Every finding on record at Medilodge of Milford

Based on observation, interview, and record review, the facility failed to properly use a Hoyer mechanical lift to transfer one resident (R51) of two residents reviewed for accidents, resulting in the mechanical lift falling on R51 causing a laceration to their head requiring a trip to the emergency room for imaging and treatment with staples to close the wound. Findings include: On 9/24/25 at 12:27 PM, a review of R51's progress notes was conducted and revealed the following: A nursing progress note entered into the record by Nurse 'I' dated 6/13/25 at 11:31 PM that read, Cena (nurse aide) informed me that lodger was being transferred to shower chair and hoyer tip <sic> and bumped her head. 1 inch laceration noted .New order to send to hospital noted . A nursing progress note entered into the record by Nurse 'J' dated 6/14/25 at 3:36 AM that read, (Ambulance Company) transported Lodger to (Hospital Name) for eval. (evaluation) due to head injury . A nursing progress note entered into the record by Nurse 'J' dated 6/14/25 at 4:45 AM that read, Lodger return with EMS (Emergency Medical Services). Recieved [sic] 6 staple [sic] to injury on top of head. Ct (CT scan) to cerical [sic] spine and head negitive [sic] for fracture . On 9/24/25 at 1:30 PM, a review of a facility investigation file regarding R51's accident involving the Hoyer lift was reviewed and revealed an incident/accident report dated 6/13/25 completed by Nurse 'I' with a note entered onto the report by the facility's Director of Nursing (DON) on 6/30/25 that read, .Resident was being transferred via a hoyer [sic] lift when the lift tipped over and bumped resident in the head. Hoyer base legs were not spread open fully. Education given to staff involved . Continued review of the file revealed a Total Mechanical Lift Competency Checklist and an Education Training for the topic, Hoyer Lift Procedure. The Education Training read, When transferring a resident with a Hoyer the support legs need to be in the spread position . The competency checklist and education training forms in the file were noted to be signed by both CNA (Certified Nurse Aide) 'K, and CNA 'L'. On 9/24/25 at 1:44 PM, a phone call was placed to CNA 'K'. A voicemail was left, however; the call was not returned by the end of the survey. On 9/24/25 at 2:45 PM, an interview was conducted with R51. They were asked about the incident and in detail described CNA 'K' and another CNA (whose name they did not recall) were transferring them from the bed to the shower chair via the Hoyer lift. They said after they were in the shower chair the lift tipped over and hit them on their head causing a wound. They said, they didn't lose consciousness but, There was blood everywhere. They further expressed fear of being transferred in the Hoyer again after the accident. On 9/24/25 at approximately 3:30 PM, an interview was conducted with the facility's Director of Nursing, and they indicated the Hoyer lift was not set up properly by the CNA's during the transfer causing it to tip and strike R51 in the head. A review of a facility provided policy titled, Safe Lifting and Movement of Residents revised 1/2022 was conducted, however; the policy did not address the steps in the procedure to properly set up a Hoyer mechanical lift.

