 resident (R37) reviewed for intravenous medication usage, resulting in R37's medical needs not being addressed timely and the potential for a life-threatening infection to become resistant to treatment. Findings include: Review of R37's face sheet dated 8/30/22 revealed he was [AGE] year-old male admitted to the facility on [DATE] due to [CONDITION(S)] (a life-threatening complication of an infection). Other pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R37 was his own responsible party. Review of R37's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R37's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/10/22 the box for 1300 )1:00 PM) was marked 9, indicating the medication was not given, on 8/11/22 the box for 0500 (5:00 AM) was blank, indicating that the medication was not given, on 8/13/22 the boxes for 1300 and 1700 (5:00 PM) were marked 9 indicating two doses were not given, on 8/14/22 the box for 1300 was marked 9 indicating the dose was not given, on 8/17/22 the box for 1700 was blank, indicating that the dose was not given (R37 missed 6 doses of IV antibiotic treatment from 8/10/22 to 8/17/22). Review of R37's laboratory report for 8/16/22 revealed R37's White Blood Cell count (WBC- measures immune response to infection) was 18.7 (normal WBC is between 4.0 and 11.0). On 7/26/22 his WBC count was 19.7, on 8/4/22 it was 13.0, on 8/11/ 22 it was 13.6 (increased slightly after missing one dose on IV medication) and on 8/16/22 it was 18.7 (increased again after missing 5 doses of IV medication). Review of R37's progress note dated 8/17/22 at 12:04 PM revealed a Licensed Practical Nurse (LPN) attempted to notify R37's Nurse Practitioner (NP) of laboratory results from 8/4/22 and 8/11/22 and did not get a response. The LPN was now notifying R37's physician directly about laboratory work from 8/4/22 to 8/16/22. The note did not indicate if the LPN got any response from R37's physician. Review of R37's electronic medical records did not reveal any notes that indicated the facility had notified R37's physician that R37 had missing 6 doses of IV antibiotic and R37's WBC had been increasing since he had missed these doses of IV antibiotic. During an interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 8/29/22 at 1:30 PM, R37's IV antibiotic orders, laboratory findings and MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON and NHA were unable to locate any information that indicated R37's physician was aware of him missing several doses of IV antibiotic and/or his WBC count was increasing. The DON and NHA attempted to reach out to R37's physician, but R37's physician could not be reached. The NHA called the Medical Director to review R37's medical needs. The NHA and DON were asked if they were aware of the reason for R37 missing multiple doses of IV antibiotic and the NHA said she was not aware of the reason for the missing doses. The DON said she just started as the DON on 8/24/22 and had not been made aware of R37's missing doses of medication until now. Upon exit no reason was provided for missing doses of IV antibiotics for R37. Deficient Practice Statement B Based on observation, interview and record review the facility failed to assess and monitor impairments in skin integrity for 4 residents (R26, R32, R92, and R343) reviewed for skin impairment. This deficient practice resulted in identified skin impairments going unassessed and unmonitored for R26, R32, R92, and R343 with the potential for non-healing and infection to occur. Findings include: The facility provided the policy/procedure for Skin Management dated October 2019 for review. The policy reflected, 1. Alterations in skin integrity will be reported to the physician/NP (Nurse Practitioner) and responsible party/family. 2. Treatment order will be obtained. 3. All alterations in skin integrity will be documented in the medical record a) Residents admitted or readmitted with alterations in skin integrity will be documented on admission evaluation. b) All newly identified areas after admission will be documented on the weekly pressure/non-pressure evaluation. 4. The wound nurse (licensed nurse assigned responsibility for wounds for the building) will be notified of alterations in skin integrity . R26 Review of R26's face sheet dated 8/24/22 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26 had a guardian in place. On 8/24/22 at 9:00 AM, Certified Nurse Aide (CNA) O removed R26's soiled sock from her right foot. There was no sign of any dressing. R26 was bleeding between the 4th and 5th toes. Along with the blood there was a white milky liquid. CNA O asked Licensed Practical Nurse (LPN) N to come look at R26's foot. LPN N said she thought R26's foot had healed, and she would have to call the doctor to get treatment orders. LPN N returned a few minutes later and said she was mistaken there were orders to treat the wound on R26's right foot. Then LPN N cleaned the wound and applied medicated powder and placed a clean sock back on R26's right foot. Review of R26's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . signs and symptoms of infection. Review of R26's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Then apply [MEDICATION(S)], calcium alginate and wrap. Review of R26's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Then apply antifungal powder leave open to air can put sock on. Every day Review of R26's physician note dated 5/12/22 revealed, Visit Type: Wound Care, Right 5th toe, Physical Exam, NPU (non-pressure ulcer): 1 x 1.3 x 0.1. There was no indication of cause or treatment ordered. Review of R26's medical record revealed no other physician notes that addressed the wound on R26's right foot. Review of R26's weekly nursing summary dated 8/16/22 at 11:30 AM, revealed R26 had an open area on right toes (no measurement noted or specific location). On 8/25/22 at 10:44 AM, the Surveyor asked the Nursing Home Administrator (NHA) for all physician notes, orders, treatments, measurements and guardian notification for the wound on her right foot between her 4th and 5th toe. The NHA was unable to locate any verification that R26's guardian was aware of the wound. Weekly wound documentation rarely documented the size or location of the wound on the right foot. There were no other notes found from R26's physician that indicated the wound was being followed by a physician. R343 Review of R343's face sheet dated 8/29/22 revealed R343 was a [AGE] year-old female that was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R343's care plan dated 8/13/22 revealed, Resident has impaired skin integrity, date Initiated: 8/13/22, Revision on 8/24/22. Interventions included: Assist x 1 staff with bed mobility to turn and reposition routinely, pressure reducing/redistributing mattress on bed, wound treatment as ordered. All interventions were dated, 8/13/22. Review of R343's admission assessment dated [DATE] revealed under skin assessment, No open wounds. R343 was observed in lying on her back in bed with her head elevated on 8/22/22 at 11:42 AM. R343 complained of her buttock (butt) hurting. R343 was observed lying on her back in bed with her head elevated on 8/25/22 at 1:00 PM. R343 was not able to remember the last time she was cleaned up or turned and complained of a painful buttock. The Surveyor was not able to locate any caregivers on the unit and asked Registered Nurse Consultant (RNC) Q and the Director of Nursing (DON) to assist R343 to roll in bed so the Surveyor could observe R343's buttocks. R343 reported she could assist with rolling in bed if she was provided bed rails. RNC Q and the DON rolled R343 on side. R343 had a urinary catheter in place for urine collect. The mattress was approximately 5 inches thick and firm foam (not a pressure reducing/redistributing mattress). R343 appear to have completely compressed the foam in the area of her buttock when sitting up in bed. When R343 was turned on her side the sheet was wet under her entire buttock. The sheet had red blood spots and dead skin on the sheets and covering the skin on her back side. A very foul odor was present when she was turned. After this observation, the surveyor requested documentation of skin checks, turning schedule, wound treatment and care schedule. Upon exit no information was provided to indicate R343 had any known skin breakdown, was being assisted to turn every 2 hours, or was receiving care for wounds on her buttock. Resident #92 (R92) Review of the Face Sheet revealed R92 admitted to the facility on [DATE] and was her own responsible party. R92's admission assessment reflected she was cognitively intact and admitted from the hospital following a surgical repair of a [CONDITION(S)]. According to the hospital discharge summary dated 8/12/22 reflected, Incision Care: Your dressing should stay in place until you're instructed to remove it. If there is drainage touching 3 or more edges of the absorbent pad of the dressing, please call the Ortho Office .This dressing is waterproof, it is OK to shower . According to the care plan for Impaired Skin Integrity due to a recent orthopedic surgery of the right hip dated 8/13/22, staff were to assess and document skin condition, notify MD of signs of infection and wound treatment as ordered During an observation and interview on 8/24/22 at 11:20 AM, R92 was observed resting on her bed wearing pants (the right hip dressing could not be observed). R92 stated that staff had not changed her dressing since she arrived on 8/12/22 and did not know what the incision looked like at this time. Review of the Order Recap Report dated 8/22/22 did not reflect an order to monitor the right hip dressing for saturation. Review of the Treatment Administration Record for August 2022 did not reflect an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The progress notes did not reflect an assessment of the dressing or surgical site. Resident #32 (R32) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed Resident #32 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 14 out of 15 which represents Resident #32 was cognitively intact. During an interview and observation on 8/25/22 at 10:35 AM, the Director of Nursing changed R32's dressing with the assistance of the Assistant Director of Nursing (ADON). Without cleaning and prepping a clean field the DON placed the dressing supplies on the over the bed table next to R32's open soda pop and newspaper. While R32 was positioned onto his left side the dressing was observed to have brown colored substance smeared on the outside of the dressing. After opening the dressing package, the DON placed it on the bedsheet next to R32. This surveyor was not able to locate the initials or date on the dressing. When asked if the dressing contained a date or initials of the person who changed it last, the DON thoroughly observed the dressing and stated that she did not see any. The DON removed the dressing from R32's coccyx area. Without changes gloves and performing hand hygiene, the DON cleansed the wound with saline wound wash. The large wound area extended across the buttock that was purple and dark red in color. The DON stated it measured 15 cm by 12 cm and was MASD (moisture-associated skin damage) with an open area to the right side of the wound that measured 2.0 cm by 1.0 cm by 0. Wearing the same gloves, the DON opened a package of skin prep and prepped the outer aspect of the wound, the with a gloved finger without performing hand hygiene applied A & D ointment, used a marker and dated and initialed a border dressing and applied it to the coccyx area. The adhesive part of the dressing was pressed directly over the top of the open area. When asked if the adhesive portion of the dressing taped directly to the open area could have contributed to the open area in the skin, the DON stated that it probably did and peeled the dressing back off and asked a staff member to obtain a larger boarder dressing. Without changing gloves and performing hand hygiene the DON reapplied a larger dressing, repositioned R32 in bed, removed the soiled gloves, handed R32 a tissue box and went the bathroom to wash her hands. During an interview on 8/25/22 at approximately 10:00 AM, the ADON and DON reviewed the July and August Treatment Administration Records (TAR). According to the TAR's R32 had an order to cleanse and change the dressing as needed for soilage or dislodgement. There was no dressing change signed out by the nurses noted from 7/19/22 - 8/25/22 (34 days). When confirmed by the DON and ADON both stated there is no evidence documented on the TAR's those daily dressings were being done. The weekly (7/14/22 - 8/19/22) assessments of the wound were reviewed and did not reflect any measurement of the MASD (Moisture Associated Skin Damage) or the open area. When asked if the wound was improved, stable or worsened neither the DON or ADON could answer regarding the status of the wound. The DON stated that hospice also changed the dressing on their visits (twice weekly) but could not provide any evidence to support that prior to the exit of this survey.

This deficient practice pertains to intake MI 052 and MI 426. Based on observation, interview and record review, the facility failed to measure, monitor, and promote the healing of a pressure ulcer for 1 resident (R25) reviewed for pressure ulcers. The deficient practice resulted in R25 having a nonhealing stage 3 pressure ulcer and the increased risk for infection and further decline. Findings include: Resident #25 (R25) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed Resident #25 admitted to the facility on [DATE]. Brief Interview for Mental Status (BIMS) reflected a score of 12 out of 15 which represents Resident #25 was cognitively intact. During an interview on 8/29/22 at 11:40 AM, R25 showed this surveyor the blanket that was under her bottom and stated that it was there in case she leaked through. Several old blood stains were observed on the blanket. R25 reflected, it (the blood) is from the seeping wounds on my back. My sheets have not been changed in 5 days. According to the care plan dated 6/22/22 for Impaired Skin Integrity, R25 had a pressure ulcer to the right and left buttock. The goal reflected, Tissue injury will heal and be free from complications. The interventions included (but not limited to) assess and document skin condition, notify MD of signs of infection, notify MD of worsening or no improvement of wound, and wound treatment as ordered. According to the MDS dated [DATE] Section M Skin reflected that R25 had 2 pressure ulcers that were both stage 2. According to the Treatment Administration Record (TAR) for August, the wound treatment order reflected, Buttocks treatment: cleanse with normal saline apply [MEDICATION(S)] or equivalent and collagen crystals to wound base. Cover with non-adhesive foam dressing or abdominal pad. Change daily and prn (as needed). NO ADHESIVE TO AREA. Every day shift for wound treatment start date 8/17/2022. This was the most recent treatment order. On 8/30/22 at approximately 2:30 PM, the surveyor asked Doctor I about R32's pressure ulcers. Doctor I stated that he was just taking over care for R32 and was unable to answer questions related to R32's wounds. According to the doctor's progress notes date 7/7/22 and 8/16/22 the Doctor I documented the presence of a Stage 3 pressure ulcer. During an interview on 8/25/22 at approximately 9:00 AM, the ADON reviewed the weekly wound assessments from 7/14/22 - 8/18/22 and there were no measurements documented. The wound assessment dated [DATE] reflected a wound areas as MASD (Moisture Associated Skin Damage). The right buttock that measured 9.0 cm by 2.5 cm by 0.1 cm and the left buttock that measured 9.5 cm by 1.0 cm by 0.1 cm. When asked if there were open areas to the wounds that required treatment, the ADON stated, Yes. The ADON stated the wound healed from a stage 3 to a stage 2 then it was documented as a MASD. When asked if the facility was back staging or reverse healing the pressure ulcers stages as they healed, the ADON stated, Yes. The ADON and facility was asked to provide a policy or professional reference that back staging or reverse healing was an acceptable way to monitor and assess a pressure ulcers healing. No further documents were made available for review prior to the exit of this survey. The facility was unable to provide a policy for staging pressure ulcers therefore the State Operations Manual definition was referenced. The definition reflected, Stage 3 Pressure Ulcer: Full thickness skin loss. The description for Healing Pressure Ulcers/Injuries reflected, Ongoing evaluation and research have indicated that PU/PIs do not heal in reverse sequence, that is, the body does not replace the types and layers of tissue (muscle, fat and dermis) that were lost during development. After obtaining permission from R25 to observe the dressing changes, this surveyor notified her assigned nurse on 8/24/22 and 8/25/22 at approximately 9:00 AM both days and the nurse stated she would let the surveyor observe the dressing change but failed to notify the surveyor before the treatment was completed. No additional observations were made during the onsite survey.

This citation pertains to intake numbers MI 737, MI 399 and MI 930. Based on observation, interview and record review facility failed to: 1) accurately assess, monitor and prevent the development and worsening of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; 2) follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in the development of a stage 4 pressure ulcer and wound infection and subsequent death for R110, worsening of pressure wounds requiring re-hospitalization for [CONDITION(S)] for R103, re-admission to the hospital, nine days after admission, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility, Skin Management Policy, dated October 2019, reflected, Purpose: To assess each resident to determine the risk of potential skin integrity. Policy: It is the policy of [named facility] to assess each resident to determine the risk of potential skin integrity impairment. Residents will have a skin assessment completed upon admission and no less than weekly by the licensed nurse in an effort to assess overall skin condition, skin integrity, and skin impairment .PREVENTION: 1. All resident beds will have a pressure reducing mattress. 2. All residents who utilize a wheelchair will have a pressure reducing cushion in chair. 3. A head to toe assessment will be completed by a licensed nurse upon admission/re-admission and no less weekly. 4. The Braden will be completed by the IDT within 72 hours of admission, quarterly and as needed. 5. IDT reviews risk factors upon admission and quarterly. a) Care plan interventions will be implemented based on resident specific risk factors .7. All residents who require assistance with mobility will be encouraged and assisted to turn and reposition at a minimum of every 2 hours or per their plan of care. 8. Any skin alterations noted by direct care givers during daily care and/or shower days must be reported to the licensed nurse for further assessment, to include but not limited to bruises, open areas, redness, skin tears, blisters, and rashes. a) The licensed nurse is responsible for assessing any and all skin alterations as reported by the direct caregivers on the shift reported. 9. Residents identified at risk for skin breakdown will have appropriate prevention interventions put into place. a) A care plan will be developed specific to the resident ' s needs including prevention interventions. PROCEDURE FOR ALTERATIONS IN SKIN INTEGRITY 1. Alterations in skin integrity will be reported to the physician/NP and responsible party/family. 2. Treatment order will be obtained. 3. All alterations in skin integrity will be documented in the medical record a) Residents admitted or readmitted with alterations in skin integrity will be documented on admission evaluation. b) All newly identified areas after admission will be documented on the weekly pressure/non pressure evaluation. 4. The wound nurse (licensed nurse assigned responsibility for wounds for the building) will be notified of alterations in skin integrity. a) The facility assigned wound nurse will complete further evaluation of the wounds identified and complete the appropriate skin evaluation on the next business day. 5. Skin Care interventions will be added to the caregiver Kardex. 6. IDT review of new alteration in skin integrity will be completed weekly. 7. A plan of care will be initiated to include resident specific risk factors with appropriate interventions. Resident #103 (R103) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R103 was a [AGE] year old female admitted to the facility on [DATE] with most recent re-admission 12/31/21 post hospital admission for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected R103 had a BIM (assessment tool) score of 10 which indicated her ability to make daily decisions was moderately impaired, and she required two-person physical assist with bed mobility(repositioning), transfers, toileting, hygiene, bathing and one person physical assist with dressing. The MDS reflected R103 had one unstageable(covered with slough and/or escar) pressure ulcer that was present on admission/reentry, one stage 4 pressure ulcer that was present on admission/reentry, and two stage 2 pressure ulcers present on admission/reentry. Review of the admission MDS, dated [DATE], reflected R103 had three stage 3 pressure ulcers present on admission with no unstageable areas for either slough or suspected deep tissue injury. Review of the facility Matrix, dated 3/9/22, provided at 1:26 p.m. by the Administrator (ADM) A, who indicated was the final edited version, reflected four residents with pressure ulcers that were present on admission with no facility acquired pressure ulcers. The Matrix indicated R103 had stage IV, stage III and unstageable wounds that were worsening. During an interview on 3/9/22 at 5:30 p.m. Licensed Practical Nurse (LPN) NN reported skin assessment should be done weekly and documented in resident medical records. LPN NN reported Nurse Practitioner (NP) performs weekly wound rounds and reported would round on residents tomorrow 3/10/22. During an interview on 3/10/22 at 7:51 a.m., LPN N reported resident skin assessments were completed weekly and documented in the Treatment Administration Record (TAR) and the Progress Notes. LPN N reported the NP and Wound Nurse (WN) round weekly and plan to round today. LPN N reported, on occasion, treatment orders had not been completed as ordered as evidenced by dates on the dressings, mostly from night shift for residents who have orders for every shift dressing changes. During an interview on 3/10/2 at 8:40 a.m., Nurse Practitioner (NP) U reported working with the facility for two weeks with contracted group. NP U reported performs weekly wound rounds with plans to round today with Wound Nurse (WN) Z. This surveyor verified permission to observe during rounds. During an interview on 3/10/22 at 9:35 a.m. WC Z reported had worked at facility for four months and was new as the facility Wound Nurse for past two weeks and was wound care certified. During an observation and interview on 3/10/22 at 1:40 p.m., R103 way laying in bed and appeared calm and pleasant and able to answer questions appropriately. R103's hair appeared greasy and ungroomed and was wearing a gown with a double lumen Peripheral Inserted Central Catheter (PICC) in right upper arm with foam disc over insertion site covered with clear dressing dated 2/4/22. R103 reported had not received medication through the PICC and staff had not flushed or completed dressing changes to the PICC line site for at least a week. R103 reported pain from right knee up to buttock area related to open wound and reported had not received any as needed pain medications recently. R103 granted this surveyor permission to observe wound care treatments. During an observation on 3/10/22 at 2:29 p.m., Certified Nurse Aids (CNA) TT and DD entered R103 room after reported plan to perform personal care prior to dressing wound care. CNAs removed R103 covers and R103 lower legs, including heels, were resting directly on folded blanket at the foot of the bed with moderate amount of dried, crusted bloody drainage to right lateral lower leg dressing that was dried and stuck to the blanket. CNA staff carefully separated R103 leg dressing from dried drainage on blanket. R103 did not have foam boots on and had loose dressing to left heel with one corner of border dressing intact. R103's bilateral lower legs appeared very dry, flaky, and crusted with very long, thick and curled toenails on bilateral feet. R103 had undated dressings noted to bilateral hips and a saturated undated dressing covering the coccyx area. At 2:36 p.m. LPN N entered R103 room with supplies and exited and returned with unopened bottle of Dakin's Half Strength solution. Wound supplies included, ABD pad, foam border, Medi honey, gauze, ns, and tape. At 2:44 p.m. LPN N removed R103 undated saturated coccyx dressing, including packing gauze. R103 reported area felt black and blue. R103 coccyx wound appeared large, about the size of a small football, opening with presents of exposed bone, slough, undermining between 9 and 12 o'clock, tunneling between 2 and 3 o ' clock and open wound close by on left buttock that appeared long and thin with bright red drainage with dime size open area between both wounds. LPN cleaned coccyx wound with normal saline, packed with six Dakin's-soaked gauze pads and covered with ABD and secured with tape. LPN N cleaned R103 left buttock wound with normal saline, applied gauze with Medi honey and covered with border foam dressing. R103 stated, ouch, ouch when LPN N applied pressure to wounds. Review of the Treatment Administration Record (TAR), dated 3/1/22 current(3/10/22), reflected R103 had a treatment order that included, Coccyx wound: cleanse with NS, pat dry, pack Dakins wet to dry. Cover with ABD pad and secure with tape. (soak kerlix roll with dakins solution to use for packing wound. Read below for strength) two times a day for Use Dakins quarter strength 0.125% for 1 Week -Start Date- 03/09/2022 2100 . (Observed LPN N use Dakin's Half Strength 3/10/22). Review of the facility Nursing Admission/Readmission Evaluation, date 9/29/21, reflected R103 had the following skin condition and wounds described with Site and description: Coccyx .3cm wide x 4cm long x 1.5cm depth open wound; Right buttock .12cm wide x 4.5cm long x 5.5 cm depth open wound; Left buttock .15cm wide x 4cm long x 5cm depth open wound; Right heel .