Based on observation, interview, and record review the facility failed to implement timely preventative interventions for pressure injury for one (R30) of one Resident reviewed for pressure injury prevention/management. Findings include:R30A review of R30's electronic medical record (EMR) revealed that they were admitted to the facility on [DATE] with diagnoses that included diabetes, heart failure, chronic kidney disease, depression and bladder dysfunction. Based on R30's Minimum Data Set (MDS) assessment dated [DATE], R30 needed substantial staff assistance for their mobility in bed. A Brief Interview of Mental Status (BIMS) completed on admission R30 had a score of 15/15 (indicative off intact cognition). A wound care provider note dated 6/17/25 revealed that R30 had a recommendation for a wheelchair cushion. An initial observation was completed on 9/23/25, at approximately 10:15 AM. R30 was observed sitting in their wheelchair on a Hoyer lift (total body lift) sling with no wheelchair cushion. An initial interview with R30 was completed during this observation. They were asked how they were doing, and R30 mentioned that they had sores on their bottom. When asked further they reported that they had the sores when they came to the facility, and they felt like the sores had gotten worse. When further asked about treatment, R30 reported that CNA H was putting some cream on their bottom, and they were not getting any wound treatment from nursing. When asked how they knew about the status of the sore they reported that their bottom was very sore, and they could feel it. When asked if they had any type of support/cushion on their wheelchair, R30 reported that they did not have one and demonstrated that they did not have one. R30 was sitting on top of a Hoyer sling and there was no cushion on their wheelchair. R30 was queried if they ever had one and they reported that they did not have one. There were no cushions or any other positioning devices in the room or in the bathroom. When queried how long they were sitting up in their wheelchair, R30 reported that they stayed up in wheel wheelchair till 8 or 9 PM at times, except when they needed a brief change. A follow up observation was completed later that day at approximately 1:50 PM. During this observation completed from the room entrance R30 was observed in bed receiving care. R30's wheelchair was parked near the foot end of the bed and there was no cushion or any type of pressure reducing support surface on the wheelchair.On 9/24/25 another follow-up observation was completed at approximately 10:20 AM. R30 was observed in their bed. They were queried about how they were doing. R30 reported that their bottom was very sore. R30 stated, They tell me it is not open, but I can't see it. R30's wheelchair was observed parked in the bathroom with a Hoyer lift sling and no cushion or any other supportive surface on the wheelchair. On 9/24/25 at approximately 11:55 AM R30 was observed sitting in their wheelchair. When asked how they were doing they reported again that their bottom was sore. They were sitting on top of the Hoyer lift sling and there was no cushion or any other type of pressure reducing support surface on their wheelchair.An observation of R30's buttock/sacral area was completed on 9/25/25 at approximately 8:30 AM with Wound Care Coordinator (WCC) M. During the observation R30 reported that pain in their bottom felt like a sun burn. The observation revealed bilateral buttocks were red and appeared inflamed. Left buttock was observed with an approximate 0.5 centimeter (cm) oval shaped excoriation (skin tear). A pinpoint sized opening on the coccyx (tailbone) was observed surrounded by reddened inflamed skin. While performing the observation, WCC M had acknowledged that the pinpoint area on the coccyx and left buttock excoriation were new. When questioned WCC M about R30's skin condition on the buttock, WCC M reported that the concern was first brought to their attention on 9/24/25 by the surveyor.Review of R30's care plan revealed that resident was at risk for impaired skin integrity due to their diagnoses and impaired mobility. Interventions listed on the care plan dated 6/5/25 and after did not reveal preventative measures that included the recommendation of a wheelchair cushion by the wound care provider dated 6/17/25. An interview with Licensed Practical Nurse (LPN) N was completed on 9/24/25 at approximately 12:20 PM. They were queried about the about the facility's protocol on preventative interventions or pressure ulcer for residents who had a history of pressure ulcer and or at risk. LPN N indicated multiple interventions including the use of a wheelchair cushion. When queried about where they would find the information, they reported that it would be on the resident's care plan.An interview was completed with Wound Care Coordinator (WCC) M 9/20/25, at approximately 12:40 PM. They were queried about the facility process for initiating/continuing preventative interventions for residents who had a history of pressure ulcer with limited mobility at risk for recurrence. WCC M added that every resident should have a regular cushion, and they were unsure why R30 did not have anything on their wheelchair. They were notified of the concern, and they reported that they understood the concern. On 9/25/25 at approximately 9:35 AM, the DON (Director of Nursing) came and reported that R30 had a BIMS score of 11/15 (moderate cognitive impairment) and were being followed by their psychiatric services team as R30 had some delusions. When they were queried further on how these would impact the observations of R30 not having any support surface on their wheelchair, the observation of buttock area with new pressure injury and R30's complaints of pain, the DON did not provide any further explanation and reported that they agreed on the concerns. Review of facility provided document titled Pressure Injury Prevention Guidelines with a revision date of 3/20/24 read in part, Policy: to prevent the formation of avoidable pressure injures and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for residents who are assessed at risk or who have pressure injury present:Policy Explanation and Compliance Guidelines:1. Individualized interventions will address specific factors identified in the resident's risk assessment, and any pressure injury assessment (e.g. moisture management, impaired mobility, nutritional deficit, staging and wound characteristics).2. The goal and preferences of the resident and/or authorized representative will be included in the plan of care.3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them.4. In the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure injury prevention guidelines to provide care and will notify the physician to obtain orders.5. Prevention devices will be used in accordance with manufacturer recommendations (e.g. heel floatation devices, cushion, mattress).6. Interventions will be documented in the care plan and communicated to all relevant staff.

Based on observation, interview and record review, the facility failed to ensure social work services were implemented in a timely and efficient manner for one (R7) out of one resident reviewed for Social Service/Advanced Directives. Findings include:A review of R7's clinical record noted the resident was admitted to the facility on [DATE] with diagnoses that included: congestive heart failure, fatty liver and dementia with mood disorder. A review of the resident's Minimum Data Set Assessment (MDS) dated [DATE] noted the resident had a Brief Interview for Mental Status (BIMS) score of 6/15 (severely cognitively impaired).Continued review of R7's record noted, in part, the following:[DATE]: Nurse's Note: Pt (patient) educated, understood and signed psych medication consent form.Both forms given to social worker.XXX[DATE]: Consent of Psychoactive Medication Therapy: .Psychoactive Medication Order: Quetiapine/Seroquel 25 mg (an antipsychotic primarily used to treat bipolar and/or schizophrenia) .Specific Condition to be Treated: Depression.The Beneficial Effects Expected from the Medication: Improved Function ability.Specific side effects (checked for) Antidepressant. *It should be noted that the consent to treat was signed by R7XXX[DATE]: Order: Quetiapine 25 MG (milligrams).Give 1 tablet by mouth in the morning for depression.XXX[DATE]: Encounter: .R7.admitted to the SNF (skilled nursing facility) .after hospitalization for generalized weakness and difficulty ambulating.Nursing staff report no acute overnight issues. Hospital records were reviewed at transfer.Anti-psychotic medication use: Patient is not (emphasis added) on an antipsychotic medication.Gradual dose reduction does not have apply as the patient is not currently on an antipsychotic medication. (Authored by physician O). *It should be noted that R7 was administered the medication Quetiapine/Seroquel starting [DATE] and was not discontinued by the end of the SurveyXXX[DATE]: Advanced Directives Acknowledgement/CPR (cardiopulmonary resuscitation): .Resident is unable to make choice and does not have a representative at this time. Resident will remain a full code and receive CPR until otherwise determined. *This form was signed by Social Service Worker (SSW) F on [DATE].A Durable Power of Attorney Form dated [DATE] was found in R7's electronic record and documented that the resident had agreed to appoint a Durable Power of Attorney (hereinafter DPOA G) as their agent in the event they are unable to participate in medical treatment decisions. *It should be noted that there was no documentation in R7's electronic record that noted the resident had been deemed incompetent to make medical treatment decisions and/or confirm that they were not able to make Advanced Directive choicesXXX[DATE]: Encounter .Acute urinary tract infection.with increased confusion and lethargy.Start antibiotic treatment. On [DATE] at approximately 9:25 AM an interview was conducted with Social Worker Director (SSD) E and Social Service Worker (SSW). F. SSD E reported they had been the Director since [DATE] and noted that they were not a licensed social worker but worked with Regional Director P. SSD E noted that they generally work with residents that are at the facility long term. They also noted that SSW 'F works with those who are the facility short term. It was also noted that SSW F is not a social worker. SSD E was asked if they were familiar with R7 and whether they knew that the resident was capable of signing consent for the antipsychotic medication Seroquel on [DATE] but not capable of signing the Advanced Directive Acknowledgment/Code Status on [DATE]. When asked if at that time, R7 had been deemed incompetent, they replied no. SSD E further reported that a psychiatrist had deemed R7 incapable of making decisions on [DATE] but they were awaiting a signature from R7's physician. *It should be noted that no documentation regarding competency was found in R7's electronic record. SSD E was able to provide a document that had only been signed by a licensed psychiatrist on [DATE].On [DATE] at approximately 9:48 AM, R7 was observed sitting in their wheelchair. They were alert and able to answer most questions asked. R7 was asked if staff had ever discussed end-of-life/code status wishes. R7 stated he could not recall but noted that they wished to be DNR (do-not-resuscitate). R7 was also able to name the person listed as their DPOA and noted they should be aware of their