[0].5cm wide x 0.8cm long Healing wound; Left heel .2cm wide x 2.5cm long Healing wound; Other (specify) .Generalized dry skin; Other (specify) .Redness in groin area and under bilateral breast . Review of the facility, Braden Scale for Predicting Pressure Sore Risk assessment, dated 9/29/21, reflected R103 was at risk for developing pressure ulcers with a score of 16. Review of the facility, Initial History and Physical, dated 9/30/21, for R103, reflected, A [AGE] year-old female seen and examined at [named] Skilled Nursing Facility with nurse manager present for initial history and physical after being hospitalized .PLAN: 1. Continue 24-hour nursing care and current medical management. 2. If patient sits in bed, appropriate offloading mattress. 3. Frequent turning and positioning every two hours to the best of her ability to offload the area. 4. If sits in a wheelchair, appropriate offloading cushion . 6. Reinstitute negative pressure wound VAC system, -125 mmHg negative pressure to the right ischial wound at 3.9 x 11.6 x 5.6. 7. Left ischial wound at 3.2 x 11.5 x 6.6. 8. Coccyx wound at 1.5 x 6.9 x 1.5. 9. Bridge the areas. 10. Until the negative pressure wound VAC system comes in, you can use Dakin's soaked wet to dry dressings. Change Tuesday, Thursday, Saturday and as necessary . The History and Physical reflected no mention of right or left heel wounds and was completed by Former Medical Director/Wound Physician MM. Review of the facility, Physician Wound Progress Note, dated 10/7/21, for R103, reflected, ASSESSMENT: A [AGE] year-old female seen and examined at [named facility] Skilled Nursing Facility with wound care team, wound care nurse and nurse manager. admitted to the facility with recalcitrant sacral and ischial wounds, undergoing negative pressure wound VAC system, surgically debrided at the hospital. 1. Right ischial at 3.9 x 11.6 x 5.6. 2. Left ischial at 3.2 x 11.5 x 6.6. 3. Coccyx at 1.5 x 6.9 x 1.5. 4. Right heel at 3.5 x 3.4 x 0.1. 5. Bottom of the right foot at 2.3 x 2.2 x 0.1. 6. Bottom of the left heel, 3.9 x 4.4 x 0.1. 7. Back of the left heel, 2.9 x 2.3 x 0.1 . PLAN . 2. If patient sits in bed, appropriate offloading mattress. 3. Frequent turning and positioning every two hours to the best of her ability to offload the area. 4. If sits in a wheelchair, appropriate offloading cushion. 5. Reapply negative pressure wound VAC system, -125 mmHg negative pressure to the ischial wounds on the right and the left continuous. Change Monday, Wednesday, Friday and as necessary. 6. Dakin's soaked gauze to the coccyx, dry dressing twice a day, wet to dry. 7. For the heels on the left and the right, and the feet: Skin prep twice a day, Prevalon boot, float the heels, offload the area . The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility, Physician Wound Progress Note, dated 10/21/21, for R103, reflected, Plan: 1. Areas were supposed to be skin prep twice a day, Prevalon boot, float the heel, offload the area. Changing the heels to [MEDICATION(S)] and calcium alginate to bilateral heels, gentle dressing and change Monday, Wednesday, Friday and as necessary. Prevelon boot, float heels, offload the areas . Review of the facility, Physician Wound Progress Note, dated 11/18/21, for R103, reflected, Right outer superior leg ulcer, vascular in nature, 2.3 x 1.4 x 1.0. [MEDICATION(S)], collagen matrix and foam .Right outer leg inferior, 2.5 x 1.9 x 1.0. [MEDICATION(S)], collagen matrix and foam. Change three times a week and as necessary . R103's two right leg wounds were not mentioned on the prior Physician Wound Progress Notes, dated 11/11/21. Review of the of the Electronic Medical Record, including the Treatment Administration Record (TAR), Assessments and Progress Notes, dated 11/1/21 through 11/30/21, reflected R103 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the EMR reflected no evidence of a completed, Weekly Skin Observation. Review of the facility, Treatment Administration Record (TAR), dated 10/1/21 through current (3/10/22), reflected R103 had several (greater than 120) missed wound treatment orders as evidenced by holes (no documentation to indicate completed) on the TAR. Review of the TAR, dated 10/1/21 through 10/31/21, reflected R103 had no evidence of wound treatments from 10/1/21 to 10/4/21(three days) for stage III coccyx wound noted on admitted [DATE], no evidence of wound treatment 10/1/21 to 10/7/21(six days) for stage III bilateral ischial wounds noted on admission, and no evidence of wound treatment orders from 10/1/21 to 10/6/11(five days) for DTI of bilateral heels noted on admission. The same TAR reflected, cleanse bilateral heels and apply skin prep one time a day for pressure with start date 10/5/21 to 11/4/21. (Physician had ordered skin prep twice daily, prevalon boots, float heels and offload area on 10/7/21 and again on 10/21/21 that was not reflected on R103 TAR). The same TAR reflected no evidence of change in wound treatment orders after R103 Physician visit on 10/21/21 for bilateral heels that included, Changing the heels to [MEDICATION(S)] and calcium alginate to bilateral heels, gentle dressing and change Monday, Wednesday, Friday and as necessary . According to the Fundamentals of Nursing, 6th edition (Potter-Perry, Mosby, 2005, page 419), The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm clients. The reference goes on to indicate that all orders must be assessed and further clarification from the physician retrieved if necessary. Review of the facility Electronic Medical Record (EMR), dated 9/29/21 through 3/10/22, reflected several missing Pressure Non-Pressure/Weekly Observation assessments including: --No comprehensive wound assessment between 10/21/21(included 5 wound assessments) (Physician assessment for same day included 7 wound) and 11/4/21(included 3 wounds assessments) (Physician assessment for same day included 5 wounds); --Two New wounds located on R103 right lower leg on 11/18/21 Physician note(Non-Pressure wound observation not completed until 11/23/21(5 days later). --No comprehensive wound assessments between 1/27/22 and current (3/10/22) with exception on one left heel assessment completed on 2/3/22(6 weeks straight no record of non-pressure/pressure observations assessments including worsening stage 4 pressure wounds requiring Intravenous antibiotic treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Non-Pressure/Weekly Observation, dated 11/23/21, reflected R103 developed two stasis ulcers to the stasis ulcers to the right lower leg on 11/23/21. (Wounds were documented on 11/18/21 Physician wound visit.) Review of the facility Non-Pressure and Pressure/Weekly Observations, dated 11/18/21 to 12/22/21, for R103, reflected coccyx, bilateral ischial areas, bilateral heels, and right lower leg wounds had signs of decline including increased purulent drainage, foul odor, and wound bed changes. Review of the Pressure Weekly Observation, dated 12/16/21 for R103 were as follows: Left Ischial Stage III Pressure Ulcer measured: 2cm x 9cm x 1cm with bloody drainage, present on admission. Right Ischial Stage III Pressure Ulcer measured: 3.2cm x 11cm x 1.0cm with bloody drainage, present on admission. Coccyx Stage III Pressure Ulcer measured: 3cm x 3.5cm x 2.3cm with large amount bloody drainage and odor, slough present in wound bed with yellow and pink tissue present, present on admission. Left Heel Suspected Deep Tissue Injury (SDTI) measured: 5.5cm x 6cm x 0cm with moderate amount purulent drainage, present on admission. Right Heel SDTI measured: 2cm x 1.5cm x 0cm with moderate purulent drainage, peri wound macerated and pickish red, present on admission. Right outer leg inferior Stasis Ulcer measured: 5cm x 2.5cm x 3cm with moderate amount blood drainage with odor, facility acquired 11/23/21. Right outer leg Superior Stasis Ulcer measured: 10cm x 5cm x 3cm with moderate amount bloody drainage with odor, facility acquired 11/23/21. Review of the facility Skin Care Plans, last revised 3/1/22, reflected R103, has impaired skin integrity r/t bilateral ischial wounds and chronic sacral wound, [CONDITION(S)] of BLE[bilateral lower extremities] with stasis dermatosis. Date Initiated: 09/30/2021 Revision on: 10/13/2021 .Goals: Tissue injury will heal and be free from complications. Revision on: 12/22/2021. The Care Plan reflected interventions that included, Assess and document skin condition, notify MD of signs of infection (redness, drainage, pain, fever) Date Initiated: 10/01/2021 .Assess for pain and treat as indicated Date Initiated: 10/01/2021 .Coordinate care with Hospice. Date Initiated: 03/01/2022 .Assist with bed mobility to turn and reposition routinely Date Initiated: 10/01/2021 .pressure reducing/redistributing mattress on bed. Date Initiated: 10/01/2021 .wound treatment as ordered. Date Initiated: 09/30/2021 . The Care Plans reflected no evidence of Physician recommendations from 9/30/21 visit for frequent turning and positioning every two hours, orders for use of Negative Pressure Wound VAC for wounds or Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Progress Note, dated 12/22/21 at 11:26 a.m., for R103 reflected, A 0800 Resident sent out to hospital for change of condition per MD. Review of the Hospital Discharge Summary, dated 12/31/21, reflected R103 was admitted to the hospital 12/22/21 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .Acute [CONDITION(S)] sacrum, Acute [CONDITION(S)] right fibula .Sacral decubitus ulcer .Right lateral deep calf wound with suppuration .Right gluteal pressure ulcer of 7-8 cm .Left heel pressure ulcer with necrotic tissue . The Discharge Summary reflected R103 had Procedures that included, Excisional Debridement of the Sacral ulcer and Sacral Bone Biopsy and Right Lateral Calf Ulcer Bone Biopsy on 12/23/21 and Peripheral Inserted Central Catheter (PICC) on 12/30/21 for Intravenous(IV) antibiotic treatment. The Discharge Summary reflected R103 had an Infectious Disease Consult related to bone cultures from sacrum and right leg were positive for [CONDITION(S)] with recommended 6-8 weeks of IV [MEDICATION(S)], oral [MEDICATION(S)] and oral [MEDICATION(S)] (second antibiotic) and wound care. The Hospital Discharge Summary reflected R103 was discharged back to the facility with orders for daily IV and oral antibiotic related to acute [CONDITION(S)] (wound infection). Review of R103 Nursing Progress Notes, dated 12/31/21 at 4:27 p.m., reflected, Resident readmitted from [named hospital] after short stay due to [CONDITION(S)] and wound infection. Requested wound timelines for R103 from Administrator (ADM) A via email on 3/11/22 at 9:37 a.m. and informed no access to Electronic Medical Records at 9:45 a.m. after arrival to facility prior to 8:30 a.m. Review of the Physician Orders, dated 12/31/21 through 1/31/22, reflected no wound treatment orders for R103's, who readmitted to the facility on [DATE] post-acute care admission for [CONDITION(S)] and [CONDITION(S)] related to worsening stage 4 pressure ulcer, until 1/10/22(ten days). Review of the TAR, dated 1/1/22 through 1/31/22, reflected R103 was readmitted to the facility 12/31/21 with no evidence that R103 received wound care treatments from 1/1/22 to 1/11/22. (11 consecutive days with no wound care for six wounds including; coccyx stage 4 pressure wound, bilateral ischial stage 3 pressure wounds, bilateral heel unstageable pressure wounds, right lower leg stasis ulcer.) Further review of the TAR reflected wound treatments for R103's infected stage 4 coccyx and two stage 3 pressure ulcers were not started until 1/15/22(15 days after readmission). Further review of the TAR reflected 28 missed wound treatments after orders obtained 1/10/22. According to the Fundamentals of Nursing, 6th edition (Mosby, Patricia A. Potter, Anne G. Perry, 2005 page 419) the physician should write all orders, and the nurse must make sure that they are transcribed correctly. Review of the Medication Admiration Record and Nurse Progress Notes, dated 1/1/22 through 1/31/22, reflected R103 did not receive ordered medication on 11 occasions, indicated by notes that not available from pharmacy to administer, including pain medications and antibiotic with no mention of provider notified. Review of the facility, Physician Wound Progress Note, dated 1/6/22, for R103, reflected, Assessment . 1. Patient has an unstageable 5.0 x 4.0 x 0.1 necrotic scab on the left heel, black eschar. 2. Left posterior side 4.3 x 3.5 0.1 Red abrasion, 80% granulation tissue, 20% slough at the wound bed. 3. Left ischium 10.0 x 2.5 x 5.8. 4. Left buttock communicates with coccyx, sacral at 4 to 6 o'clock. Clustered wound as per above 17. 1 x 5.4 x 4.4, undermining at 10 o'clock approximately 1.5 cm. 5. Right heel 100% slough at wound bed 1.4 x 0.8 x 0.1. 6. Right lower leg, bone exposed, 17.1 x 5.4 x 4.4. Surgically debrided at hospital. A 1.5 undermining is noted. 7. Right ischium at 11.5 x 2.0 x 0.1. Red granulation tissue noted . PLAN . 1. Continue 24-hour nursing care . 2. If patient sits in bed, appropriate offloading mattress. 3. Frequent turning and positioning every two hours to the best of her ability to offload the area. 4. If sits in wheelchair, appropriate offloading cushion. 5. Wound VAC to the bilateral ischial areas, washing with Dakin's, Dakin's soaked gauze packing with a dry dressing. 6. [MEDICATION(S)], calcium alginate to bilateral heels. 7. Dakin's soaked gauze to the coccyx area with dry dressing. 8. To the right outer leg, wet to dry dressing. 9. Vascular surgery to see. 10. Prevalon boot, float the heel, offload the area. 11. Negative pressure wound VAC system to the ischial areas, -125mmHg negative pressure. Change three times a week and as necessary . Review of the facility, Interdisciplinary Team(IDT) Progress Note, dated 1/14/22, reflected, Careplan reviewed and updated by IDT, Dietician, UM's, DON, Social worker. Continue with plan of care. (Skin Care Plans reflected no updates after R103 hospitalization on [DATE] for septic wound infection that required PICC insertion for antibiotic treatment). Review of the TAR and Nursing Progress Notes, dated 2/1/22 through 2/28/22, reflected R103 had 34 missed ordered wound treatments. Review of the Nurse Practitioner Wound Care Progress Note, dated 2/23/22, for R103, reflected, General: Patient is a [AGE] year old female with past medical history significant for pressure ulcer of sacral region stage III pressure ulcer right buttock stage III type 2 diabetes [CONDITION(S)] [CONDITION(S)] [CONDITION(S)] [CONDITION(S)] from myalgia dementia [CONDITION(S)] sarcopenia [CONDITION(S)] psoriasis B12 deficiency. Patient is seen today for wound care rounds of multiple chronic wounds. Patient has completed IV antibiotics for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient states she has constant pain related to wounds . Review of the Nurse Practitioner Wound Care Progress Note, dated 3/3/22, reflected, Chief Complaint-Multiple wounds - wound care rounds .recently signed on to hospice services . Location/type: Left heel chronic unstageable pressure ulcer. Measurement: 3.5x4.5cm . Location/type: RLE NPU (proximal and distal now combined as one wound) Measurements: 19.0cm x 2.5cm . Location/type: Stage 3 PU Right ischial buttock Measurements: 9.0cmx2.0cm . Location/type: PU stage 3 Left ischial buttock Measurements: 4.5cm x 1.5cm . Location/type: Coccyx unstageable PU Measurements: 8.5cm x 14.5cm 12*[o'clock] 1.5cm, 4* 5.9cm, 6* 0.1cm 9* 2.5cm Wound bed: 50% slough, 50% granulation, sacral bone palpated . Review of R103 requested wound timeline, received 3/15/22, reflected Physician Wound Round notes with measurements and orders that did not reflect consistent weekly monitoring, or evidence that facility was following Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on 3/15/22 at 8:40 a.m., R103 was in bed positioned on left side with Prevalon boot on right foot only, eating breakfast. R103 appeared to have greasy ungroomed hair and reported recently woke up for breakfast and had not received assistance with morning care yet. R103 had dressing to the left heel that was not intact and Prevalon boot was not on. R103 had a dressing to the right upper arm, where the PICC was located last week, dated 3/10/22. R103's bilateral lower legs appeared very dry with moderate amount dry crusted dark areas with continued very long, thick, and curled toenails. During an interview and record review on 3/15/22 at 11:32 a.m., WC Licensed Practical Nurse Z reported R103 was admitted to the facility 9/29/21. WC Z reported residents should have weekly skin assessments documented in the Electronic Medical Record under Evaluations. WC Z verified R103's last wound assessment was completed on 2/3/22 for left heel wound and 1/27/22 for stage 4 coccyx pressure wound, stage 3 bilateral ischial wounds, right heel and right leg and was unable to answer why R103 wound assessments had not been completed for 6 weeks. When asked what R103 wound intervention had been since admission, WC Z reported he did not have access to dates of Care Plan revisions. WC Z reported would have to check with ADM A. ADM A educated WC Z on how to obtain past Care Plan revisions with dates and WC A reported R103 had several changes since admission. WC Z verified this surveyor did not have access to R103 changes in care plans between admission and current care plans. This surveyor requested copy of all R103 care plans, including revisions with dates, and WC Z reported would have to verify with ADM A that he could do that. WC Z verified R103 had no mention of left heel wound including treatments until 3/10/22 and verified R103 had left heel wound on admission and Care Plan should have reflected that. WC Z reported Unit Managers and Director of Nursing make changes to Care Plans as changes occur. WC Z verified R103 did not have a Care Plan for the PICC line placement and was unable to report when it was placed. WC Z reported would send R103 requested Care Plans with revisions and dates surveyor had not been able to access since start of survey on 3/9/22 via email. Received requested Care Plans at 12:12 p.m. During an interview on 3/15/22 at 4:35 p.m., DON B reported would expect nurses to follow Physician orders. LPN N verified used Dakin's Half Strength for R103 dressing change when observed by this surveyor on 3/10/22. LPN N reported uses Dakin's half strength if Physician does not indicated strength. During a telephone interview on 3/15/22 at 9:20 p.m., Confidential Staff (CS) PP reported R103 had worsening wounds since admission and reported was present for R103 dressing change on 3/7/22 and reported had observed old dressing dated 3/3/22 for bilateral ischial, left heel and right lower leg wounds. CS PP reported only one nurse present in facility, who was an agency nurse, shift prior who had been passing evening medication at midnight. During an interview on 3/16/22 at 8:32 a.m. NP U reported wounds were measured with length, width and depth and documented in that order. NP U verified, when this surveyor observed during wound rounds on 3/10/22, that R116 old dressing removed was dated 3/7/22 and should have been changed once daily. During an observation and interview on 3/17/22 at 10:27 a.m. WC Z reported plan to perform wound rounds with Physician(MD) KK for R103. WC Z collected treatment supplies and entered R103 room along with MD KK, and LPN J. WC Z placed R103 wound treatment supplied directly on soiled bedside table, opened drape, and placed same supplies on top of drape. WC Z removed old dressing from R103 left heel and appeared to have bright red drainage with slough noted at 2 o'clock. WC Z measured area and verbalized 4cm by 2.4cm(no depth observed taken). WC Z completed left heel dressing. WC Z removed right lower leg dressing and appeared R103 had two open areas with beefy red wound beds. WC Z measured wounds and verbalized 6cm by 1 cm and 8cm by 1.5cm (no depth observed taken). WC Z performed wound treatments and exited room. Immediately after exiting R103 room at 10:54 a.m. WC Z was questioned to verify R103 wound measurements. WC Z reported did not recall measurements and reported normally writes down measurements at time taken and reported R103 distal right wound was located closest to knee and proximal right leg wound was located closed to foot. MD KK clarified and reported proximal was located closed to knee and distal was