choices. R7 was not aware of any medication they had consented for.A return interview was conducted with both SWD E and SSW F on [DATE] at approximately 10:30 AM. SWD E' was asked how they determined R7 was not capable of expressing their Advanced Directives/CPR Consent form. SSD E reported that they had determined R7 had a low BIMS score. SSW F also noted that R7 was confused as to where they resided and who they lived with and determined the resident was not capable of determining their wishes. SWD E was asked about the consent for the Antipsychotic Seroquel and what indicated they were capable of making the choice to take the medication based on depression/dementia diagnoses and were there any social worker notes indicating they and or SSW F met with R7. SWD E reported that there were no notes to review.The facility policy titled, Social Services (revised [DATE]) was reviewed and documented in part: Policy: The facility regardless of size, will provide medically related social services to each resident.The social worker, or social service designee, will complete an initial.assessment of each resident.Any need for medically-related social services will be documented in the medical record.The social worker, or social service designee, will pursue the provision of any identified need for medically-related social services.Attempt to meet the needs of the resident may include.Assisting residents with advance care planning.Identifying and promoting individualized, non-pharma logical approaches to care that meet the mental and psychological needs of each resident.

This citation pertains to Intakes: MI00146265 and MI00148408. Based on observation, interview, and record review, the facility failed to ensure fall precautions were implemented for one resident (R904) with a history of falls out of three residents reviewed for falls resulting in the potential for recurrence of falls and injury. Findings include: On 12/4/24, a clinical record review revealed R904 was admitted to the facility for nursing care and rehabilitation on 11/15/24. R904 required surgical intervention for a fall sustained at home resulting in a right hip fracture. R904's medical history included chronic kidney disease, urinary retention, heart disease, and heart attack. A BIMS (Brief Interview for Mental Status) score was unobtainable when assessed due to acute delirium with hallucinations. Clinical record review revealed R904 sustained a fall at the facility on 11/17/24 and 11/26/24. Care plan initiated on 11/16/24 and revised on 11/27/24 documented Resident Focus: .at risk for falls/injury related to debility, right hip <sic> FX (fracture), encephalopathy and possible delirium with hallucinations. R904 was documented with the following interventions: Fall mats on each side of the bed. Initiated 11/27/24 Ensure resident's room is free from accident hazards (e.g., ensuring there are no trip hazards). Initiated 11/27/24 Food/fluids within reach. Initiated 11/27/24 Place call light within reach. Initiated 11/27/24 On 12/4/24 at 10:40 AM, R904 was observed in a wheelchair in the middle of the room facing towards the window. No floor mats were observed next to the bed, within the room, closet, or bathroom. One square of carpeting was observed under the right wheel of the head of bed, unattached, lying across, exposing the subfloor. Two squares of carpet in the middle of the room, in front of where R904 was sitting, was observed with minimal lifting and not flush with majority of square surface area. Three Styrofoam cups, one dated 12/4 with a lid and straw, and a plastic bottled water was observed on a dresser table next to the wall, under a mounted television. The tray table was placed in front of the dresser table preventing reach to fluids. The call light was observed at the head of the bed, clipped to the bed linens, out of reach. On 12/4/24 at 11:30AM, R904's care plan was reviewed with R904's assigned Licensed Practical Nurse A (LPN A). LPN A performed an observation of the above findings and acknowledged fall precaution interventions were not in place. On 12/4/24 at 11:55, the Director of Nursing (DON) observed the findings and acknowledged fall precaution interventions were not in place. Review of the facility policy titled: Fall Prevention Program, dated 10/2023 documented: .Residents will receive care and services in accordance with the level of risk to minimize the likelihood of falls .risk factors and environmental hazards will be evaluated .

Based on observation, interview, and record review, the facility failed to provide nursing care and services according to professional standards of practice for one (R203) of one resident reviewed for tube feeding. Findings include: On 8/12/24 at 10:18 AM, R203 was observed lying in bed. R203 was receiving nutrition via a PEG (Percutaneous Endoscopic Gastrostomy) tube (a tube surgically placed into the stomach to deliver nutrition). The PEG tube pump was running at 45 milliliters per hour (ml/hr) and the bottle of formula was dated 8/12/24. On 8/13/24 at 9:01 AM, R203 was observed lying in bed. R203 was receiving nutrition via a PEG tube. The PEG tube pump was running at 45 ml/her and the bottle of formula was dated 8/13/24. A review of R203's clinical record revealed R203 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: prostate cancer, chronic kidney disease, and ST elevation myocardial infarction (STEMI), and gastrointestinal hemorrhage. A review of an Minimum Data Set (MDS) assessment dated [DATE] revealed R203 had intact cognition and had a feeding tube. A review of R203's Physician's orders revealed no order for tube feeding that indicated the prescribed formula, rate, and feeding instructions until 8/13/24, five days after R203 was readmitted into the facility. It should be noted that R203's tube feeding was observed to be administered on 8/12/24 and 8/13/24. There was an active order with a start date of 8/9/24 to Cleanse (PEG) tube site with soap and water daily and as needed. Apply drain sponge as needed. site may be left open to air if clean and no drainage. A review of R203's August 2024 Treatment Administration Record (TAR) indicated this order was completed on 8/9/24, 8/10/24, 8/11/24, and 8/12/24 as evidenced by an electronic signature from the nurse who carried out the order. On 8/13/24 at approximately 10:30 AM, an observation of R203's PEG tube site was conducted with the Wound Care Coordinator, Licensed Practical Nurse (LPN) 'A'. LPN 'A' lifted R203's gown and revealed a dressing applied to R203's PEG tube site. The dressing was dated 8/9/24, four days earlier. LPN 'A' removed the dressing which was soiled with thick, caramel colored drainage. It should be noted that it was documented on the TAR that R203 received treatment to the PEG tube site daily since his readmission on 8/9/24. On 8/13/24 at approximately 10:50 AM, an interview was conducted with the Director of Nursing (DON). When queried about how often PEG tube sites should be monitored, cleaned, and dressed, the DON reported at least daily. At that time, the DON was asked when R203's tube feeding order was put into place. The DON reported he would look into it. On 8/13/24 at 11:05 AM, the DON followed up and reported the PEG site dressing should have been changed according to physician's orders and the nurse should not have signed out that it was done if it was not. The DON further said the order for R203's tube feeding was not entered until that day, 8/13/24, but the nurse wrote the order in the progress note on admission on 8/8/24. When queried as to how the nurses knew what tube feeding to administer each day since 8/8/24 and how it was known whether or not R203 received daily tube feeding, the DON did not offer a response.