This citation pertains to intake MI 730 Based on observation, interview and record review the facility failed to: 1.) ensure the safety, 2.) implement care-planned and non-care-planned interventions, 3.) ensure that those interventions were functional and in place, and 4.) thoroughly investigate cause of fall to decrease risk of injury related to additional falls for 2 of 2 sampled residents (Resident #114 and Resident #101) reviewed for falls, resulting in Resident #114's fall with left [CONDITION(S)] on 1/4/22 with history of multiple falls. This deficient practice placed 50 residents at risk for serious harm and injury. Findings include: Review of the facility, Fall Management Policy and Procedure, dated October 2019, reflected, Purpose: To prevent injuries related to falls. Policy: It is the policy of [named facility] to ensure residents residing within the facility will maintain maximum physical functioning trough the establishment of physical, environmental, and psychosocial guidelines to prevent injury related to falls. Procedure: Fall Risk 1. Fall risk will be assessed upon admission, quarterly and with significant change utilizing a formalized fall assessment too, ie: Morse. 2. A care plan will be developed at time of admission with specific care plan interventions to address each resident's fall risk factors. Care plan including interventions and fall risks will be reviewed at least quarterly. 3. The resident specific care requirements will be communicated to the assigned caregivers utilizing the Kardex. 4. The interdisciplinary team will discuss new residents on the 1st business day after admission in the clinical meeting. *Fall risk will be discussed at this time, including appropriate interventions. Post Fall 1. Any resident experiencing a fall will be assessed immediately by the charge nurse for possible injuries and necessary treatment will be provided. *A neurological assessment will be initiated on all un-witnessed falls. *A neurological assessment will be initiated on all residents with a suspected head injury based upon the fall. *Information will be entered into Risk Management. 2. If the resident experienced an injury from the fall, contact facility DNS/ED per facility policy. 3 The physician will be contacted immediately, if there are injuries, and orders will be obtained .4. The family will be notified immediately by the charge nurse of falls with injury .5. All falls will be discussed by the interdisciplinary team at the 1st IDT meeting after the fall to determine root cause and other possible interventions to prevent future falls. *The fall will be reviewed by the team *IDT note will be written *The care plan will be reviewed and updated, as necessary. Per the Falls/Fall Risk Process Guidelines (MDCH, 2001) residents who have fallen are at risk for delayed consequences which may occur within several days after the fall; occasionally they can occur several weeks later. The professional standard of quality for analyzing falls is the facility's staff and practitioners attempt to identify causes of the conditions or problem .the facility's staff and practitioners use the information to decide how to best manage a resident's condition, symptom, or situation. (Clinical Process Guideline: Evaluation of Falls/Falls risk, Memorandum Dated 2/13/14, MDCH Clinical Advisory Panel) Resident #114(R114) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R114 was an [AGE] year-old male admitted to the facility on [DATE] with recent re-admission 1/7/22 post fall with left [CONDITION(S)] at facility 1/4/22, with other diagnoses that included hypertension (high blood pressure), heart failure, [CONDITION(S)], dementia, and [CONDITION(S)]. The MDS reflected R114 had a BIM (assessment tool) score which indicated his ability to make daily decisions was severely impaired, and he required one person physical assist with locomotion on unit, dressing, eating, and two person physical assist with transfers, toileting, bed mobility, hygiene and bathing. Review of the MDS, dated [DATE], reflected required one person physical assist with hygiene and bathing and scored 2(not steady, only able to stabilize with human assistance), on balance transitions and walking with no Range of Motion limitation prior to fall with fracture on 1/4/22. Requested Administrator via email for four months of Incident/Accident Reports including complete investigations for R101 and R114 on 3/11/22 at 9:37 a.m. Received Incident/Accident(I/A) reports R114 via email from ADM A on 3/11/22 at 2:34 p.m. with no evidence of investigation including no written witness statement. I/A reports included falls on 12/4/21 at 4:33 p.m., 1/3/22 at 12:55 p.m., 1/3/22 at 7:36 p.m., 1/4/22 at 9:48 a.m., and 1/7/22 at 3:44 p.m. Review of the facility, History and Physical, dated 10/11/21, for R114, reflected, REASON FOR EVALUATION: New patient. SUBJECTIVE: This is an [AGE] year old white male who is up in the chair. Patient is not oriented to himself or to other people. Has recurrent falls. Patient was admitted from [named] Hospital. Patient was admitted to [different named] Area Hospital on 10/06/2021 for fall. Patient had a prolonged QTC, generalized weakness. Patient was with a sitter in the hospital .[MEDICATION(S)] was stopped. COVID was negative. Patient had a fall in someone else's room. I helped the nursing staff to place patient back in the wheelchair . Review of the facility, Incident Audit Report, dated 12/4/21 at 4:33 p.m., reflected R114 had a witnessed fall in hall from chair with no injuries. The report reflected the witness description, Resident was at the end of hall 2 when I saw him turn sideways and placed his self on the floor. The provided information did not include any evidence of investigation to determine root cause of fall. Report did not indicate what intervention were in place at time of the fall including what type of footwear resident had on. The reported did not mention immediate interventions implemented. Review of the Progress Notes, dated 12/4/22 through 12/16/21, reflected nurse follow up note for one day on 12/5/21 and no evidence of IDT meeting. Review of the R 114 Fall Care Plan, revised 11/16/21, reflected, [NAME] is at risk for falls or fall related injury r/t repeated falls, h/o falls, recent falls, [CONDITION(S)], [CONDITION(S)], polyneuropathy, impaired balance, antianxiety and antidepressant medication use Date Initiated: 10/13/2021 .Interventions . Encourage and assist to wear appropriate nonskid footwear Date Initiated: 10/13/2021-Keep call light and frequently used personal items within reach Date Initiated: 10/13/2021 . Resident to be in common areas when not in bed. Date Initiated: 10/10/2021. Resident to be in Tilt Peddler Broda wheelchair when out of bed Date Initiated: 10/11/2021 .Keep call light and frequently used personal items within reach Date Initiated: 10/13/2021. -Keep bed in lowest position. Date Initiated: 10/11/2021 .Keep call light and frequently used personal items within reach Date Initiated: 10/13/2021. -Keep bed in lowest position. -Date Initiated: 10/11/2021 . Review of the facility, Fall Audit Report, dated 1/3/22 at 12:55 p.m., reflected R114 had a witnessed fall, as indicated at the top of report, and indicated the reported was created by former Director of Nursing (DON) W on 1/9/22. The report reflected details, On 1/3/2022 resident had a fall, this fall was unwitnessed. Resident was observed laying on his back near his bed. Resident denied any pain to RN. RN preformed ROM to upper and lower extremities. Resident had full ROM to all extremities. Resident was alert to baseline, resident appeared to be self-transferring. Resident was in wheelchair prior to fall, resident wheelchair was to his right of him. and his bedside table was on his left, not in arms length distance .Resident had regular socks on and no shoes. Will obtain non-slip grip socks for resident to have in his room .Immediate action taken .Resident was assessed with no injury noted, resident mood was pleasant. placed shoes on resident, and resident does prefer socks over shoes, most times, so will obtain non-slip grip socks for resident. Appeared resident was attempting to self-transfer out of his wheelchair, potentially back to bed. Resident was asked after evaluation if he wanted to lay down, resident declined. Resident was assisted back to his wheelchair, and resident agreed to go to the nurses station with this RN . The reported reflected care planned interventions were not in place at time of fall and did not mention who was notified. The reported had no mention when R114 was last observed and by who, or position of bed. Review of the R114 Fall Care Plans, dated 1/3/22 to 1/4/22, reflected interventions added after fall on 1/3/22 at 12:55 p.m. included, Non slip grip socks and or footwear-Date Initiated: 01/03/2022 . Same intervention was on Care Plan prior to fall from 10/13/21 . Kennedy cup for drinks-Date Initiated: 01/03/2022 . Review of the facility, Fall Audit Report, dated 1/3/22 at 7:36 p.m., reflected R114 had a second fall on 1/3/22 that was witnessed with no injuries. The reported reflected details, Resident was observed from the hallway moving from his chair to his bed, when he was observed in a slow motion going down to the floor. When this RN walked into the room, the resident had slipped on his water, that he had slipped on Resident was moving from his chair to his bed, when he slipped on his water and slid down and under his bed .Description of Action Taken: Water was cleaned off of floor, and assisted to his bed, where his clothes were changed, and he was repositioned into a comfortable position . The reported reflected care planned interventions were not in place at time of fall and did not mention who, if anyone, was notified. The reported had no mention of when R114 was last observed and by who or footwear. Review of the facility, Fall Audit Report, dated 1/4/22 at 9:48 a.m., reflected R114 had an un-witness fall in room. The report reflected nurse details, Resident observed laying on left hip bedside, resident was c/o of increased pain, crying out in pain over his left side. Nurse was able to distract resident by distracting him by touch in order to distract him to assess him. Resident observed laying on left hip bedside . The report nurse details were entered on 1/9/22 by former DON W. The reported reflected additional details that included, On 1/3/2021 Resident had a second unwitnessed fall. Resident was observed by staff after resident yelled out for help .Immediate action taken: Resident was unable to extend left leg during nurse evaluation. MD notified and requested resident be sent to ED for eval and treat as indicated . The reported had no mention who or when had observed R114 prior to fall, position of bed and did not reflect evidence of compete and through investigation. Review of the Hospital Radiology Reported, dated 1/4/22, reflected R114 had Left Hip and Pelvis X-Ray the revealed, Acute mildly displaced, impacted, and valgus angulated left femoral neck fracture. Review of the Hospital Record, dated 1/4/22 through 1/7/22, reflected R114 had Left Hip Hemi-Arthroplasty. Review of the Progress Notes, dated 3/7/22 at 1:50 p.m., reflected R114 readmitted to the facility post hospital stay for surgical repair of left [CONDITION(S)] after fall at facility. The note indicates R114 had hip precautions in place. Review of the facility, Fall Audit Report, dated 1/7/22 at 3:55 p.m., reflected R114 had an un-witnessed in room. The report reflected nurse description, CNA called on radio that resident had fallen out of bed. Resident on floor vitals .Resident confused and not sure if he hit his head. No injuries noted. Ordered X-ray for hip .Immediate action taken: Assessed resident, got vitals and ordered X-ray for left hip. Notified PACE, notified provider . The report had no mention of who or when had observed R114 prior to fall, position of bed, if call light was in reach or on or if other care planned interventions were in place at time of fall. The report did not included witness statements. Review of the Fall Care Plans, revised 3/10/22, reflected, [named R114] needs assistance with activities of daily living r/t [CONDITION(S)], repeated falls, weakness, recent fall with left femur fracture s/p surgical repair, [CONDITION(S)]-Date Initiated: 10/13/2021-Revision on: 01/07/2022 .Continence - assist with incontinent care-Date Initiated: 03/10/2022 . BED MOBILITY: Staff assistance extensive 1 assist-Date Initiated: 10/13/2021-Revision on: 03/09/2022 .DRESSING: [named R114] is extensive 1 person assistance. Date Initiated: 03/10/2022 . TRANSFER: Resident is Weight bearing as tolerated with 2 staff with gait belt Date Initiated: 10/13/2021 Revision on: 01/09/2022 . During a telephone interview on 3/17/22 at 3:20 p.m., former DON W reported was facility DON 12/17/21 through 2/11/22. Former DON W reported falls included investigation with written statements from staff involved that were kept by Unit Manages. During an interview on 3/17/22 at 3:45 p.m., ADM A was asked a second time for R114 complete investigations related to falls from past four months. ADM A reported R114 fall on 1/4/22 was reported to the State of Michigan and closed by desk review and reported could provide proof. This surveyor informed ADM A would need to review the complete investigation for R114 falls for the last four months including the fall with fracture on 1/4/22. ADM A provided this surveyor file folder with Facility Reported Incident documents and typed Summary of events with no written witness statements or evidence of complete and thorough investigation. During an interview on 3/18/22 at 2:58 p.m., ADM A was asked a third time if I had been provided with the facility complete investigation for R114 falls for past four months. ADM A verified R114 fall on 1/3/22 did not include witness statements and everything was included on provided Fall Audit Reports. During an interview and record review on 3/22/22 at 11:48 a.m., no evidence of Request R114 Hospital Discharge Summary was located in the EMR. Medical Records FF reported would look for documents. During an interview on 3/22/22 at 12:11 p.m., Certified Nurse Aid(CNA) R reported was present for R114 fall on 1/4/22. CNA R reported R114 functional and cognitive abilities would change from day to day and reported some days R114 could not follow simple commands. CNA R reported knows how to care for resident by reviewing Kardex during shift and verbal shift report. CNA R was asked how he would know if something changed on Kardex and CNA R stated, from verbal shift report. CNA R reported was called to R114 on 1/4/22 to assist and on arrival nurse was in the room and R114 was laying on the floor close to the bed, crying with movement. CNA R reported no fall mat present, unsure of call light placement, or R114 footwear. During an interview on 3/22/22 at 1:37 p.m., CNA CC would review resident Kardex for changes in care needs during shift and reported would always review prior to transferring resident to determine proper transfer status prior to providing assistance. During a telephone interview on 3/22/22 at 8:37 p.m., Confidential Staff QQ reported facility does not do root cause analysis related to falls. During an interview on 3/24/22 at 11:37 a.m., Director of Nursing (DON) B reported had worked at the facility for about one month and reported staff are expected to stay with resident who had fallen and alert help. DON B reported staff are expected to no move resident until nurse completes assessment. Staff are expected to observe surroundings to determine possible cause of fall. DON B reported was not present for R114 two falls on 1/3/22 or fall with fracture on 1/4/22 or fall on 1/7/22. DON B reported R114 fall on 1/3/22 at 1255pm was unwitnessed and verified report indicated both witnessed and unwitnessed appeared to be during self-transfer from wheelchair to bed with regular socks on. DON B verified immediate interventions were to add grip socks and DON B verified grips socks had been prior intervention already in place that should have been implemented at time of fall and was not. DON B reported would expect nurse staff to implement interventions and add to Care Plans. DON B verified R114 had second witnessed fall same day at 7:36 p.m. with no named witness or statement and verified no mention of interventions in place. DON B reported interventions for falls on 1/3/22 were not appropriate as grip sock had already been an intervention that had not been in place at time of falls. DON B verified no evidence of root cause analysis completed. DON B reported R114 had unwitnessed fall next day, 1/4/22 and was found on floor next to bed on left side yelling out in pain with bed low. DON B reported was unable to determine by Fall Audit Report evidence of thorough investigation had been completed and verified there was no documented detail until 1/7/22. DON B reported was unable to say what if any intervention were in place at time of fall. DON B reported would expect staff to complete investigation including interviews with details to complete root cause analysis, determine if care planned interventions had been in place, add and implement new interventions, and document. DON B reported would expect staff to also document notifications with details on I/A report and continue to monitor resident. DON B reported IDT review all falls including root cause and appropriate interventions and DON B verified no evidence IDT meeting for R114 after fall with fracture. DON B verified R114 had unwitnessed fall on day of readmission, 1/7/22, from hospital after surgical repair of left hip related to fall at facility 1/4/22. DON B verified the report indicated R114 self-transferred with improper footwear and was unsure who was notified and reported no evidence of witness statements for staff who had last observed R114. DON B reported interventions did not appear appropriate and would have implemented a scoop mattress and verified Progress Notes did not mention 1/3/22 evening fall or fall on 1/7/22. DON B reported would expect complete investigation for every fall along with root cause to be able to develop appropriate interventions. Resident #101(R101) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R101 was an [AGE] year-old female admitted to the facility on [DATE] with hypertension (high blood pressure), heart failure, [CONDITION(S)], kidney disease, cerebral infarct, and repeat falls. The MDS reflected R101 had a BIM (assessment tool) score which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with dressing, eating, hygiene, bathing, toileting and two person physical assist with transfers, bed mobility, and walking in the room. Review of the facility Fall Risk Assessment, dated 11/15/21, reflected R101 was at high risk for falling. Received Incident/Accident(I/A) reports R101 via email from ADM A on 3/11/22 at 2:34 p.m. with no evidence of investigation including no written witness statement. I/A reports included un-witnessed falls on 11/27/21 at 4:34 p.m. after self transfer, un-witnessed fall 12/6/21 at 2:32 a.m. from bed after self transfer, witnessed fall 12/11/21 at 8:41 a.m. from bed after self transfer, un-witnessed fall 12/29/21 at 7:00 p.m. in room during self-transfer, and un-witnessed fall 2/5/22 at 1:01p.m., in room after attempt to self transfer. Review of the reports reflected no evidence of if care planned interventions had been in place including, footwear, position of bed, call light function, or last time R101 had been toileted prior to falls. Review of the R101 Fall Care Plan, dated 11/16/21 through 2/16/22, reflected goals that included, [named R101] will have reduced risk of falls and fall related injuries .Interventions .Encourage and assist to wear appropriate non skid footwear. Date initiated: 11/16/21 *Encourage resident to utilize call light for assistance with transfers. Date initiated: 12/6/21 Revision Date: 12/20/21 *Follow facility fall protocol. Date Initiated: 11/16/2021. *require a room close to the nursing station Date Initiated: 12/30/2021. *I require a soft touch call light Date Initiated: 11/30/2021. * Keep call light and frequently used personal items within reach Date Initiated: 11/16/2021. *keep pathways clear and well lit Date Initiated: 11/16/2021. *Please keep my walker next to my bed. Date Initiated: 02/16/2022. *Reminder sign to call for help Date Initiated: 12/20/2021 .Assist with toileting Date Initiated: 11/16/2021. *Assist with transfers Date Initiated: 11/16/2021 . Review of Nurse Progress Note, dated 12/6/21, for R101, reflected, Resident was found sitting next to bed, attempting to pull herself up at approx. 0200 by CENA. Resident states she hit her head and is having 10/10 back pain. Resident is transferring self to bathroom without assistance; she was strongly encouraged to utilized call light when she needs to transfer. No evidence of completed neurological assessments. Review of the facility, Fall Audit Report, dated 12/29/21 at 7:00 p.m., for R101, reflected, Resident observed on floor and self-transferred back to bed. Resident had a bump on the back of the head that was not open .Pain noted to head . The report did not include evidence care planned interventions were in place, no witness statements when resident was last observed or toileted, no mention of footwear or if call light was functioning, or no evidence of neurological assessments post fall. Review of the Nurse Progress Note, date 1/18/22, reflected R101 in and out of bed self transferring. Review of the facility, Fall Audit Report, dated 2/5/22 1:31 p.m., reflected R101 had an un-witnessed fall with details that included, Resident was found the floor by end of bed. Resident was no crying out in pain but emotional and confused. Resident was unable to voice what happened and why she was on the floor she was confused and upset .Description of Action Taken: Resident was fully assessed; vitals were obtained and baseline. Resident was asked if any abnormal pain and declined. Resident was stood up and accompanied to bed when this nurse noticed that she was unable to utilize the right leg and it was dragging behind her, Neuro checks were started and continued to be completed and normal findings. MD and granddaughter were notified of incident. MD ordered X-ray of the right hip and pelvis, and right knee. Small abrasion to left elbow, abrasion to left knee and bruising to bilateral knees noted. Resident also had blood noted to bedding and hands form nosebleed that looked like dried blood was present to nose . The reported had no evidence that care planned intervention were in place at time of fall including no witness statements to indicated when R101 was last observed or toileted prior to fall, footwear, or call light in reach. Review of the EMR, dated 2/5/22 through 2/15/22, revealed no mention of IDT or fall review for R101 after 2/5/22 fall with injury. During an interview on 3/18/22 at 2:58 p.m., ADM A was asked a third time if this surveyor had been provided with the facility complete investigation for R101 falls for past four months. ADM A verified R101 fall did not include witness statements, and everything was included on provided Fall Audit Reports. ADM A reported R101 fall on 2/5/22 was not reported to the State of Michigan. Review of Progress Notes, dated 2/5/22 through 2/16/22, reflected R101 had a noted that reflected, bruise observed to bridge of nose . Further review reflected Nurse Practitioner Note on 1/7/22 that Right hip and Right knew X-ray were negative for fracture. Further review of the Progress Note, dated 2/8/22, reflected, Skin observed. Right eye and bridge of nose has discoloration (bruising), also left lower leg with discoloration r/t fall on 2/5/22. The Progress Notes, dated 2/9/22, reflected, resident c/o pain in right leg, tib/fib are after assessment. Order a new X-ray to bilateral femurs, knees tib/fibs for further evaluation . Review of the Medication Administration Record, dated 2/1/22 through 2/16/22, reflected R101 developed pain after 2/5/22 fall with several changes made to pain control with several documented 9/10 score on pain scale. Review of the Physician Note, dated 2/9/22, reflected R101 was seen for uncontrolled pain with plan that included, Order for patient's 2mg [MEDICATION(S)] was sent yesterday. Apparently it has not reached the pharmacy. Patient's [MEDICATION(S)] is sent. Multiple conversation with the nurse about this patient's [MEDICATION(S)] 2mg 3 times a day as needed, sent to pharmacy. Multiple conversations with the nurse in charge. Apparently [MEDICATION(S)] is not in the backup medication. In the meantime we'll give Tylenol. Multiple conversations with [named former DON W], the director of nursing, about this patient's care . Review of the Progress Note, dated 2/15/22, reflected R101 was sent to the hospital for right blue cold foot and leg had large blue area as well. Review of the IDT Care Plan Conference, dated 2/16/22, Reflected R101 was hospitalized for blood clot to right lower leg at the time of the meeting and indicated R101 responsible party was present along with the ombudsman, unit manager, administrator, social work, and activity staff. During a telephone interview on 2/11/22 at 1:31 p.m. Medical Examiner Investigator YY confirmed R101 death had been reported as suspicious death related to neglect and an Investigation was currently open. During an interview on 3/23/22 at 10:58 a.m., R101 responsible party WW reported was not notified of R101 fall until she visited R101 and observed facial bruising and R101 had informed Responsible party(RP) WW had a fall. RP WW reported R101 had elevated pain after fall and was sent to the hospital on 2/15/22. RP WW reported met with facility staff for Care Conference with ombudsman XX on 2/16/22 and staff discussed plans for R101 after hospital discharge. RP WW reported had conversation with facility at that time was upset that she had not been notified of R101 fall on 2/5/22 and reported was upset that R101 had repeat falls with injury on 2/5/22 with delay in transfer to hospital.

This citation pertains to MI 015 Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer and routinely assess the pressure ulcer for one (Resident #1) and failed to ensure care planned pressure ulcer interventions were in place for one (Resident #3) of two reviewed for pressure ulcers, resulting in Resident #1 developing a stage 3 pressure ulcer which required a wound vac and the potential for worsening of Resident #3's pressure ulcer. Findings include: Resident #1 Review of the medical record revealed Resident #1 (R1) was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) and was at risk for developing pressure ulcers. In an observation and interview on 9/16/20 at 8:20 AM, R1 was observed with a wound vac to her left inner thigh. When asked about her wound, R1 reported the aides were not putting the hoyer sling under her correctly. R1 stated you have to turn the buckles under and reported staff were not doing so. R1 stated I had a buckle imbedded in my leg and it kept imbedding in my leg. R1 stated I kept telling them for one month or a month and a half that the buckles were hurting me. Now I have a wound vac because it turned into a bad wound. Review of R1's Braden Scale for Predicting Pressure Sore Risk dated 7/7/20, revealed R1 scored 13 which was a moderate risk for developing pressure ulcers. The form revealed R1's ability to change and control body position was very limited, and friction and shear were a problem. Review of the Concern Form dated 6/22/20 revealed R1 initiated a concern in person and stated sling buckles are not always tucked in/under pillow. Resident asks for them to be tucked in but it does not always happen, even if the resident asks more than once. The Concern Form was assigned for follow up on 7/14/20 and the care plan was updated per resident request. Review of the General Progress Note dated 6/25/2020 revealed Guest verbalized concern over irritation of the rubbing between her thighs. PRN (as needed) pain meds given post repositioning with effectiveness . Makes needs known unto staff. Slept well in bed last night. Said that her bed was very comfortable. Review of the General Progress Note dated 7/12/20 revealed .Resident has open area noted on inner left thigh near fold measuring 1.5 cm x 1.0 cm x 0.1 cm. Wound has pink skin noted and pink wound bed . Review of R1's Activities of Daily Living care plan revealed an update on 7/16/20 that stated Hoyer pad clips to be underneath pillow while in Wheelchair. Not to be between patient legs. This update was done two days after the grievance was assigned for follow-up and 22 days after R1 filed a grievance. Review of the General Progress Note dated 7/16/20 revealed .Complaint of discomfort to left inner thigh. Observation showed 2 open areas. The outer aspect area measures 3.0 x 1.5 cm. The inner aspect measures 2.0 x 1.2 cm . The General Progress Note dated 7/28/20 revealed .wounds to lt (left) inner thigh with serosanguineous drainage. txs (treatments) done per order. area (sic) is tender to touch. The General Progress Note dated 7/29/20 revealed .wound bed to lt (left) inner thigh firm with white and gray tissue present. lt (light) pink drainage observed on drsg (dressing) removed. tender to touch . The General Progress Note dated 8/1/20 revealed lt (left) inner thigh wound with white tissue, firm, painful to touch. no foul odor . The General Progress Note dated 8/5/20 revealed Writer in to speak with resident about wound to inner left leg. She requested to go to the wound clinic. Writer got her an appointment for Thursday 8/6/2020 @930 in the wound clinic. Patient is aware. Another General Progress Note dated 8/5/20 revealed .Treatment to her left inner thigh completed. Wound bed grayish in color peri wound pink. The General Progress Note dated 8/6/20 revealed the wound clinic appointment was scheduled for 8/11/20. Review of the General Progress Note dated 8/7/20 revealed Writer in to measure wound on patient left inner thigh. Measurements are 9.2 (cm) X 3.5 (cm) X 1.3cm. Wound bed is white/gray in color. Non blanchable in the wound bed and surrounding area. A new sling was given to the resident to prevent the wound from worsening. Staff has been educated on how to properly use the sling and tuck the straps so they are not rubbing on her inner thighs . There were no other measurements documented between 7/16/20 and 8/7/20. The General Progress Note dated 8/11/20 revealed res (resident) went to wound clinic for appt this am for lt thigh wound. res to start wound vac when arrives. unit manager notified to order, follow-up on 8/18/20. Review of the wound clinic Consultation Report dated 8/11/20 revealed R1 had a pressure ulcer to her left thigh with large slough and biofilm. Review of the General Progress Notes dated 8/13/20 revealed Resident on ATB for wound infection, Left inner groin. Wound vac was applied to area today, resident tolerated well . and Writer was in to place wound vac on inner thigh. The wound had moderate amount of yellow drainage noted and very tender to touch. The wound measurements 10cm x 4.2cm x 0.4cm deep. Writer placed wound vac without any complications and the pressure is set at 125mm/hg per order from wound clinic. The wound clinic sent back notes stating this is a pressure wound from the maxi lift sling clips. Review of the wound clinic Consultation Report dated 8/18/20 revealed R1 had a stage 3 pressure ulcer to her left thigh. According to the National Pressure Injury Advisory Panel, stage 3 Pressure Injury is defined as full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf) In an interview on 9/17/20 at 8:26 AM, Licensed Practical Nurse (LPN)/Unit Manager (UM) K reported R1 had a pressure ulcer as a result of her hoyer sling. UM K reported the black clamps on the sling were right at her thigh area and staff were leaving the clamps up, against R1's thigh. UM K reported she did not realize there was a longer hoyer sling available until she spoke with maintenance. Resident #3 Review of the medical record revealed Resident #3 (R3) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS datd 8/3/20 revealed R3 required extensive assistance of two staff members for ADLs. On 9/15/20 at 12:52 PM, R3 was observed lying on her back in bed. R3 had a PRO technology ES2 mattress on her bed. The settings were observed to be on standby. At 2:45 PM, R3 was observed in the same position with her mattress still on standby. In an interview on 9/15/20 at 2:53 PM, when asked about R3's mattress settings, LPN C stated we don't personally do that .maintenance usually puts them on and then inflates them. When asked how she would know there was an issue with a mattress, LPN C reported it would beep. At 3:19 PM, the surveyor and LPN C entered R3's room to look at the mattress, which was still on standby. LPN C reported she did not know what standby meant and reported she would check with maintenance. On 9/15/20 at 3:45 PM, Maintenance Staff D reported R3's mattress did not have an alarm. Maintenance Staff D reported R3's mattress could be used when on standby, but that it would not alternate pressure on standby. When asked what the mattress was now set at, Maintenance Staff D stated normal and alternating pressure every 5 minutes. When asked how he knew what settings need to be entered, Maintenance Staff D stated I don't control that.

This citation pertains to MI 934, MI 986 and MI 933. Based on observation, interview and record review, the facility failed to ensure residents were free from abuse and neglect in four of 18 residents reviewed for abuse and neglect, resulting in sexual abuse (Resident #53, #54, #61) and neglect (Resident #60). Findings include: Resident #54 (R54) R54's Minimum Data Set ((MDS) dated [DATE], indicated he was admitted to the facility on [DATE]. R54's same MDS introduced the Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener for nursing home (NH) residents, score was 05 (Scale: 00-07 Severe Impairment). The same assessment revealed R54 did not exhibit any physical, verbal or other behavioral symptoms during the 7-day look-back period. The same assessment revealed R54 had the [DIAGNOSES REDACTED]. R54's Inappropriate Sexual Behavior care plan initiated 10/04/18 and revised 11/15/19 revealed an intervention dated 09/30/19 R54 was not to be left unattended in Sunshine Room. Resident #53 (R53) R53's MDS dated [DATE], revealed a she was admitted to the facility on [DATE], had BIMS score of 15 (13-15 Cognitively Intact) and had the [DIAGNOSES REDACTED]. R53's same MDS assessment indicated she did not exhibit any physical, verbal or other behavioral symptoms during the 7-day look-back period. According to a witness Statement, R53 stated on 09/28/19, she was sleeping in her wheelchair in the sunshine room and was awoken by R54 grabbing her breast. The same statement indicated the event occurred three times on this day, she slapped R54's hand and told him to stop it. In review of R54 progress note dated 11/14/19, at 6:52 PM, at around 1:30 PM, R54 was observed with his hand touching another residents hand in the entry to the sunshine room and was educated to keep his hands to himself. The other resident (R53) reported R54 grabbed her breast and what the writer saw was her pushing his hand away from her. The same note indicated the incident was reported to the nursing home administrator (NHA). The same note indicated later, around 5:30 PM, a certified nurse assistant (CNA) reported R54 grabbed at her groin and breasts when she was getting him up for dinner. The same note indicated the Director of Nursing (DON) was notified. R53 was observed lying in bed and was interviewed on 01/16/20 at 7:55 AM. R53 stated during the same interview her breast was touched without her consent, on two different dates, in September and November of 2019 by R54. Resident #61 (R61) R61's MDS dated [DATE], revealed she was admitted to the facility on [DATE], had a BIMS score of 12 (08-12 Moderate Impairment) and did not exhibit any physical, verbal or other behaviors during the 7-day look-back period. The same MDS indicated R61 had the [DIAGNOSES REDACTED]. According to a physician's progress note dated 10/12/19, R61 was not competent to make informed decisions. In review of an Investigation Report dated 12/25/19 and witness statement dated 12/26/19, on 12/25/19 R54 and R61 were in the main dining room at 11:15 AM, R54 had his hand over R54's breast, then moved his hand between her legs. Both residents were separated and placed on 15-minute checks for 24 hours. The same Investigation Report included an interview with R61, that indicated she reported to the nurse she had ask R54 to stop when he touched her, but later stated she wasn't sure why they could not do those things. During an interview with Floor Care staff N on 01/15/20 at 12:00 PM, he stated on 12/25/19 at 11:15 AM, he went into the main dining room to check the trash and observed R53 with his hands between R61's legs. Floor Care staff N stated in the same interview, if they see R54 going to the main dining room, they re-direct him into the small assisted dining room. On 01/14/20 at 9:55AM, R61 was observed lying in bed wearing hospital gown. R61 stated she recalled the incident on that happened with R54 on Christmas Day and stated she was not in agreement with R54 touching her on her breast and between her legs. DON B was interviewed on 01/15/20 at 3:55 PM and when asked how the facility ensured R54 was not touching other residents inappropriately, she stated they have him in the main areas in the building and he was not left alone in the sunshine room. DON B stated in the same interview she was not aware of the 11/14/19 incident with R53 in the sunshine room. On 01/16/20 at 8:20 AM, Social Worker (SW) I was interviewed and stated she was new to the position as of 01/15/20, but prior to yesterday was consulting at the facility. SW I stated she had not had any conversations with R53 regarding incidents with R54. Resident #60 Review of the medical record and Minimum Data Set (MDS) assessment dated [DATE] revealed resident #60 was an [AGE] year old female resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS revealed Resident #60 had unclear speech, rarely/never understood others, rarely/never understands, was moderately impaired cognitively and required moderate to extensive assistance of 2 staff members for activities of daily living to include transfers. Review of Resident #60's radiology report dated 12/26/19 revealed, There is soft tissue swelling. There is a minimally displaced acute or subacute spiral fracture (A spiral fracture, also known as torsion fracture, is a type of complete fracture. It occurs due to a rotational, or twisting, force) of the distal tibia. There is a minimally displaced subacute or old healing/healed [MEDICAL CONDITION] third of the fibula .Conclusion: Fractures of the distal tibia and fibula (bones in the lower leg) . Review of Resident #60's Emergency Department Trauma note dated 12/26/19 revealed, Closed fracture of left tibia and fibula .The patient is nonambulatory at baseline. Probably fractured the extremity when pivoting though caregivers were not exactly sure .There is no fall noted by family members or caregivers. Review of the Employee Warning Notice form dated 1/6/20 revealed that Certified Nursing Assistant (CNA) D's employment was terminated related to, Violation of work rule .Comply with all health and safety rules, prohibiting unsafe conduct or unsafe acts that jeopardize the health and safety of self or others or result in serious injury. (CNA D) admitted to independently transferring a patient who requires mechanical lifts (Maxi lift) with the patient sustaining injury. During a telephone interview on 1/15/20 at 11:30 a.m., when asked about Resident #60's fractured leg and how it was sustained, CNA D stated, I did get fired for it. I transferred a resident with another staff member and they fired me. When asked to explain how she transferred Resident #60, CNA D stated, From chair to bed, we held her under her arms and foot between her legs. When asked how Resident #60 was supposed to be transferred from the bed to a chair, CNA D stated, A hoyer (maxi-lift). When asked why she didn't use the lift, CNA D stated, It was dinner time and we didn't have time to get the hoyer. When asked to confirm that Resident #60's care plan was not followed, CNA D stated, Right. When asked what neglect is CNA D stated, Leaving a person in a room by themselves, and with like no TV on or anything. When asked what the facility educated her as to what the definition of neglect is, CNA D stated, Improper care for a resident. When asked if transferring Resident #60 without the use of a lift would be considered improper care, CNA D stated, Yes. Review of a typed statement that was taken by Lead Licensed Practical Nurse (LPN) E dated 12/26/19 and signed by CNA D revealed, Have you ever self-transferred (Resident #60)? Yes. When did you self transfer: I don't remember, it was when I was short and I was trying to do it really quickly. Have you ever transferred (Resident #60) without a mechanical lift? Yes, see above. Review of a second typed statement that was taken by LPN E dated 12/26/19 and signed by CNA D revealed, Did you self-transfer this patient (Resident #60) on 12/21/19 or 12/23/19? The 23rd I did. Any time you have self-transferred this patient (Resident #60), were there any issues with the transfer? .I lifted her up under her arms and then I twisted with the patient to get her from her chair into the bed .Are there any good reason that you did not follow proper transfer techniques with this patient (Resident #60)? There is no good reason for me to do it the way I did. I do know that she is a Maxi-Lift for transfers. During an interview on 1/16/20 at 9:30 a.m., when asked why CNA D's written statement indicates that she transferred Resident #60 by herself, but when asked CNA D states it was her and another staff member that transferred Resident #60, Director of Nursing B stated, That was interesting, (CNA D) had originally stated that her hall partner would not help her, and that is why she transferred (Resident #60) on her own. Then a week later she changed her statement and said that she did get help, from the same partner that she originally stated wouldn't help her. When asked who the partner was, DON B stated it was CNA G. During an interview on 1/15/20 at 2:27 p.m., when asked if she helped CNA D improperly transfer Resident #60, CNA G stated, I did not help that lady transfer her, no I did not help her. I know she is a lift transfer. Review of the medical record revealed the following nurse notes: 12/20/2019 1:43 a.m. Type: General Progress Note Resident confused. Takes medications crushed in applesauce .Dependent for position changes while in bed. No evidence of pain or discomfort. 12/24/2019 11:22 a.m. Type: General Progress Note Spoke with (Resident #60's physician) regarding resident increase in pain, and yelling out with care. Also noted resident left lower leg/knee is more swollen with some [MEDICAL CONDITION]. Orders to add Bengay patch to left knee/lower leg and increase in Tylenol orders. Also, to monitor daily for pain . 12/26/2019 4:37 a.m. Type: General Progress Note Note Text: Patient is long term care. She is alert to self. She answers when you call her by name. She takes her meds crushed with applesauce but would only take one bite of her meds. When writer and aide were in to change her she was hitting, scratching and trying to bite staff .When we moved her legs she did scream out in pain but she would not open to take any meds for it. Once we got patient dressed and positioned to comfort she was not screaming out anymore. It was only when we moved her legs. She does have her call light in reach but she does not know how to use it. Staff in frequently to check patient. 12/26/2019 7:04 a.m. Type: General Progress Note Note Text: CNA complaining to writer that patient was screaming again when they got her out of bed. Writer went to examine her leg and it is around her left ankle. The outside of the leg is warm to the touch above the ankle. She does scream to the touch of that area. (Resident #60's physician) notified and we are ordering a XRAY 12/26/2019 2:04 p.m. Type: General Progress Note Note Text: Resident LLE (Left Lower Extremity) with increase swelling and painful when moved. X-Ray .done. Results as follows soft tissue swelling, fx (fracture) of the distal tibia and fibula (bones in the lower leg). Order received to send to (emergency room for Evaluation) . 12/26/2019 6:40 p.m. Type: General Progress Note Note Text: Resident returned to facility with new orders to ensure baby aspirin ordered for [MEDICAL CONDITION] ([MEDICAL CONDITION] [MEDICATION NAME], and to follow up with Ortho (orthopedic) physician. Resident returned with splint/cast to left lower leg. At this times resident does not display any s/sx (signs or symptoms) of pain for discomfort. Review of Resident #60's Activities of Daily Living Care Plan dated 10/9/18 revealed, .Self care deficit related to pain, generalized weakness, poor nutritional intake, history of falls, and osteoartritis (sic) .Interventions: Resident is a Maxi-lift (hoyer lift) for all transfers. Sling size is Red Date Initiated: 05/16/2019. Review of the facility's Transfer: Bed-Chair/Wheelchair policy dated 01/2011 revealed, PURPOSE: To move safely from bed to chair or wheelchair and back again .Attachment 4 Lift Program Skills Check-off Sheet Full Sling Mechanical Lifts (I.E. Tenor/Maxi .) .Maxi .is for totally dependent, partial non-weight-bearing individuals .Maxi .takes someone from bed to chair, floor to bed, chair to bed . During an interview on 1/15/20 at 1:26 p.m., when asked how many staff members are to be used when transferring a resident using the Maxi Lift, CNA F stated that Maxi Lift transfers are Always a 2 person assist. During an interview on 1/15/20 at 2:27 p.m., when asked how many staff members are to be used when transferring a resident using the Maxi Lift, CNA G stated that a Maxi Lift is a 2 person assist transfer. Review of Resident #60's physician orders [REDACTED].#60's pain management regiment were made: -12/26/19, Bengay ultra strength patch, 1 patch one time a day. -12/24/19, Extra Strength Tylenol 500 milligrams, give 1 tablet by mouth four times a day for pain.