Based on observation, interview, and record review, the facility failed to accurately assess wounds, perform wound care treatments, coordinate with a comprehensive wound care team consisting of a wound care practitioner, document treatment plans, and implement physician's orders for wound care treatments for two residents, (R#'s 101 and 305) of three residents reviewed for skin impairments, resulting in verbalized complaints, fear of staff competency and infection, and R101 voluntarily leaving the facility for wound care at the hospital. Findings include: R101 On 8/13/24 at 2:09 PM, a review of R101's closed record revealed they admitted to the facility on [DATE] and discharged [DATE]. R101's diagnoses included: cutaneous abscess of buttock, and hidradenitis suppurativa, a chronic inflammatory skin disorder characterized by painful nodules, abscesses, and scarring. R101's post-operative records from the hospital revealed they underwent incision and drainage of multiple buttock, back, thigh, and perianal abscesses with significant abscess cavities under the skin and, .extensive purulent material and tunneling The paperwork further revealed R101 had three penrose drains (a straight, flexible tube that drains fluid from a surgical site) placed to the wound. A review of a Nursing Admission Evaluation dated 5/21/24 was reviewed and revealed R101 admitted with a right buttock surgical wound. Neither the evaluation nor the nursing admission note dated 5/21/24 made any mention of the presence of wound drains. It was further noted the first practitioner note entered into the record by Nurse Practitioner G made no mention of the drains or the treatment to be applied to the wound, the note only read, .Wound Care consult for ongoing wound management . Continued review of R101's closed record revealed a Skin & Wound Evaluation dated 5/22/24 and documented R101 had a, 22. Other skin impairment specified on the form as rose pin, it was unclear what was meant by a rose pin wound. The form contained 21 types of wounds the assessing nurse could have checked including, 10. Hidradenitis Suppurativa (R101's diagnoses), or, 20. Surgical. It was of note, the assessment did not include any mention of the three wound drains. R101's Treatment Administration Record (TAR) was reviewed and revealed an order dated 5/24/24 (three days after admission and the day R101 left the facility) to monitor the wound drains. It was further discovered two orders were written on 5/22/24 for treatment to R101's buttocks that both read, .Cleanse with wound cleanser. Pat dry. Apply Bordered Foam as directed to buttock . It was noted both orders on the TAR were blank and not signed off as having been completed on 5/22/24. A review of Dr. 'H's progress note dated 5/23/24 was reviewed and read, .I am evaluating .today for an admission history and physical. Patient has a history of hydradenitis <sic> suppurativa and was hospitalized and treated for a right gluteal abscess status post incision and drainage .patient says he felt he got good wound care here .but today his nurse did something different and he is not sure he is getting the best wound care .all wounds to be managed by the wound care team here at the facility . It was noted Dr. 'H's progress notes did not indicate the type of wound care treatment or how often the treatment was to be done, nor did the note indicate the presence of drains. A review of a progress note dated 5/24/24 at 10:05 PM was conducted and read, Lodger Requested to Leave Stating He Does Not Feel He Is Receiving the Care He Needs for His Surgical Wound. This Nurse Offered to Change the Dressing, Lodger Declined Stating I Have Made Up My Mind, I Am Returning to the Hospital, They Know How to Properly Care for My Wound .He Is Driving Himself to the Hospital . <sic> On 8/13/24 at 1:20 PM, an interview was conducted with Wound Care Nurse 'A'. Nurse 'A' was asked if there was a wound care physician, physician's assistant or nurse practitioner at the time of R101's admission and said there was not. Nurse 'A' then said they assessed R101 on admission, placed the treatment orders and Dr. 'H' signed off on them. They were asked about the presence of drains and confirmed R101 admitted with drains. They were asked why this was not documented and had no explanation but said it should have been noted. They were then asked about the missed treatment on 5/22/24 and said it should have been done by R101's assigned nurse. They further reported R101 told them on 5/23/24 they were concerned with the nurses ability/competency to care for their wounds and they reported the concern to Dr. 'H'. Nurse 'A' confirmed R101 left the faciity on [DATE]. On 8/14/24 11:03 AM, an interview was conducted with Dr. 'H' regarding R101. They were asked about the documentation for the specific treatment of R101's wounds and said they deferred to the facility's wound care team and did not document specific treatment orders in their progress notes. They were asked if they were aware at the time of R101's admission the Wound Care Team only consisted of Nurse 'A' and said they were aware the facility was challenged with finding a wound care physician. Dr. 'H' was then asked about the documentation of the presence of drains and agreed it was missed. Dr. 'H' further reported R101 did express to them their concerns about the treatment of their wounds and said it was reported to the facility's Administrator and Director of Nursing. An interview via telephone was conducted with R101 on 8/13/24 at 2:35 PM. They were asked about their stay at the facility and said, It was a disaster. R101 further reported they had surgery and were sent to the facility for wound care. They said the only nurse who seemed like they knew what they were doing was the first nurse, Nurse 'A'. They further reported no one seemed comfortable doing the treatments and the day before they left (5/23/24) the nurse sprayed something on their wound that caused it to, burn like crazy. R101 was asked if any treatments were missed and said they did not recall. R101 said they spoke to the doctor and they needed answers about the staff's competency to care for their wounds. They said they were told someone would come and speak to them but no one ever did. They said they were fearful of an infection and decided to return to the hospital. 38271 R305 On 8/12/24 at approximately 10:47 a.m., R305 was observed in their room, standing up next to their bed. R305 was observed to have a dry dressing on each knee that appeared to be worn and losing their adhesive properties. Neither dressing on their knees were dated and appeared to be worn. A worn dry dressing dated 8/10/24 was observed on R305's right elbow. R305 was queired if they had fallen and they indicated they had and had scraped their knees and elbow. On 08/12/24 at approximately 3:33 p.m., R305 was observed in their room, lying down in a low bed. R305 still had on the dry dressings on both knees with the edges of the dressings starting to become unattached. On 8/13/24 at approximately 8:55 a.m., R305 was observed in their room, lying in their bed. R305 was observed to have a dry dressing on their right knee that was still undated with no dressing on their left knee with an uncovered pink skin abrasion. R305's right elbow had a dry dressing dated 8/10/24. On 8/13/24 at approximately 10:46 a.m. R305 was observed in their room, lying in their bed. R305 was observed to have a dry dressing on their right knee that was undated and no dressing on their left knee with an uncovered pink skin abrasion. R305's right elbow had a dry dressing dated 3/10/24. R305 was queried if any staff had changed their dressing and they reported that nobody had. R305 was queired what happened to their dressing on their left knee and they indicated it had fallen off the previous day and that nobody had applied a new dressing. On 8/12/24 the medical record for R305 was reviewed and revealed the following: R305 was initially admitted to the facility on [DATE] and had diagnoses including Dementia and Type 2 Diabetes Mellitus. A Nursing progress note dated 8/10/24 revealed the following: At approximately 0100 (1:00 a.m.), lodger noted to be laying on his right side on the floor, in front of bathroom door, with knees bent up to waist. Lodger assessed for injury, abrasion noted to right knee, and skin tear noted to right elbow. Lodger denies hitting his head, and AROM (active range of motion) noted to all 4 extremities. Writer asked lodger what had happened and lodger states he was trying to move the mat. No mat located in room by writer. Neuro (neurological) checks complete and noted to be WNL (within normal limits) for lodger. Lodger noted to be incontinent of urine at this time. Lodger assisted to his feet per 3 staff, and assisted onto toilet. Lodger then assisted onto bed per 3 staff. On Call provider notified, and DON (Director of Nursing) notified. Will notify family in a.m. A Fall assessment dated [DATE] titled Fall-Initial-V2 was reviewed and revealed the following: Date of fall-8/10/24 New orders related to the fall: [Yes] 9a. Describe New Physician Orders-Clean right knee abrasion and right elbow skin tear with soap and water, apply TAO (triple antibiotic ointment) and dry dressing daily . Further review of R305's medical record did not reveal any noted transcribed Physician orders for R305's right knee abrasion and right elbow skin tears noted in the fall assessment dated [DATE]. A review of R305's August 2024 treatment administration record (TAR) did not reveal any treatments administered to R305's right knee or right elbow were documented as having been completed. On 8/14/24 at approximately 9:03 a.m., during a conversation with the Director of Nursing (DON), the DON was queried regarding the process for transcribing orders and they reported that the facility Nurse should have transcribed the Physician's orders for R305's dry dressing skin abrasions but did not and did not date knee dressing. The DON indicated they would input the orders for R305's dry dressings into the the electronic medical record so it can be completed by the Nurse and documented per the Physician's orders. On 8/14/24 a policy addressing the procedures for non-pressure wound care was requested from the facility Administrator and they reported they did not have a policy/procedure guide for non-pressure wounds.