This citation pertains to MI 985. Based on interview and record review, the facility failed to ensure adequate resident supervision and ensure a safe resident environment in one of four residents reviewed for smoking safety (Resident #55), resulting in second [MEDICAL CONDITION] his face. Findings include: Resident #55 (R55) R55's hospital Discharge Summary revealed he was a [AGE] year-old hospitalized from [DATE] through 12/26/19, and had the [DIAGNOSES REDACTED]. The same summary indicated R55 was to continue oxygen per nasal cannula at 3 liters (L), around the clock. R55's hospital History and Physical dated 12/19/19, indicated he was actively a smoker, and that he smoked at least one-half a pack per day. Hospital progress notes dated 12/26/19 revealed R55 used cannabis at home and his urine drug screen was positive for cannabis from 12/2019. The same note indicated R55 was aware the hospital was looking into skilled placement at a nursing home facility he was transferred to but did not indicate he was informed it was a non-smoking campus nursing home facility prior to discharge. During an interview with Director of Nursing (DON) B on 01/14/20 at 4:55 PM, she did not recall if she approved R55 admission to the facility and stated there were some referrals she did not review. DON B stated in the same interview that the facility's social worker should have notified the social worker at the hospital that smoking was prohibited on the campus. Social Worker (SW) I was interviewed on 01/16/19 at 8:20 AM and stated she did not review R55's admission referral and just started looking at admission referrals this week. SW I stated in the same interview that that facility had been without a social worker since August 2019, that she had worked on a consulting basis until yesterday, 1/15/19, and was now the facility's full-time social worker. In review of R55's Admission/Readmission Evaluation dated 12/26/19, he was admitted to the facility from the hospital on [DATE] at 4:40 PM and was alert and orientated to person, place and time. The same evaluation revealed R55 was admitted for short term rehabilitation with plan to discharge home. The same evaluation revealed R55 received oxygen therapy and was a current smoker in a non-smoking facility. There was no note in R55's record regarding a discussion to possibly transfer to a nursing home facility that allowed smoking. A Progress Note authored by DON B dated 12/26/19 at 7:20 PM, revealed R55 had requested to go outside for some fresh air and when asked if he was going outside to smoke, he answered yes. R55's same Progress Note indicated I explained to resident about the smoking policy and asked him if he had any smoking materials on his person or in his room and he stated that he did not. He was educated that all materials needed to be locked up in the med (medication) room . According to the Non-Smoking in Facility policy, dated January 2018, residents who were current smokers or had a history of [REDACTED]. In review of R55's care plan, there were no care plans to address his desire for smoking/unsafe smoking. There were no Smoking Evaluation Assessment's found in R55 medical record. During an interview with DON B on 01/14/20 at 4:55 PM, she stated R55 was frequently checked on by the nurses, but she could not recall how often. DON B stated during the same interview that no behavior agreement with R55 was considered. DON B stated she could not verify if R55's visitor(s) were educated on the facility's smoking policy. DON B stated in the same interview, one to one supervision or scheduled checks were not considered for R55. Progress Note dated 12/26/19 at 10:03 PM revealed between the hours of 9:00 PM and 9:30 PM, .a very strong odor of marijuana was noted in the hallway out side (sic) residents room (R55). Upon entering the room the odor became more pronounced in bathroom and clinging to resident himself. When confronted resident denies using. A milk carton was found in resident bathroom [MEDICAL CONDITION] both sides and ash inside of carton. On call supervisor was notified. Resident educated that this is a non-smoking facility and he cannot be doing this. He verbalizes understanding. In an interview with Registered Nurse (RN) M on 01/15/20 at 1:40 PM, she stated on 12/26/19 at around 9:00 PM, she smelled marijuana smoke when she was in the hallway passing medications. During the same interview, RN M stated the smoke came from R55's room and the smell was stronger in his bathroom. RN M stated in the same interview, she observed a burned milk carton in R55's bathroom, and it looked like he used the milk carton to put the fire out. RN M stated she reported to DON B and educated R55 on the no-smoking policy. RN M stated in the same interview, no other interventions were considered or implemented. Activities Progress Note dated 12/27/2019 at 2:12 PM, revealed R55 areas of interest included marijuana parties with friends. During an interview with Nursing Home Administrator (NHA) A and DON B on 01/16/20 at 8:37 AM, they confirmed no referrals were made to other nursing homes in the area that allowed smoking after R55's request to smoke outside or after he smoked in his room/bathroom. In a witness Statement dated 12/27/19, Physical Therapist (PT) J described details of an incident she witnessed on 12/27/19 at 8:00 PM, when she was working in the therapy gym. PT J stated she observed R55 in a wheelchair in the hallway, hitting his face in an attempt to put out a fire with his hands. The same statement indicated PT J in response to the fire, immediately jumped up, grabbed a pitcher of water that was near the door, ran out into the hall and poured the water on R55. In an interview with PT J on 01/16/20 at 7:45 AM, PT J stated that she had poured a nearly full two-quart size pitcher of water on R55's face, his nasal cannula oxygen tubing had fell off and was still burning on the floor. PT J stated the fire on the oxygen tubing was stomped out by R55. PT J stated in the same interview that after the fire was put out, she saw the nurse down the hall and waved for her to assist, and the nurse turned of the oxygen. Licensed Practical Nurse (LPN) C was interviewed on 01/14/20 at 2:00 PM and stated she responded to the fire with R55 on 12/27/19 at 8:00 PM. LPN C stated she observed black scorch marks inside his oxygen tubing that was melted from the ear piece down. In LPN C's witness Statement dated 12/27/19, LPN C noted a joint R55 had been smoking was on the floor. The same statement indicated R55 was observed with charring around is nose and redness on his face. The same statement indicated R55 was transferred to the emergency room at approximately 9:00 PM. According to an 2006 article titled Home Oxygen Therapy and Cigarette Smoking: a Dangerous Practice, retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 38/, An oxygen-[MEDICATION NAME] environment facilitates ignition and combustion of any material and nasal cannula tubing, when ignited, emitted an intense flame. Progress Note dated 12/28/2019 at 1:05AM revealed DON B was notified of the 12/27/19 at 8:00 PM incident involving R55 and arrived at the facility at 8:30 PM. The same note revealed all smoking material was obtained by resident to include half smoked joint and lighter. The same note indicated R55 was transferred to the emergency room for possible respiratory issue [MEDICAL CONDITION] upper lip and nose. The same note revealed receiving hospital was notified on 12/27/19 at approximately 12:45 AM the facility would not be taking resident back into facility as he was educated several times on smoking policy and was non-compliant with policy and bringing him back into facility would put facility at detrimental safety risk. emergency room Note dated 12/27/19 at 10:18 PM revealed R55 stated .he was lighting up a joint while wearing a nasal cannula with 3 L of O2 (oxygen) on and it blew up in his face . The same note revealed R55 had complained of pain and presented with second [MEDICAL CONDITION] his nares and on both sides of his medial (between eyes and nose) cheeks. The same emergency department notes indicated R55 was discharged home, was to schedule an appointment with the Burn and Wound Center and apply [MEDICATION NAME] (topical antibiotic) twice daily to his burn. Hospital Social Worker note dated 12/28/19 at 1:19 AM revealed the facility was contacted and would not release R55's medications. The same note indicated the hospital physician wrote prescriptions for two antibiotics that he was taking previously for pneumonia.

Based on observation, interview and record review the facility failed to monitor hot beverage temperatures for 1 of 8 residents reviewed (Resident #2) for hot beverage ingestion, resulting in 2 blistering second degree burns, excruciating pain and hot liquids served without checking temperatures first. Findings Include: On 7/25/19 at around 8:10 AM, The Electronic Medical Record (EMR) reflected R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her most recent Quarterly Minimum Data Set (MDS: resident assessment tool) dated 4/15/19 reflected R2 required extensive assistance of 1-2 persons for transfers, dressing, and toileting. Also, that she had bilateral lower extremity impairment. An incident report dated 7/11/19 at 6:00 PM for Resident #2 (R2) was reviewed. The incident report prepared by Licensed Practical Nurse (LPN C) reflected R2 developed a burn while in the dining room. The incident description reflected: Resident was in main dining room for dinner and was served hot chocolate per request with lid on drink. res stated she took off lid and put hot chocolate in front of her. When CENA (Competency Evaluated Nursing Assistant) was applying clothing protector the hot chocolate was accidentally hit knocking it onto her abdomen and lt (left) upper thigh. Res not sure whose hand hit the cup. Skin assessed and red area to left upper abdomen 4 x 5 cm with blister of 2.9 x 2 cm; lower abdomen lt with red area 5 x 9 cm with blister of 2 x 2 cm; left upper thigh with red area of 4 x 9 cm Doctor (Dr. H) notified. 97.1 - 18- 156/88 - 63. The report reflected R2 was not taken to the hospital, and the corrective action was to encourage resident to leave lid on hot drinks. The Mayo Clinic 2019 Online Burn Health Information Reference reflected the following: 2nd-degree burn. This type of burn affects both the epidermis and the second layer of skin (dermis). It may cause swelling and red, white or splotchy skin. Blisters may develop, and pain can be severe. Deep second-[MEDICAL CONDITION] cause scarring. Treatment reflected: For serious burns, after appropriate first aid and wound assessment, your treatment may involve medications, wound dressings, therapy and surgery. The goals of treatment are to control pain, remove dead tissue, prevent infection, reduce scarring risk and regain function. On 7/25/19 at 10:19 AM Dietary Worker (DW G) was asked for the hot liquids temperature log. DW G obtained the log book and handed it to writer. Temperatures were noted taken for hot beverages starting on 7/12/19 at Dinner time. When asked where were temperatures for Breakfast, Lunch, and Dinner from 7/1/19 - 7/11/19, DW G and DW J revealed the hot beverage log was newly started on 7/12/19 at Dinner time. Both staff were asked who the Dietary Manager (DM) was, and revealed there had not DM since the end of May 2019. A new DM was just hired and would be starting soon. DW J revealed, Hot water temps are taken just before we serve Breakfast at 7:00 AM, Lunch at 11:00 AM and Dinner at 5:00 PM. There were no temperatures taken for hot liquids at all on 7/11/19. Documentation of hot beverages were noted from 7/12/19 at Dinner, to 7/25/19 at Breakfast. The hot beverage temperatures ranged from 125 to 161.4 degrees Fahrenheit (F). The highest second temperature noted was 160.2 degrees F. The hot beverage log reflected the Dining Room, Cart 1, Cart 2 and Cart 3, each reflecting 2 temperatures for each item. DW W referred to a document on a clipboard in the kitchen the reflected, Clinical Insight A Proven Leader FYI Alert, dated October 2013 Number 28 Hot Beverage Safety. Under Background reflected: .However, injuries may occur when skin comes in contact with hot liquids or steam. This may happen with accidental spills or splashes of hot food and beverages. Patients are at increased risk because skin tends to be less sensitive, reaction times are reduced, and immobility may prevent the ability to remove contact with the hot liquid or cause a tendency not to pull away quickly enough. Under Safety Considerations reflected: Consider the temperature range of 150-155 degrees F as an approximate guide for hot beverages leaving the kitchen, decant hot beverages from insulated large urns to smaller containers allowing for cooling, and keep hot beverages uncovered as long as possible before serving to the patient. At 11:06 AM DW J and DW E were asked, who had been in charge of the kitchen since the end of May 2019. DW J stated, I do from day to day, but the paperwork is done by Human Resources and the Administrator. The progress notes written by LPN C on 7/11/19 at 7:30 PM reflected: Note Text: at approximately 1800 resident was in Main dining room for dinner and was served hot chocolate per request with lid on drink. Res stated she took off lid and put hot chocolate in front of her. When CENA was applying clothing protector the hot chocolate was accidentally hit knocking it onto her abdomen and lt upper thigh. Res skin assessed and red area to left upper abdomen 4 x 5 cm with blister of 2.9 x 2 cm; lower abd lt with red area 5 x 9 cm with blister of 2 x 2 cm; left upper thigh with red area of 4 x 9 cm. Dr. H notified vs. 97.1- 18- 156/88- 63 Res educated and encouraged to leave lids on hot drinks. CENA I who assisted with the clothing protector on 7/11/19, statement was reviewed. The statement dated 7/12/19 reflected, CENT I served R2 about 10 minutes after the cart was pulled from the kitchen, and that CENA I assisted R2 with cleaning it up to get the hot liquid off her with the clothing protector. R2 needed to be changed and was taken to her room. There was not documentation to reflect a cold compress, ice or any cooling element was applied to R2's affected burn areas. On 7/25/19 at 11:25 AM R2 was interviewed and asked to recall to incident on 7/11/19. R2 stated, I was just an accident, hot cocoa spilled on me, they put it on the table. She was putting the clothing protector in front of me and I was trying to get my shawl straighten out, and it spilled. Both of our hands hit the table not sure how it happened. The lid was not on it then. I had taken it off. R2 was asked if she had gotten burned and stated, Yes, and it hurts now. I had blisters. When asked how was her pain when it first happened, R2 stated, Honey you can't imagine it was higher than possible. It was painful. That was a heat, hot pain. R2 was then educated on the 0-10 pain scale (0 none, 5 moderate and 10 severe pain). R2 stated, When it happened it was a 20. Now, it's not the same type of pain. It's tender and sore now, and a 5. R2 was asked what kind of treatment did the facility provide to the burned area. R2 revealed, The first night it occurred they watched it, it had blisters. They did not put anything on it. They put cream on it the next day when the blisters broke. Now they are still putting cream on it, and its getting better. At 11:43 AM unit manager Registered Nurse (RN F) was interviewed. RN F revealed she was aware of R2's burns. When asked where was R2's hot liquid assessments, RN F looked in her computer, revealed she could not find it and referred to the Director Of Nursing (DON B). When asked where was the hot liquids care plan for R2, RN F looked in her computer and revealed she could not find one. RN F also revealed, she could not find hot liquids addressed in R2's nutritional care plan. At 11:51 AM DON B was interviewed, and asked where was R2's hot liquid assessment and hot liquid care plan. DON B replied, There would not necessarily be one. If she was assessed safe with hot liquids. If she wasn't and needed a lid then I would develop a care plan specifically for that. If she needed the lid that would have been care planed, or if she needed some type of adaptive equipment. Maybe I could have added move cup closer. DON B provided a hot liquid assessment dated [DATE] for R2 (4 days after the burn), while the most recent hot liquid assessment prior to that date was 10/9/17. On 7/25/19 at 12:29 PM the July 2019 Medication Administration Record (MAR), reflected R2 was ordered to receive (1) [MEDICATION NAME]-[MEDICATION NAME] 7.5/325 milligram (mg) tablet orally 4 x a day. R2 was administered [MEDICATION NAME]-[MEDICATION NAME] on 7/11/19 at 7:00 PM. In addition, R2 was administered (2) Tylenol Extra Strength (ES) 500 mg tablets on 7/11/19 at 6:30 PM (which was available as needed every 6 hours for pain). As of 7/25/19 12:29 PM the Tylenol ES 500 mg tablets had been administered one time only for the month of July 2019, and that was on 7/11/19 (the day of the burn). The July 2019 MAR indicated R2 did not normally take the Tylenol ES for pain. No pain level was documented or indicated on the MAR, related to the Tylenol dose. The July 2019 MAR and Treatment Administration Record (TAR), were negative related to any treatments provided to the burned and blistered areas for R2. Also, The EMR was negative for any written documentation reflecting first aid and/or treatment was provided by LPN C or any nursing staff on 7/11/19 for R2's burns. The last progress note written on 7/11/19, was at 7:30 PM. Subsequently on 7/12/19 at 9:00 AM an order was written by Dr. H reflecting, Apply [MEDICATION NAME] cream to burn blister to left abdomen three times a day and as needed until healed. WebMD 2019 Medication reference reflected [MEDICATION NAME] as: This medication is used with other treatments to help prevent and treat wound infections in patients with serious burns. Silver [MEDICATION NAME] works by stopping the growth of bacteria that may infect an open wound. This helps to decrease the risk of the bacteria spreading to surrounding skin, or to the blood where it can cause a serious blood infection (sepsis). On 7/25/19 at 12:48 PM Dr. H was interviewed by phone. He was informed that the EMR reflected R2 had redness with blisters related to a hot liquid spill on 7/11/19, and if recalled giving any orders. Dr. H revealed, he thought there were not blisters at the time. When asked what would he expect nursing staff to do if that was case, he revealed observation and an ice pack. At 1:38 PM with CENA I present and privacy established in R2's room, R2 pulled up her shirt and allowed the writer to visualize her burned areas. R2 had an area noted under her left breast, that had an oblong like shape. It was about 1-2 inches in length, and noted to be pink and light brown in color. The second affected area was noted at her upper left abdomen, around the size of a silver dollar, was darker brown (than her normal skin tone) in color, with a shiny surface. R2 expressed the area was still tender and painful. CENA I was interviewed at 1:44 PM about the incident dated 7/11/19. CENA I revealed hot cocoa was dumped down R2's left side, when R2 moved her elbow while clothing protector was being applied. CENA I revealed she soaked up the hot liquid with the clothing protector, and another CENA took R2 to her room to be changed. CENA I revealed she had since been educated, to apply something cold to areas of hot liquids to prevent blisters and burns. On 7/29/19 at 11:51 AM LPN C was interviewed and asked to recall R2's incident dated 7/11/19. LPN C revealed R2 was brought to her room, and she was informed of R2's hot liquid spill during mealtime. R2 had redness at her left upper thigh and 2 areas on abdomen that were red and wrinkled, like she had a couple creases in 2 separate areas, that could maybe become a blister. She notified the physician of what happened, and he did not give any orders, but said to monitor it. When asked what treatment she gave to the affected areas, LPN C revealed she did nothing and typed up the report. LPN C was asked when she typed up the report, did she document what she saw at the time. LPN C replied Yes. LPN C was informed that her progress note dated 7/11/19 at 7:30 and the incident report dated 7/11/19 at 7:00 PM, reflected R2 had 2 areas of redness with blisters and 1 area with redness. When asked if she should have provided some type of first aide and/or treatment, LPN C revealed there was no policy for that. If there was a burn and it needed to be treated, that would be up to the physician. When asked why she did not provide first aide or treatment LPN C stated, She did not want anything on it. LPN C was asked where was that documented. LPN C replied, she did not document it.

Based on observation, interview and record review the facility failed to monitor hot beverage temperatures for 1 of 8 residents reviewed (Resident #2) for hot beverage ingestion, resulting in 2 blistering second degree burns, excruciating pain and hot liquids served without checking temperatures first. Findings Include: On 7/25/19 at around 8:10 AM, The Electronic Medical Record (EMR) reflected R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her most recent Quarterly Minimum Data Set (MDS: resident assessment tool) dated 4/15/19 reflected R2 required extensive assistance of 1-2 persons for transfers, dressing, and toileting. Also, that she had bilateral lower extremity impairment. An incident report dated 7/11/19 at 6:00 PM for Resident #2 (R2) was reviewed. The incident report prepared by Licensed Practical Nurse (LPN C) reflected R2 developed a burn while in the dining room. The incident description reflected: Resident was in main dining room for dinner and was served hot chocolate per request with lid on drink. res stated she took off lid and put hot chocolate in front of her. When CENA (Competency Evaluated Nursing Assistant) was applying clothing protector the hot chocolate was accidentally hit knocking it onto her abdomen and lt (left) upper thigh. Res not sure whose hand hit the cup. Skin assessed and red area to left upper abdomen 4 x 5 cm with blister of 2.9 x 2 cm; lower abdomen lt with red area 5 x 9 cm with blister of 2 x 2 cm; left upper thigh with red area of 4 x 9 cm Doctor (Dr. H) notified. 97.1 - 18- 156/88 - 63. The report reflected R2 was not taken to the hospital, and the corrective action was to encourage resident to leave lid on hot drinks. The Mayo Clinic 2019 Online Burn Health Information Reference reflected the following: 2nd-degree burn. This type of burn affects both the epidermis and the second layer of skin (dermis). It may cause swelling and red, white or splotchy skin. Blisters may develop, and pain can be severe. Deep second-[MEDICAL CONDITION] cause scarring. Treatment reflected: For serious burns, after appropriate first aid and wound assessment, your treatment may involve medications, wound dressings, therapy and surgery. The goals of treatment are to control pain, remove dead tissue, prevent infection, reduce scarring risk and regain function. On 7/25/19 at 10:19 AM Dietary Worker (DW G) was asked for the hot liquids temperature log. DW G obtained the log book and handed it to writer. Temperatures were noted taken for hot beverages starting on 7/12/19 at Dinner time. When asked where were temperatures for Breakfast, Lunch, and Dinner from 7/1/19 - 7/11/19, DW G and DW J revealed the hot beverage log was newly started on 7/12/19 at Dinner time. Both staff were asked who the Dietary Manager (DM) was, and revealed there had not DM since the end of (MONTH) 2019. A new DM was just hired and would be starting soon. DW J revealed, Hot water temps are taken just before we serve Breakfast at 7:00 AM, Lunch at 11:00 AM and Dinner at 5:00 PM. There were no temperatures taken for hot liquids at all on 7/11/19. Documentation of hot beverages were noted from 7/12/19 at Dinner, to 7/25/19 at Breakfast. The hot beverage temperatures ranged from 125 to 161.4 degrees Fahrenheit (F). The highest second temperature noted was 160.2 degrees F. The hot beverage log reflected the Dining Room, Cart 1, Cart 2 and Cart 3, each reflecting 2 temperatures for each item. DW W referred to a document on a clipboard in the kitchen the reflected, Clinical Insight A Proven Leader FYI Alert, dated (MONTH) 2013 Number 28 Hot Beverage Safety. Under Background reflected: .However, injuries may occur when skin comes in contact with hot liquids or steam. This may happen with accidental spills or splashes of hot food and beverages. Patients are at increased risk because skin tends to be less sensitive, reaction times are reduced, and immobility may prevent the ability to remove contact with the hot liquid or cause a tendency not to pull away quickly enough. Under Safety Considerations reflected: Consider the temperature range of 150-155 degrees F as an approximate guide for hot beverages leaving the kitchen, decant hot beverages from insulated large urns to smaller containers allowing for cooling, and keep hot beverages uncovered as long as possible before serving to the patient. At 11:06 AM DW J and DW [NAME] were asked, who had been in charge of the kitchen since the end of (MONTH) 2019. DW J stated, I do from day to day, but the paperwork is done by Human Resources and the Administrator. The progress notes written by LPN C on 7/11/19 at 7:30 PM reflected: Note Text: at approximately 1800 resident was in Main dining room for dinner and was served hot chocolate per request with lid on drink. Res stated she took off lid and put hot chocolate in front of her. When CENA was applying clothing protector the hot chocolate was accidentally hit knocking it onto her abdomen and lt upper thigh. Res skin assessed and red area to left upper abdomen 4 x 5 cm with blister of 2.9 x 2 cm; lower abd lt with red area 5 x 9 cm with blister of 2 x 2 cm; left upper thigh with red area of 4 x 9 cm. Dr. H notified vs. 97.1- 18- 156/88- 63 Res educated and encouraged to leave lids on hot drinks. CENA I who assisted with the clothing protector on 7/11/19, statement was reviewed. The statement dated 7/12/19 reflected, CENT I served R2 about 10 minutes after the cart was pulled from the kitchen, and that CENA I assisted R2 with cleaning it up to get the hot liquid off her with the clothing protector. R2 needed to be changed and was taken to her room. There was not documentation to reflect a cold compress, ice or any cooling element was applied to R2's affected burn areas. On 7/25/19 at 11:25 AM R2 was interviewed and asked to recall to incident on 7/11/19. R2 stated, I was just an accident, hot cocoa spilled on me, they put it on the table. She was putting the clothing protector in front of me and I was trying to get my shawl straighten out, and it spilled. Both of our hands hit the table not sure how it happened. The lid was not on it then. I had taken it off. R2 was asked if she had gotten burned and stated, Yes, and it hurts now. I had blisters. When asked how was her pain when it first happened, R2 stated, Honey you can't imagine it was higher than possible. It was painful. That was a heat, hot pain. R2 was then educated on the 0-10 pain scale (0 none, 5 moderate and 10 severe pain). R2 stated, When it happened it was a 20. Now, it's not the same type of pain. It's tender and sore now, and a 5. R2 was asked what kind of treatment did the facility provide to the burned area. R2 revealed, The first night it occurred they watched it, it had blisters. They did not put anything on it. They put cream on it the next day when the blisters broke. Now they are still putting cream on it, and its getting better. At 11:43 AM unit manager Registered Nurse (RN F) was interviewed. RN F revealed she was aware of R2's burns. When asked where was R2's hot liquid assessments, RN F looked in her computer, revealed she could not find it and referred to the Director Of Nursing (DON B). When asked where was the hot liquids care plan for R2, RN F looked in her computer and revealed she could not find one. RN F also revealed, she could not find hot liquids addressed in R2's nutritional care plan. At 11:51 AM DON B was interviewed, and asked where was R2's hot liquid assessment and hot liquid care plan. DON B replied, There would not necessarily be one. If she was assessed safe with hot liquids. If she wasn't and needed a lid then I would develop a care plan specifically for that. If she needed the lid that would have been care planed, or if she needed some type of adaptive equipment. Maybe I could have added move cup closer. DON B provided a hot liquid assessment dated [DATE] for R2 (4 days after the burn), while the most recent hot liquid assessment prior to that date was 10/9/17. On 7/25/19 at 12:29 PM the (MONTH) 2019 Medication Administration Record (MAR), reflected R2 was ordered to receive (1) [MEDICATION NAME]-[MEDICATION NAME] 7.5/325 milligram (mg) tablet orally 4 x a day. R2 was administered [MEDICATION NAME]-[MEDICATION NAME] on 7/11/19 at 7:00 PM. In addition, R2 was administered (2) Tylenol Extra Strength (ES) 500 mg tablets on 7/11/19 at 6:30 PM (which was available as needed every 6 hours for pain). As of 7/25/19 12:29 PM the Tylenol ES 500 mg tablets had been administered one time only for the month of (MONTH) 2019, and that was on 7/11/19 (the day of the burn). The (MONTH) 2019 MAR indicated R2 did not normally take the Tylenol ES for pain. No pain level was documented or indicated on the MAR, related to the Tylenol dose. The (MONTH) 2019 MAR and Treatment Administration Record (TAR), were negative related to any treatments provided to the burned and blistered areas for R2. Also, The EMR was negative for any written documentation reflecting first aid and/or treatment was provided by LPN C or any nursing staff on 7/11/19 for R2's burns. The last progress note written on 7/11/19, was at 7:30 PM. Subsequently on 7/12/19 at 9:00 AM an order was written by Dr. H reflecting, Apply [MEDICATION NAME] cream to burn blister to left abdomen three times a day and as needed until healed. WebMD 2019 Medication reference reflected [MEDICATION NAME] as: This medication is used with other treatments to help prevent and treat wound infections in patients with serious burns. Silver [MEDICATION NAME] works by stopping the growth of bacteria that may infect an open wound. This helps to decrease the risk of the bacteria spreading to surrounding skin, or to the blood where it can cause a serious blood infection (sepsis). On 7/25/19 at 12:48 PM Dr. H was interviewed by phone. He was informed that the EMR reflected R2 had redness with blisters related to a hot liquid spill on 7/11/19, and if recalled giving any orders. Dr. H revealed, he thought there were not blisters at the time. When asked what would he expect nursing staff to do if that was case, he revealed observation and an ice pack. At 1:38 PM with CENA I present and privacy established in R2's room, R2 pulled up her shirt and allowed the writer to visualize her burned areas. R2 had an area noted under her left breast, that had an oblong like shape. It was about 1-2 inches in length, and noted to be pink and light brown in color. The second affected area was noted at her upper left abdomen, around the size of a silver dollar, was darker brown (than her normal skin tone) in color, with a shiny surface. R2 expressed the area was still tender and painful. CENA I was interviewed at 1:44 PM about the incident dated 7/11/19. CENA I revealed hot cocoa was dumped down R2's left side, when R2 moved her elbow while clothing protector was being applied. CENA I revealed she soaked up the hot liquid with the clothing protector, and another CENA took R2 to her room to be changed. CENA I revealed she had since been educated, to apply something cold to areas of hot liquids to prevent blisters and burns. On 7/29/19 at 11:51 AM LPN C was interviewed and asked to recall R2's incident dated 7/11/19. LPN C revealed R2 was brought to her room, and she was informed of R2's hot liquid spill during mealtime. R2 had redness at her left upper thigh and 2 areas on abdomen that were red and wrinkled, like she had a couple creases in 2 separate areas, that could maybe become a blister. She notified the physician of what happened, and he did not give any orders, but said to monitor it. When asked what treatment she gave to the affected areas, LPN C revealed she did nothing and typed up the report. LPN C was asked when she typed up the report, did she document what she saw at the time. LPN C replied Yes. LPN C was informed that her progress note dated 7/11/19 at 7:30 and the incident report dated 7/11/19 at 7:00 PM, reflected R2 had 2 areas of redness with blisters and 1 area with redness. When asked if she should have provided some type of first aide and/or treatment, LPN C revealed there was no policy for that. If there was a burn and it needed to be treated, that would be up to the physician. When asked why she did not provide first aide or treatment LPN C stated, She did not want anything on it. LPN C was asked where was that documented. LPN C replied, she did not document it.

This citation pertains to MI 595 Based on observation, interview, and record review, the facility failed to ensure admission medication orders were transcribed properly for 1 (Resident #3) of 3 reviewed for medication errors, from a total sample of 3, resulting in Resident #3 receiving an incorrect dose of Oxcarbazapine (anticonvulsant/[MEDICAL CONDITION] medication), sustaining 2 [MEDICAL CONDITION], and transfer to the hospital. Findings include: Medication reconciliation is the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care. This process comprises five steps: (1) develop a list of current medications; (2) develop a list of medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the patient. (Barnsteiner JH. Medication Reconciliation. In:(NAME)RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 38. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2648/) Review of the facility's Requirements and Guidelines for Clinical Record Content dated 2017, revealed .Physician orders [REDACTED]. The nurse is responsible for the accuracy of transcription and signs and dates the orders as noted. The licensed nurse, noting the order, transcribes the new medication or treatment onto the patient's Medication Administration Record [REDACTED]. Review of the facility's Requirements and Guidelines for Clinical Record Content dated 2017, revealed .Physician orders [REDACTED]. The nurse is responsible for the accuracy of transcription and signs and dates the orders as noted. The licensed nurse, noting the order, transcribes the new medication or treatment onto the patient's Medication Administration Record [REDACTED]. Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 was a [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An observation on 8/24/17 at 8:57 am, revealed Resident #3 was asleep in bed. Review of Resident #3's hospital medication list printed 7/28/17, revealed [MEDICATION NAME] take 600 mg tablet by mouth once daily and [MEDICATION NAME] take 750 mg by mouth every evening. Takes 600 mg in AM, 750 mg in PM every day. The doses were listed on 2 separate lines and there was an asterisk (*) next to each entry. The medication list revealed * Notice: This list has 2 medication(s) that are the same as other medications prescribed for you. Read the directions carefully, and ask your doctor or other care provider to review them with you. Review of Resident #3's facility Admission Physicians Orders dated 7/28/17, revealed [MEDICATION NAME] 600 mg daily for [MEDICAL CONDITION]. There was no additional order transcribed for [MEDICATION NAME] 750 mg every evening. Review of Resident #3's MARs dated 7/2017 and 8/2017 revealed he received [MEDICATION NAME] 600 mg daily at 8:00 am. Review of the Incident Report-Patient Involved dated 8/11/17 at 9:00 pm, revealed Resident's admission medications prescribed incorrectly. Resident was to have scheduled [MEDICATION NAME] 750 mg PO (by mouth) every evening in addition to 600 mg PO daily every morning. Review of Resident #3's General Progress Note dated 8/6/17 at 17:32 (5:32 pm), revealed Resident was observed having a [MEDICAL CONDITION] around 60 seconds at 1430 hrs (2:30 pm). He soon came out of it but seemed anxious as he stated that was the first time he ever had the experience . Review of the Medical Practitioner Note (Physician/NP) dated 8/8/17, revealed Nurse Practitioner (NP) G assessed Resident #3. The note revealed I was just made aware that he had a [MEDICAL CONDITION] on Sunday [MEDICATION NAME] 60 seconds .I have added prn (as needed) [MEDICATION NAME] for breakthrough [MEDICAL CONDITION] activity. The note mentioned Resident #3's [MEDICATION NAME] level which was in normal range and his [MEDICATION NAME] (anticonvulsant/[MEDICAL CONDITION] medication) dose. The note mentioned that [MEDICATION NAME] and Tileptal ([MEDICATION NAME]) were used for Resident #3's [MEDICAL CONDITION], but the note did not mention the dose of [MEDICATION NAME] nor that a transcription error had occurred. Review of Resident #3's General Progress Note dated 8/11/17 at 17:00 (5:00 pm), revealed Resident's roommate notified nurse that his roommate needed assistance. When I entered room resident was laying supine on his bed actively seizing. I did not witness the start of the [MEDICAL CONDITION], the [MEDICAL CONDITION] lasted for 3 minutes once I entered the room and laid eyes on him. Neuros performed, pupils equal and very slow to react. NP and daughter notified, NP stated that he could remain in facility and we could continues (sic) to monitor. Sister and DPOA requested that resident be sent to ER. We did as she requested. Review of the hospital Emergency Department Note dated 8/11/17, revealed patient is a [AGE] year-old male presenting to the ED with [MEDICAL CONDITION] activity .(name of facility) states that patient had a [MEDICAL CONDITION] on 8/6 that lasted roughly 2 minutes. Patient had an additional [MEDICAL CONDITION] earlier today that lasted 3 minutes and they decided to send him to the ED for medication review. Patient was recently hospitalized and his [MEDICAL CONDITION] medications were adjusted .Medications were reviewed with patient sister and nursing home. Patient was receiving [MEDICATION NAME] twice a day 2000 mg and [MEDICATION NAME] ([MEDICATION NAME]) 600 mg in the morning. Patient's medication had recently been adjusted and he was supposed to be taking an additional 750 [MEDICATION NAME] at night. Patient given a 1 mg dose of [MEDICATION NAME] in ED. Patient's night dose of [MEDICATION NAME] 750 given in ED .nursing home was notified that patient's nigh dose of [MEDICATION NAME] has been skipped for some time. Instructed nursing home to give second dose of medications. Patient's increase in [MEDICAL CONDITION] activity is most probably due to mismanagement of [MEDICAL CONDITION] control medications . In a telephone interview on 8/24/17 at 12:11 pm, Registered Nurse (RN) D reported she assisted Licensed Practical Nurse (LPN) E with verifying Resident #3's admission orders [REDACTED]. RN D stated we missed one medication .it was all the stress. It was late and we had our patients and an admission. The surveyor attempted to contact LPN E via telephone on 8/24/17 at 10:54 am. A voicemail was left requesting a return call. A return call was not received prior survey exit. In an interview on 8/24/17 at 12:23 pm, NP G reported when a resident was admitted to the facility, orders were verified over the phone between the physician and the facility's nursing staff. NP G stated we don't know what he's on in the hospital .meds are verified over the phone. We wouldn't have a med list in front of us over the phone. In an interview on 8/24/17 at 11:25 am, Director of Nursing (DON) B stated he (Resident #3) had a [MEDICAL CONDITION] on 8/11 and when they reviewed the chart, there was a med error that was found .it was a transcription error.

This citation pertains to MI 595 Based on observation, interview, and record review, the facility failed to prevent a significant medication error for 1 (Resident #3) of 3 reviewed for medication errors, from a total sample of 3, resulting in Resident #3 receiving an incorrect dose of Oxcarbazapine (anticonvulsant/[MEDICAL CONDITION] medication), sustaining 2 [MEDICAL CONDITION], and transfer to the hospital. Findings include: Review of the facility's Requirements and Guidelines for Clinical Record Content dated 2017, revealed .Physician orders [REDACTED]. The nurse is responsible for the accuracy of transcription and signs and dates the orders as noted. The licensed nurse, noting the order, transcribes the new medication or treatment onto the patient's Medication Administration Record [REDACTED]. Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 was a [AGE] year old male, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An observation on 8/24/17 at 8:57 am, revealed Resident #3 was asleep in bed. Review of Resident #3's hospital medication list printed 7/28/17, revealed [MEDICATION NAME] take 600 mg tablet by mouth once daily and [MEDICATION NAME] take 750 mg by mouth every evening. Takes 600 mg in AM, 750 mg in PM every day. The doses were listed on 2 separate lines and there was an asterisk (*) next to each entry. The medication list revealed * Notice: This list has 2 medication(s) that are the same as other medications prescribed for you. Read the directions carefully, and ask your doctor or other care provider to review them with you. Review of Resident #3's facility Admission Physicians Orders dated 7/28/17, revealed [MEDICATION NAME] 600 mg daily for [MEDICAL CONDITION]. There was no additional order transcribed for [MEDICATION NAME] 750 mg every evening. Review of Resident #3's MARs dated 7/2017 and 8/2017 revealed he received [MEDICATION NAME] 600 mg daily at 8:00 am. Review of the Incident Report-Patient Involved dated 8/11/17 at 9:00 pm, revealed Resident's admission medications prescribed incorrectly. Resident was to have scheduled [MEDICATION NAME] 750 mg PO (by mouth) every evening in addition to 600 mg PO daily every morning. Review of Resident #3's General Progress Note dated 8/6/17 at 17:32 (5:32 pm), revealed Resident was observed having a [MEDICAL CONDITION] around 60 seconds at 1430 hrs (2:30 pm). He soon came out of it but seemed anxious as he stated that was the first time he ever had the experience . Review of the Medical Practitioner Note (Physician/NP) dated 8/8/17, revealed Nurse Practitioner (NP) G assessed Resident #3. The note revealed I was just made aware that he had a [MEDICAL CONDITION] on Sunday [MEDICATION NAME] 60 seconds .I have added prn (as needed) [MEDICATION NAME] for breakthrough [MEDICAL CONDITION] activity. The note mentioned Resident #3's [MEDICATION NAME] level which was in normal range and his [MEDICATION NAME] (anticonvulsant/[MEDICAL CONDITION] medication) dose. The note mentioned that [MEDICATION NAME] and Tileptal ([MEDICATION NAME]) were used for Resident #3's [MEDICAL CONDITION], but the note did not mention the dose of [MEDICATION NAME] nor that a transcription error had occurred. Review of Resident #3's General Progress Note dated 8/11/17 at 17:00 (5:00 pm), revealed Resident's roommate notified nurse that his roommate needed assistance. When I entered room resident was laying supine on his bed actively seizing. I did not witness the start of the [MEDICAL CONDITION], the [MEDICAL CONDITION] lasted for 3 minutes once I entered the room and laid eyes on him. Neuros performed, pupils equal and very slow to react. NP and daughter notified, NP stated that he could remain in facility and we could continues (sic) to monitor. Sister and DPOA requested that resident be sent to ER. We did as she requested. Review of the hospital Emergency Department Note dated 8/11/17, revealed patient is a [AGE] year-old male presenting to the ED with [MEDICAL CONDITION] activity .(name of facility) states that patient had a [MEDICAL CONDITION] on 8/6 that lasted roughly 2 minutes. Patient had an additional [MEDICAL CONDITION] earlier today that lasted 3 minutes and they decided to send him to the ED for medication review. Patient was recently hospitalized and his [MEDICAL CONDITION] medications were adjusted .Medications were reviewed with patient sister and nursing home. Patient was receiving [MEDICATION NAME] twice a day 2000 mg and [MEDICATION NAME] ([MEDICATION NAME]) 600 mg in the morning. Patient's medication had recently been adjusted and he was supposed to be taking an additional 750 [MEDICATION NAME] at night. Patient given a 1 mg dose of [MEDICATION NAME] in ED. Patient's night dose of [MEDICATION NAME] 750 given in ED .nursing home was notified that patient's nigh dose of [MEDICATION NAME] has been skipped for some time. Instructed nursing home to give second dose of medications. Patient's increase in [MEDICAL CONDITION] activity is most probably due to mismanagement of [MEDICAL CONDITION] control medications . In a telephone interview on 8/24/17 at 12:11 pm, Registered Nurse (RN) D reported she assisted Licensed Practical Nurse (LPN) E with verifying Resident #3's admission orders [REDACTED]. RN D stated we missed one medication .it was all the stress. It was late and we had our patients and an admission. The surveyor attempted to contact LPN E via telephone on 8/24/17 at 10:54 am. A voicemail was left requesting a return call. A return call was not received prior survey exit. In an interview on 8/24/17 at 12:23 pm, NP G reported when a resident was admitted to the facility, orders were verified over the phone between the physician and the facility's nursing staff. NP G stated we don't know what he's on in the hospital .meds are verified over the phone. We wouldn't have a med list in front of us over the phone. In an interview on 8/24/17 at 11:25 am, Director of Nursing (DON) B stated he (Resident #3) had a [MEDICAL CONDITION] on 8/11 and when they reviewed the chart, there was a med error that was found .it was a transcription error.

Based on observation, interview, and record review, the facility failed to implement preventive measures to prevent the development and worsening of a pressure ulcer in 1 of 3 residents (Resident #8) reviewed for pressure ulcers, from a total sample of 14 residents, resulting in the development and worsening of an unstageable pressure ulcer. Findings include: According to the facility document labeled, Skin Practice Guide , provided by the DON (Director of Nurses) B as the facility pressure ulcer policy and procedure, dated 01/203, reflected Purpose: The purpose of the Skin Practice Guide is to describe the process steps for identification of patients at risk for development of pressure ulcers, identify prevention techniques and interventions to assist with the management of pressure ulcers and skin alterations .A comprehensive skin evaluation is completed upon admission .Complete the Patient Admission/Readmission Screen in Point click Care(PCC) including a head-to-toe full body audit to identify the presence of pressure ulcers or other skin alterations .If a skin disruption is found, the type of skin injury will need to be identified by a qualified health professional (physician, certified wound specialist, Advanced Registered Nurse Practitioner(ARNP) .Alteration In Skin Integrity: If an alteration in skin integrity is identified on admission, a designated member of the wound team evaluates the status of the wound (ideally within 24-hours of admission) and collaborates with the licensed nurse, physician or ARNP to determine the type of alteration present .A qualified health professional .can assist the wound team by evaluation the documenting the etiology of the skin alteration, especially if the wound has the characteristics consistent with a pressure ulcer .If non-pressure ulcer or other skin alterations .are identified; Skin Alteration Record is initiated. If a pressure ulcer is identified, a Pressure Ulcer Scale for Healing is initiated by the member of the wound team for each site identified. A comprehensive evaluation is completed and documented in the patient ' s clinical record .Daily skin evaluations are completed by the licensed nurse for any patient with a pressure ulcer .Ongoing Management Strategies .Skin Evaluations: Patients at risk for skin breakdown have a head-to-toe skin evaluation weekly by a licensed nurse. Patients with pressure ulcers have a head-to-toe skin evaluation completed daily by the licensed nurse to identify additional skin changes .Positioning, Mobility, Restraints .minimize direct pressure over vulnerable areas and actual pressure ulcers .Moisture and Incontinence Management: Moist skin is more vulnerable to injury .Nutrition and Hydration Management: The role of nutrition in maintaining healthy skin and healing wounds is complex .The Registered Dietitian (RD) will screen and assess nutritional status for each patient with skin alterations at admission, with change in condition and when wound healing is not observed .Wound Management .Wound Management Team .The wound management team re-evaluates pressure ulcers and complex wounds weekly and other types of wounds as clinically indicated. Documentation of findings is completed on the PUSH Tool or Skin Alteration Record .If a pressure ulcer fails to show some evidence of progress toward healing within 2-4 weeks, the pressure ulcer (including potential complications) and patient ' s overall clinical condition needs to be re-evaluated .Wound Team Documentation Guidelines .1. Distinguish pressure ulcers from other [MEDICAL CONDITION] and document the distinction. (Progress note may indicate there was discussion with the physician to concur that an ulcer was not from pressure but other causes .) 2. Describe pressure ulcers consistent with initial evaluation and compare observation over time. Document a comprehensive description of the wound each week .10. What stage was the ulcer when present at the time of admission or reentry? Onging Wound Evaluations: The licensed nurse provides wound treatments as order by the physician or ARNP and documents completion of the treatment on the Treatment Administration Record .Weekly alteration evaluations are completed by the licensed nurse for those wounds not being evaluated by the wound team, e.g., skin tears, surgical incisions, rashes, etc. The findings are documented on the Skin Alteration Record . Included in the, Skin Practice Guide 40 page packet was a document labeled, Skin Practice Guide Process Flowchart . Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected Resident #8 was a [AGE] year of male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS reflected Resident #8 had a BIM (assessment tool) score of 10 which indicated his ability to make daily decisions was moderately impaired(decreased from 14 on 9/8/16), and he required two person physical assist with bed mobility, toileting, bathing and one person physical assist with dressing and hygiene. Review of the facility acquired pressure ulcers list, provided by Unit Manager E on 1/3/17, revealed 3 residents including Resident #8. In an observation and interview on 1/3/17 at 12:45 p.m. to 1:15 p.m., in Resident #8 ' s room, Resident #8 was noted to be laying on his back on an air mattress with a foley catheter bag hanging from the right side of the bed as well as a wound VAC machine. Resident #8 had a trapeze in place over the bed with a call light attached to the trapeze triangle in reach. Resident #8 reported he had developed a pressure ulcer to his right hip prior to admission to the facility and currently had the wound VAC in place. Resident #8 reported the wound doctor (who is also the medical director D ) visited every Thursday. Resident #8 denies pain and reported he is paralyzed from the waist down. This surveyor asked about the food at the facility and Resident #8 reported, the food is always cold . Resident #8 reported he had reported his concern of cold food to the staff but he reported the food is still cold. Resident #8 reported he has had weight loss but thought it was stable at the present time and had met with the Dietician and agreed to add a supplement. Resident #8 reported he had requested vanilla or strawberry but the staff keep bring chocolate. Resident #8 reported call light response time is slow at times on third shift. Resident #8 reported he was incontinent of stool and has had to wait between 15 minutes to 60 minutes on three occasions laying in stool for staff to arrive and perform incontinence care in the last 2 months. Resident #8 reported he was upset that he had to wait but reported the staff are always busy. Resident #8 reported the staff come in every 3 hours to turn him from side to side and if they do not Resident #8 uses his call light to request staff turn him. Resident #8 reported he does not refuse to be turned. Resident #8 reported he was in the hospital in September of 2016 related to a bone infection in the right hip wound that required intravenous (IV) antibiotics and reported he no longer had an IV presently. Review of the facility document labeled, Patient Admission/Readmission Screen v.6 , dated 9/1/16, reflected Resident #8 had an existing pressure ulcer to the right trochanter (hip) that measured 7cm x 7cm x 1cm, pink in color, light drainage. The document also reflected a coccyx area that was noted as, Reddened weak area on coccyx 3cm x 4cm . Review of the facility document labeled, Braden Scale for Predicting Pressure Sore Risk v2 , dated 9/2/16, reflected Resident #8 was at risk. The document reflected notes under preventative care plan that included, Focus: At risk for alteration in skin integrity related to: Impaired mobility, incontinent, [MEDICAL CONDITION], pelvic osteo[DIAGNOSES REDACTED], DM (diabetes), CKD3 ([MEDICAL CONDITION] stage 3), foley . Review of the facility unsigned document labeled, Skin Alteration Record, do not use for pressure ulcers , dated 9/2/16, reflected documentation that Resident #8 had a coccyx skin alteration that measured 3cm x 4cm with no additional documentation completed including: depth, description, drainage, or skin surrounding alteration. Review of the Pressure Ulcer Healing Chart , dated 9/2/16, revealed documentation that Resident #8 had an right hip pressure wound with a total PUSH score of 15(scored 17 through 0 with 0 equals healed). Review of the Admit/Readmit progress note dated 9/1/16 at 8:03 p.m. for Resident #8 reflected, Res. arrived to facility via ambulance .Primary [DIAGNOSES REDACTED]. here for IV antibiotics therapy, wound care, and rehabilitation . Review of the progress note dated 9/1/16 at 11:36 p.m., for Resident #8, reflected, .No behavioral concerns observed. Paraplegic, requires assistance x 2 for ADL ' s, transfers . Review of the skin progress note dated 9/2/16 at 3:14 p.m., for Resident #8, reflected, .Coccyx observed; area measured 4x3.6x0.1 cm, area has slough present, surrounding area macerated .Dx: paraplegic, Diabetes, CKD, [MEDICAL CONDITION] and VRE .Resident to turn and reposition frequently Q shift . Review of the progress note dated 9/2/16 at 3:31 p.m., for Resident #8, reflected, Coccyx is blanchable at this time . Review of the progress note dated 9/5/16 at 10:42 a.m., for Resident #8, reflected, Resident is alert and oriented, able to make needs known. Calm and cooperative with care .Resident would like to be checked every 2 hours for incontinence, even throughout the night. Review of the progress notes dated 9/2/16 through 9/16/16, for Resident #8, revealed 6 entries that reflected, cooperative with care and no documentation was noted related to refusing care. Review of the Skin Care Plan, dated 9/2/16, reflected Resident #8 was at risk for alteration in skin integrity related to impaired mobility, incontinence, [MEDICAL CONDITION], pelvic osteo[DIAGNOSES REDACTED], diabetes, [MEDICAL CONDITION]. The care plan goal was to decrease/minimize skin breakdown risks. The care plan had interventions that included: barrier cream to peri area/buttocks as needed, diet and supplements per physician orders, encourage fluids, encourage to reposition as needed and use assistive devices as needed, turn and reposition frequently every shift, and provide preventable skin care routinely and prn. Review of the signed Physician Orders, dated 9/2/16 and 9/9/16, for Resident #8, included wound orders to cleanse coccyx with normal saline, apply biostep-[MEDICATION NAME], foam daily and as needed. Review of the Medication Administration Record [REDACTED]. Review of the Progress Notes, dated 9/4/16 through 9/8/16 revealed no documentation related to wound care performed for Resident #8 ' s coccyx area. Review of the facility Skin Alteration Record document dated 9/13/16 reflected Resident #8 had a skin alteration on the coccyx that measured 4 cm length and 3.5 cm width with no documented depth with scant serosanguinous thin red drainage and normal appearance of surrounding tissue. Review of the Progress Note dated 9/16/16 at 5:19 p.m. reflected, Took message for the nurse from the (named) wound center regarding this patient .called to inform this center that they are sending the patient to the (named) emergency room due to [MEDICAL CONDITION]. She states he had a fever currently with respirations of 44 and pulse of 148 and the patient states he does not feel well . According to the hospital admission history and physical dated 9/17/16 at 12:11 a.m. reflected Resident #8 was sent to the hospital during a routine wound care clinic visit due to concern [MEDICAL CONDITION]. The history and physical assessment and plan included, .1. Concern [MEDICAL CONDITION] - Patient has history of chronic R ischial ulcer c/w un-resectable osteo[DIAGNOSES REDACTED], [MEDICAL CONDITION] bladder s/p SPC (suprapubic catheter placement and recent admission for MSSA, VRE bacteremia and [DIAGNOSES REDACTED] lilely 2/2 line infection. He presents today with [MEDICAL CONDITION] leukocytosis to 19. Source of infection is unclear. Possible 2/2 osteo vs UTI vs blood stream infection vs C, diff . 2. Decub ulcer - patient has a history of R ischial ulcer followed by wound with wound vac in place. He also appears to have new stage 2 sacral ulcer . Review of the hospital, Nurse Wound Care Consult Note (Wound) , dated 9/17/16, located in Resident #8 ' s facility medical record, reflected Resident #8 had assessment documentation for a sacrococcygeal wound. The wound assessment indicated the etiology as pressure and the wound assessment reflected, Upon assessment of the sacrococcygeal area, there is an open, full thickness stage III pressure ulcer measuring 3cm x 3.3cm. The wound bed presents with pinkish/red dry tissue with layer of dry white slough interspersed throughout the pink tissue. The periwound skin presents with blanchable [DIAGNOSES REDACTED] and darker brown discoloration around the anus . Noted under, Wound/Ostomy Recommendation/Plan .Individualized turning schedule and avoid supine positioning as patient condition allows . Review of the hospital, Nutrition Reassessment - consult, wounds , dated 9/23/16, located in Resident #8 ' s facility medical record, reflected Resident #8 ' s consult noted, Diet History from 9/18: Met with pt at bedside. Pt reports decreased intake PTA due to not liking the food at the facility he resides. He states he tries to eat at his meals but a lot of the time the food is too cold and unappetizing and therefore has to skip many meals. Pt. states he thinks he may have lost weight but is not sure how much . Review of the hospital, Inpatient Discharge Summary , dated 9/26/16, located in Resident #8 ' s facility medical record, reflected Resident #8 had an active decubitus ulcer of the buttock, stage 3 with wound care orders that included: Sacral Wound: 1. Dressing changes daily. 2. Gently cleanse wound with saline moistened gauze and pat dry. 3. Apply [MEDICATION NAME] no sting skin barrier .to periwound skin and allow to dry. 4. Primary dressing: Impregnate gauze with hydrogel Wound Gel .and apply directly to wound bed. Secondary dressing: Cover with dry gauze . Review of the facility Progress Notes, dated 9/26/16 at 9:18 p.m., reflected Resident #8 arrived to the facility from the hospital at 7:30 p.m. and a body audit was completed. Review of the complete medical record, dated 9/26/16 through 11/22/16, revealed no Skin Alteration Record or Pressure Ulcer Healing Chart documents for Resident #8 coccyx wound. Review of the Progress Notes, dated 9/27/16 through 11/25/16, for Resident #8, reflected notes that included: -9/27/16 - .Coccyx observed; area measured 2.7x3.5x0.1cm, area is beefy red with granulation and blanchable, surrounding area reddened. New order for biostep-[MEDICATION NAME] cover with foam . Same wound order as prior to hospital admission. -10/7/16 - Treatment completed on coccyx; area measured 3.2x 3.4 .Body audit completed . No body audit located in Resident #8 ' s medical record. -10/11/16 - .Coccyx observed; area measured 2.8x3.5, area with granulated tissue .Resident to turn and reposition frequently Q shift . No depth noted. -No coccyx wound measurements or assessment noted between10/11/16 and 11/1/16. -11/1/16 - .coccyx wound 4.3x4.0 with hard yellow/gray area of 1.0 x 2.6 in wound bed. Surrounding tissue pink and blanchable . -11/2/16 - .coccyx .wounds measures 4.0 x 3.8 cm with hard yellow/gray area of 1.0 x 2.5 cm wound bed. Surrounding tissue pink and blanchable. No drainage. -11/5/16 - .coccyx .wounds measures 3.8 x 3.5 cm with hard yellow/gray area of 0.9 x 2.5 cm wound bed. Surrounding tissue pink and blanchable . -No coccyx wound assessment, including measurement, noted between 11/5/16 and 11/22/16. -11/18/16 - .coccyx continued center of wound dark greenish in color with some yellow, surrounding skin pink . -11/21/16 - .Center of wound to coccyx is grayish in color surrounding skin pink. -11/22/16 - Coccyx wound observed measuring 6x7x0.1 with eschar present in wound bed, surrounding skin with maceration present, moderate amount of slough . -11/22/16 - Resident with weight loss following admit with weight loss of 8.5% from admit. Current weight of 134.4# is up 2.4# with the addition of supplements . 11/25/16 - Addendum to 11/25/ skin note coccyx has necrotic areas in wound bed. Wound physician in to see residents coccyx and deems this area pressure. Review of the Skin Alteration Record , dated 11/22/16, revealed Resident #8 had a coccyx wound that measured 6cm x 7cm with no noted depth and positive Eschar with serosanguineous and purulent(creamy white to yellow) drainage and macerated wound edges. Review of the Medication Administration Record, [REDACTED]. Review of the physician progress notes [REDACTED]. In an interview on 1/4/17 at 9:10 a.m. (MRS) Medical Records staff J reported she had not filed physician progress notes [REDACTED].#8 and would look for them. MRS J reported doctor had a new system from dictation to electronic in October or Novemeber. MRS J reported the physician sees residents usually on Thursdays and returns the following week with the previous week printed progress notes. MRS J reported she is behind in filing. Review of the physician progress notes [REDACTED].#8 ' s coccyx wound. In an observation on 1/4/15 at 2:15 p.m. RN (Registered Nurse) H entered Resident #8 ' s room after she reported she was ready to perform Resident #8 ' s coccyx dressing change. Unit manager E and LPN unit manager O were present in the room and assisted Resident #8 on his left side. This surveyor observed a large golf ball sized open wound on Resident #8 ' s coccyx area with positive slough noted at the base of the wound and appeared to be at least 2 cm deep with slightly red periwound noted. RN H did not perform wound measurements. RN H cleaned the wound with normal saline on a 4 x 4 gauze and dabbed the wound. Thereahoney was applied in the coccyx wound and pieces of biostep were placed in the wound and covered with a foam dressing. Resident #8 appeared to tolerate the procedure well. In an interview on 1/4/17 at 3:10 p.m., directly after Resident #8 ' s dressing change, RN H reported she does not regularly work with Resident #8 and reported that was the first time she had performed his coccyx wound care. RN H reported she did not measure the wound because the wound team does that once a week. RN H reported she planned to document the dressing change in the progress notes and described Resident #8 ' s coccyx wound as having 50 percent slough in wound base and unstageable. In an interview on 1/4/17 at 4:40 p.m. RN (Registered Nurse) unit manager O reported the MDS nurse stages the pressure wounds. RN O reported she is part of the wound team that monitors the facility wound weekly and records assessments in the resident progress notes. RN O reported she performed the wound measurement noted in the progress notes on 1/3/16(1 day prior to this surveyor ' s observation) that measured 5x4x1.1cm and reported she had contacted the physician D related to decline. RN O reported Resident #8 ' s coccyx wound was a stage 3 because of the slough in the wound. RN O reported there is no necrotic tissue present in the coccyx wound so therefore it was not unstageable. RN O reported when Resident #8 was re-admitted to the facility on [DATE] he had moisture related skin alteration to the coccyx area and it was not until 11/25/16 that the physician/wound doctor deemed Resident #8 ' s coccyx wound pressure related. RN O reported she had not yet reviewed the physician progress notes [REDACTED]. RN O reported she did not have any specialized wound training. In an interview on 1/5/17 at 9:05 a.m. CNA (Certified Nurse Aide) W reported she had worked at the facility for over a year and had worked with Resident #8 many times. CNA W reported resident #8 needs to be repositioned every 2 hours and she stated, I just knows that , when asked how she knows that. CNA W reported Resident #8 uses his call light when he wants to be repositioned and never refuses care or repositioning. CNA W reported Resident #8 is alert and oriented and able to make needs known. CNA W reported she positions Resident #8 on right hip, back and the left hip. In an observation on 1/5/7 at 11:25 a.m. RN O entered Resident #8 ' s room and stated the nurse planned to change the right hip stage 4 VAC dressing. The MD D , RN E , LPN O and 2 CNA ' s were noted to be in the room as well. Resident #8 ' s right hip dressing had already been removed and was noted to have a red area in the shape of a square around the wound. RN Y performed the wound VAC dressing change with the use of transparent drape times 2 times related to difficulty with no skin prep to periwound area to Resident #8 ' s right hip. RN Y placed the black foam in the wound and covered with drape, cut an opening and placed the TRAC pad directly over the right hip stage 4 pressure ulcer. No bridging of the VAC was noted. MD D stated resident #8 was a diabetic with a history of osteo[DIAGNOSES REDACTED] of the pelvic bone and reported he was concerned about coccyx wound infection and ordered wound care changes, labs and x ray to rule out osteo[DIAGNOSES REDACTED]. Resident #8 requested MD D to order a clinitron bed. MD D reported would like to wait on that until the results of the recently ordered tests came back. Coccyx wound measurements were taken and noted 5.5x3.4x2.3cm. Coccyx wound appeared to have slough in base of wound. RN Y performed a wet to dry dressing covered with an allevyn dressing times 2 related to first dressing not placed in correct location. In an interview on 1/5/17 at 12:15 p.m. MD D reported he is Resident #8 ' s wound doctor and has been caring for him for several months once a week. MD D reported Resident #8 ' s coccyx wound is unavoidable related to his history of right hip stage 4 pressure ulcer with osteo[DIAGNOSES REDACTED] to the pelvic bone, diabetes, [MEDICAL CONDITION] and [MEDICAL CONDITION]. MD D reported he did not plan to order the resident requested clinitron bed now because Resident #8 currently has an off loading mattress. MD D stated, the clinitron bed is the cadillac of off-loading mattresses. This surveyor asked MD D how he wound stage Resident #8 ' s coccyx wound and MD D stated, I am 99.9% it is a stage 4 wound . MD D reported it is difficult to say before receiving the test results back. MD D reported he would expect the facility should have his progress notes in the medical records within one month at the latest. MD D reported the progress notes were in the facility but may not have been in the chart related to slow filing. In an interview on 1/5/16 at 2:15 p.m. CNA X reported he works first shift and frequently cares for Resident #8. CNA X reported Resident #8 uses his call light when he wants to be repositioned and has never refused care or repositioning during his shift. CNA X reported he positions Resident #8 from right hip to back to left hip depending on Resident #8 ' s request. CNA W reported Resident #8 was alert and oriented and able to make needs known. ( )

This citation pertains to intake numbers MI 523 and MI 597. Based on interview, and record review, the facility failed to prevent a significant medication error for 1 (Resident #101) from a total sample of 4 residents reviewed for medication administration, resulting in Resident #101 receiving four times the prescribed dose of a pain medication and being hospitalized for [REDACTED]. Findings include: Review of the Admitting Record dated 1/30/2014 and the most recent MDS dated [DATE], revealed Resident #101 was a [AGE] year old female with [DIAGNOSES REDACTED]. Resident #101 had clear speech, was understood, understands others, and had no impairment in cognition. Review of the facility Incident Report dated 1/30/14, revealed that on 1/29/14 at 8:40 p.m., Licensed Practical Nurse (LPN #8) administered to Resident #101 60 milligrams (mg) of [MEDICATION NAME] Extended Release (ER), instead of the prescribed 15 mg. The report revealed that LPN #8 "Gave different patient's medication to patient". Review of the Progress Notes dated 1/30/14 at 12:40 a.m., revealed, "(Resident #101) received [MEDICATION NAME] sulfate ER 60mg instead of [MEDICATION NAME] sulfate ER 15mg at 2040 (8:40 p.m.)". Review of Resident #101's medical record failed to reveal an order for [REDACTED]. Review of the hospital Emergency Record/Note dated 1/30/14, revealed Resident #101 was unresponsive at the ECF (Extended Care Facility) due to an accidental overdose. Review of the hospital History & Physical dated 1/31/2014, revealed Resident #101 was admitted to the hospital "with accidental overdose on long-acting [MEDICATION NAME], acute metabolic [MEDICAL CONDITION]". Resident # 101 was "admitted on a [MEDICATION NAME] (medication used to reverse the affects of [MEDICATION NAME] overdose) drip (using an intravenous line to provide a continual dose of medication). During an interview on 2/4/14 at 11:20 a.m., LPN #8 stated, "I gave (Resident #101) the wrong med, instead of 15 mg I gave (Resident #101) 60 mg, when I did the narc (narcotic) count we realized (the mistake). LPN #8 stated, "I had the other nurse (Registered Nurse (RN) #6) come down to (Resident #101's) room, and then paged the physician". During a telephone interview on 2/3/14 at 3:00 p.m., RN #6 stated, "When we figured out that (Resident #101) got the wrong dose, we went to the room to assess (Resident #101), her respirations were low and it was apparent that (Resident #101) received the larger dose of [MEDICATION NAME]. When asked how to prevent further errors from happening, RN #6 stated, "I don't know, with the system that is currently used, how you could eliminate 100% of med (medication) errors". During an interview on 2/4/14 at 11:20 a.m., When asked how this error happened, LPN #8 stated, "I pulled the other patients [MEDICATION NAME] card and documented it on Resident #101's controlled substance log". LPN #8 stated, "I was taught that you were supposed to check the card amount with the amount written on the controlled substance log, but I didn't do that...I picked the wrong card, didn't even pull it out of the box, just popped (the pill) out and wrote on the wrong card...yes, I was taking a shortcut..." ( )

This citation pertains to MI 202. Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices for the prevention of falls in 2 of 3 residents reviewed for falls (Resident #101 and Resident #103), from a total of 3 sampled residents, resulting in 2 falls with injuries (one of which was a serious injury) for Resident #101, 8 falls in the last 3 months with the potential for injury for Resident #103. Findings include: Per facility Gait Belt Policy and Procedure, dated 12/2009, "Purpose: To safely and effectively transfer...Place gait belt around waist...Grip belt at patient's sides..." Resident #101 Per the Minimum Data Set (MDS), dated [DATE], Resident #101 was admitted on [DATE], scored 11/15 on the Brief Interview for Mental Status (moderate cognitive impairment), needed staff guidance for transfers, was not steady with moving on and off the toilet, surface-to-surface transfers and moving from seated to standing position. The MDS indicated Resident #101 used a walker, and had a history of [REDACTED]. Per a hospital Progress Note, dated 8/04/12, Resident #101 had [DIAGNOSES REDACTED]. "Most people with sick sinus syndrome initially have few or no symptoms. In some cases, symptoms may come and go. When they do occur, sick sinus syndrome symptoms may include: Slower than normal pulse (bradycardia), Fatigue; Dizziness or lightheadedness; Fainting or near fainting; Shortness of breath; Chest pains; Interrupted sleeping; Confusion or difficulty remembering things; A sensation of rapid, fluttering heartbeats (palpitations). Many of these signs and symptoms are caused by reduced blood flow to the brain when the heart beats too fast or too slowly." (http://www.mayoclinic.com/health/sick-sinus-syndrome/DS /DSECTION=symptoms). Per Resident #101's nursing Progress Notes, dated 8/8/12 at 7:34 AM, "(Resident 101) medicated with prn (as needed) norc (Norco, a narcotic pain medication)...and prn zanax (Xanax) for anxity (anxiety) and restlessness. (Resident #101) needs assist to and from br (bathroom) and with transfers r/t (related to) her pain and weakness". Per the Medication Administration Record on 8/14/12 Resident #101 received Norco 7.5/325 mg at 12:00 AM, 6:00 AM, 12:00 PM 6:00 PM and on 8/15/12 at 12:00 AM. Per Resident #101's Progress Notes, dated 8/15/12 at 3:15 AM, "(Resident #101) observed lying on floor next to bed...(Resident #101) stated 'I was trying to get OOB (out of bed) to go to the bathroom...2 cm laceration on L (left) cheek bleeding and c/o neck and back pain...to ER (emergency room )...remained A & O (alert and oriented) entire time period involved...O 2 (oxygen) on at 2 L n/c (liters per nasal cannula)." Review of a Witness Statement written by nurse aide #7, dated 8/15/12, revealed 1 hour and 45 minutes had elapsed between (Resident #101) was last seen in bed before fall. Nurse aide #7 documented, "...I had last checked (Resident #101)...about 1:30 (AM)..." Per Resident #101's nurse aides "Intervention/Task" checklist, Resident #101 was to be toileted and transferred "Q Shift (every shift)". The checklist revealed Resident #101 was toileted one time per shift (on 8/14/12 at 4:42 AM and 9:48 AM, and on 8/14/12 at 9:36 PM). There was no additional documentation regarding toileting for Resident #101 after 9:36 PM. In a telephone interview on 11/21/12 at 11:14 AM, nurse aide #7 reported that she was assigned to Resident #101 on 8/15/12 and stated, "(Resident #101's) roommate said (Resident #101) had gone to the bathroom, slipped and fell on her way back to bed...(Resident #101) was always trying to get up by herself and do things for herself and she couldn't. I reminded (Resident #101) to use the call light, (Resident #101) hardly ever used it...(Resident #101) wanted to be independent." Per Resident #101's "At risk for falls due to unsteady gait" care plan, dated 8/8/12 and updated on 8/15/12, revealed fall interventions for Resident #101 included: "encourage to transfer and change positions slowly, fall mats, provide assist to transfer and ambulate as needed, and to reinforce need to call for assistance". The frequency of toileting, interventions to address non-compliance with use of call light, and the use of body alarms/pressure alarms were not included in Resident #101's fall interventions. Per Resident #101's "Tinetti Assessment Tool: Balance" (assessment tool used by the facility PT/Physical Therapy Department), dated 8/12/12, PT #12 documented, "(Resident #101) needs supervision (during) ambulation in her room and out in the hall with walkers. Needs O 2 (oxygen) all the time." Per Resident #101's nurse aide Task List, dated 8/7/12, Resident 101 was identified as a fall risk, and "Frequency" of toileting and transfers were scheduled "Every Shift" (facility staff worked 8 hour shifts). Per Resident #101's physician orders, dated 8/20/10 at 4:30 PM, Cipro (antibiotic) x 10 days was ordered for "Dx (diagnosis) UTI (urinary tract infection). S/S (signs/symptoms) confusion, urinary frequency and hesitancy". Per Resident #101's nursing Progress Notes, dated 8/22/12 at 9:13 PM, RN/Registered Nurse #14 documented, "Continues PO (by mouth) ATB (antibiotic) for UTI...Complains of burning upon urination". Per Resident #101's "Tinetti Assessment Tool: Balance", PT/Physical Therapy Department) dated 8/22/12, PT #12 documented, "Supervision for ambulation with walker. SaO2 (oxygen level in blood) levels drops even with O2 of 2 liters. Independent with her transfers from bed to wheelchair only. Needs supervision for toileting." Per Resident #101's nursing Progress Notes, dated 8/22/12 at 10:40 PM, RN #2 documented, "Pt/patient (Resident #101) was observed by CENA lying on floor next to bed...bleeding from scalp laceration...transferred to (hospital)...". The nursing Progress Note indicated Resident #101's neurological examination was within normal limits and vital signs were within normal limits. The note documented, "Pt (Resident #101) was talking the entire time and A&O (alert and oriented) x 3, ROM (range of motion) to all extremities WNL (within normal limits), PEARL (pupils equal and reactive to light). Pt has 2 cm laceration on right side of scalp near hairline. 2 x 2 dressing applied and pressure applied until bleeding stopped. No neuro (neurological) deficit upon transfer (to hospital)." Review of the Facility Investigation Report - 5 Working Days, dated 8/23/12, revealed, "(Resident #101) was last admitted to the facility on [DATE]...On 8/22/2012 at 10:40 PM, staff responded to a call light initiated by (Resident #101's) roommate. Staff entered and observed (Resident #101) on the floor with an abrasion to the forehead. Bed was in the lowest position and fall mats in place. The resident stated she had stood up to go to the bathroom and fell striking her head on the oxygen concentrator. Documentation shows the resident was toileted at 9:32 PM (1 hour and 8 minutes elapsed since Resident #101 was last seen in room)...Upon arrival in the ER their staff noted one fixed pupil, left side facial drooping and weakness. A CT scan (imaging test) revealed a CVA (stroke) and C2 (neck) fracture..." The report indicated that Resident #101 had been last toileted at 9:32 PM on 8/22/12 and that Resident #101's roommate had witnessed Resident #101 get out of bed without using the call light or asking for help. The report revealed Resident #101 had a fall on 8/15/12 and new interventions put in place included use of a low bed and bilateral floor mats. The report documented "all fall interventions were in place and appropriate". There was no documentation regarding a need for increased supervision or documentation to indicated the facility addressed the issue of Resident #101 not consistently utilizing her call light for assistance. Per the hospital Admission History and Physical, dated 8/23/12 at 5:42 AM, "(Resident #101) ...hit her head and sustained C2 (neck) fracture along with a laceration (cut) to her scalp. (Resident #101) believes that she did lose consciousness when she fell and the next thing she knows is that the staff at the (facility) came in and got her. While (Resident #101) was in the ED (emergency room ) they discovered that she was having significant left sided weakness and was not able to lift her arm up...transferred over for a neuro (nerve) consult..." Per Resident #101's ED (Emergency Department) Physician Notes, dated 8/22/12, "CT Scan (imaging report) head...is negative for any acute intracranial (in the brain) bleed..." Per Resident #101's facility Post Fall Assessment, dated 8/23/12, RN #3 documented, "(Resident #101) has been seen by CENA's (nurse aides) getting up by herself and going to the bathroom...(Resident #101) has previous fall similar to this one within 2 weeks of the occurrence (occurrence)". In a telephone interview on 11/21/12 at 10:12 AM, RN #3 reported that she was assigned to Resident #101 on both nights Resident #101 fell (8/15/12 and 8/22/12). RN #3 stated, "(Resident #101) was admitted for frequent falls...had been repeatedly up to the bathroom without the call light or asking for assistance...(Resident #101) was alert, but got disoriented at night mainly. (Resident #101) had vision problems - blind corner due to a previous stroke...The facility has no (body/sensor) alarms, they were phased out by then...they don't use (body/sensor) alarms in this building. (Resident #101's) room was not near the nurses station there were no beds available near the nurses station, I made that suggestion...both times (falls) (Resident #101) hit something. (Resident #101's) roommate heard (Resident #101) stumble before (Resident #101) fell ." In a telephone interview on 11/21/12 at 11:14 AM, nurse aide #7 reported that she was assigned to Resident #101 on both nights Resident #101 fell (8/15/12 and 8/22/12). Regarding the first fall, nurse aide #7 stated, "(Resident #101's) roommate said (Resident #101) had gone to the bathroom, slipped and fell on her way back to bed...(Resident #101) was always trying to get up by herself and do things for herself and she couldn't. I reminded (Resident #101) to use the call light, (Resident #101) hardly ever used it...(Resident #101) wanted to be independent. Regarding the second fall, nurse aide #7 stated, "...I asked (Resident #101) why didn't you push the call button, you can use me for help and (Resident #101) said 'well its fine to go by myself'...(Resident #101) normally had walker next to her drawer table...I don't think she used her walker either time...(2nd fall) it was not next to her like she had used it...I talked to (RN #3) that (Resident #101) didn't use her call light...Rounds are q (every) 2 hours, but I would check on her every 30-40 minutes if I could..." In an interview, on 11/21/12 at 1:12 PM, DON #2 stated she taught nursing staff to place walkers within all residents' reach when they were in bed. In an interview on 11/21/12 at 1:52 PM, nurse aide #21 stated, she "...worked with (Resident #101) once in a while...some days (Resident #101) was confused and would do things on her own. Her walker would be away from her, not at hands reach. I don't put it (walker) next to them (residents) if they are confused". In an interview on 11/21/12 at 2:20 PM, DON #2 revealed (Resident #101) was discharged from the hospital to a different skilled nursing facility, and did not return to the facility. In a telephone interview, on 11/29/12 at 2:00 PM, DON #2, "It is our premise that (Resident #101) fell due to a CVA (stroke). (Resident #101) had her walker and got up unattended. (LPN #3) had to move (Resident #101's) walker out of the way; it was lying on its side." In a telephone interview, on 11/29/12 at 2:00 PM, DON #2 stated she believed Resident #101 had no cognitive impairments and did not need supervision to be up in her room with her walker. ( and ) Resident #103 Per the Minimum Data Set, dated dated [DATE], Resident #103 was admitted on [DATE], scored 15/15 on the Brief Interview for Mental Status (no impairment), required extensive assistance (2+ persons physical assist) with transferring, used a wheelchair and had history of falls. Resident #103 has [DIAGNOSES REDACTED]. A review of Resident #103's facility fall reports revealed that Resident #103 had fallen 8 times between 8/27/12 and 11/20/12: ? On 8/27/12 at 10:25 AM due to, "...tried to ambulate by herself" ? On 9/01/12 at 10:10 AM/no reason given ? On 9/27/12 at 11:30 PM due to, "Impaired balance during transitions...gait problems". ? On 10/09/12 at 7:00 AM due to, "need to rock body or push off on arms of chair when standing up from chair...difficulty maintaining standing position...impaired balance during transitions...gait problem...pt (Resident #103) stated that she didn't want to wait for assistance to the bathroom, so she attempted to walk to the bathroom by herself. She (Resident #103) did not use call light...pts wheelchair was in the corner..." ? On 10/10/12 at 4:30 PM, "resident said she (Resident #103) was just sitting on bed and the next thing she knew she was on the floor. She (Resident #103) thinks she was sleeping." ? On 10/31/12 at 8:05 PM due to, "...slid out of bed trying to transfer herself." ? On 11/15/12 at 1:00 AM due to, "Impaired balance during transitions...pt stated she (Resident #103) was getting back into bed..." ? On 11/20/12 at 2:45 AM due to, "Impaired balance during transitions...Res (Resident #103) stated she was transferring back to bed and forgot to lock her brakes on her wheelchair...wheelchair moved back causing her to fall..." On 11/26/12 at 8:44 AM, Resident #103 was observed sitting on the edge of her bed attempting to transfer to her wheelchair without assistance. Wheelchair repeatedly rolled backwards as Resident #103 was reaching for the arm of the wheelchair. In an interview on 11/26/12 at 9:40 AM, Resident #103, when asked if she (Resident #103) uses her call light and she replied, "It depends. They get mad at me because I'm independent. I hate waiting. If I want to do something, I might get into my chair and take off". In an interview on 11/26/12 at 10:55 AM, nurse aide #11 stated, "Normally (Resident #103) is already up when I get to her after call light has been used...usually does not use call light for transferring". When asked what Resident #103's PIW/Patient Information Worksheet (nurse aide care guide) said about transferring for stated Resident #103, nurse aide #11 looked at the PIW and stated, "It says + 1 extensive assist with transfers. It tells me we should be in there and helping (Resident #103) with extensive assistance. I don't think the PIW is correct". Nurse aide #11 said she was not aware that Resident #103 had fallen 8 times in the last 3 months. In an interview on 11/26/12 at 11:18, PT/Physical Therapist #12 stated, "(Resident #103) is contact guard assist (and required gait belt for transfers)...definitely needs that (gait belt)...difficult with transfer, been falling...(Resident #103) is not suppose to transfer by herself because she has very poor safety and memory issues. (Resident #103) won't put call button on and she transfers herself...(body) alarms would be good for her. (Resident #103) is not compliant..." When asked about Resident #103's wheelchair rolling backwards, PT #12 stated, "I do not know why it is rolling backwards, it has anti-roll back (device installed on wheelchair to prevent it from rolling backwards unless someone is sitting in chair) on it (wheelchair)." Per Resident #103's Physical Therapy Summary dated 11/20/12, "...(Resident #103) has got anti-roll backs on her chair fitted yesterday..." In an interview on 11/26/12 at 1:45, Maintenance Worker #13 stated, "...the (anti-roll back device on Resident #103's chair) worked properly when installed...should not hang bags on back of wheelchair...because with bag on it always has the opportunity to interfere with the functioning of the anti-roll back device...(anti-roll back device) is like a second set of brakes...I didn't do any education with staff...the arms (of the anti-roll back device) can come loose...I've had to do adjustments on them (anti-roll back device) before". Maintenance Worker #13 reported Resident #103's anti-roll back device was was not preventing Resident #103's wheelchair from rolling backwards as designed, when he tested it on 11/26/12, because there was a bag on the back of her (Resident #103's) wheelchair that was rendering the device ineffective. Maintenance Worker #13 reported he had not educated facility staff about the functioning of the anti-roll back devices, or how often they should be checked to ensure proper functioning. Per Resident #103's "At risk for falls due to impaired balance/poor coordination, unsteady gait, history of falls, noncompliance with use of assistive devices and recent CVA" care plan, dated 4/23/12, interventions included "Offer to toilet frequently throughout waking hours. Assist to toilet before bedtime...Provide assist to transfer and ambulate as needed". In an interview on 11/26/12 at 3:17 PM, DON #2 stated that frequent toileting is defined as "every 2 hours". In addition, DON #2 reported that two other residents, in addition to Resident #103, had anti-roll back devices on their wheelchairs (off sample resident #26 and #28), and that she was unaware that the anti-roll back device needed to be checked for proper functioning. DON #2 stated it was not the duty of the nurse aides to make sure the anti-roll back devices were working properly; rather it was the responsibility of Maintenance Worker #13 to check the anti-roll back devices once a week. Per Resident #103's nurse aide Task List, dated 4/19/12, Resident #103 was not identified as a a fall risk, and "Frequency" of toileting and transfers were scheduled "Every Shift". (Facility staff worked 8 hour shifts), this did not match Resident #103's care plan. In an interview on 11/26/12 at 3:50 PM, Administrator #1 confirmed that according to the electronic medical record, Resident #103' nurse aides were routinely charting that Resident #103 was only offered toileting every shift. In an interview on 11/26/12 at 4:06 PM, RN #15 identified herself as the nurse currently assigned to Resident #103 and stated "(Resident #103) usually transfers by herself; sometimes she needs assistance". In an interview on 11/26/12 at 4:07 PM, nurse aide #16 identified herself as the nurse aide currently assigned to Resident #103 and stated she kept Resident #103 "safe during transfers" by "watching her (Resident #103)". Nurse aide #16 stated, "(Resident #103) transfers by herself; we watch...no gait belt, we just watch her". When asked what the PIW recommended for safe transfers for Resident #103, nurse aide #16 stated, "I would have to go check the PIW/Patient Information Worksheet (nurse aide care guide)", and then nurse aide #16 walked to a different nurse's station to locate the PIW. The PIW dated 11/26/12, revealed that Resident #103 was to have "X 1 ext assist" (extensive assistance x 1 with transfers and mobility). When asked what extensive assistance x 1 means, nurse aide #16 stated, "someone needs to stand by her...no gait belt". When asked if any resident needed a gait belt, nurse aide #16 stated, "No, the ones (residents) you would use a gait belt with, you would need to use a lift (mechanical device) on them". In an interview on 11/26/12 at 4:15 PM RN #14 reported that she could not think of any resident that needed a gait belt for transfers or mobility. On 11/26/12 at 4:18 PM in the presence of OT/Occupational Therapist #17 and nurse aide #19, off sample resident #27 was observed attempting to transfer herself from her wheelchair to her bed; neither OT #17 nor nurse aid #19 had a gait belt on their person. When nurse aide #19 was asked about off sample resident #27's transfer status, she stated, "She's 1 person assist with a gait belt" and then she exited the room and returned with a gait belt a minute later. ( and )