Based on observation, interview, and record review, the facility failed to timely assess pressure ulcers present on admission into the facility in a timely manner, and implement preventative measures to maintain skin integrity for one (R203) of two residents reviewed for pressure ulcers. Findings include: On 8/12/24 at 10:18 AM, R203 was observed lying on his back in bed. Two pairs of heel protector boots were observed in the room, on a chair and on the floor, not applied to R203's feet. R203's feet were pressed against the foot board of the bed. A low air loss mattress was observed. R203 reported he had sores on his feet. A review of R203's clinical record revealed R203 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: prostate cancer, chronic kidney disease, and ST elevation myocardial infarction (STEMI). A review of an Minimum Data Set (MDS) assessment dated [DATE] revealed R203 had intact cognition, required substantial/maximum assistance for bed mobility and transfers, did not walk, and had three unstageable pressure ulcers (obscured full-thickness skin and tissue loss) that were present on admission. On 8/13/24 at 9:01 AM, R203 was observed lying in bed. R203 reported staff applied heel protector boots on that day, but they did not always put them on. Further review of R203's clinical record revealed the following: A review of a Nursing Admission Evaluation dated 7/22/24, that was not complete and in progress revealed R203 was admitted with pressure ulcers to the left toe, left heel, right toe, and right heel with eschar (dead or devitalized tissue). A review of a Nursing Evaluation Summary progress note dated 7/22/24 written by the Director of Nursing (DON) and MDS Coordinator revealed, .Unstageable heel ulcers bilateral and necrotic areas noted on both great toes . A review of a History of Physical completed by Physician 'E' revealed no documentation of R203's pressure ulcers. Further review of all evaluations conducted by the facility's medical providers (Physician 'E' and Nurse Practitioner - NP 'G') revealed no documentation that R203 had pressure ulcers or an evaluation of the pressure ulcers. A review of a Skin assessment dated [DATE] revealed R203 had existing pressure ulcers to the bilateral heels and great toes. It was documented that boots and offloading in place. A review of R203's Wound Evaluations and Skin & Wound Evaluations revealed R203's feet were not assessed by LPN 'A' until 8/9/24 when he was readmitted into the facility from the hospital. R203 was transferred to the hospital on 7/29/24 and 7/31/24 and returned the same day and was admitted to the hospital from 8/4/24 through 8/8/24. A review of Skin & Wound Evaluations for R203 on 8/9/24 and 8/12/24 revealed R203 had an unstageable pressure ulcers to the left and right heels that were present on admission, filled with 100 percent eschar; and deep tissue injuries (DTIs) to the left and right great toes that were present on admission. A review of R203's Physician's Orders revealed orders dated 7/22/24 for treatment to the bilateral heels and toes for unstageable ulcers. An order for offloading boots on at all times while in bed was ordered on 7/22/24 and discontinued on 7/22/24. However, R203 continued to have pressure ulcers to his bilateral great toes and heels. A review of a Nursing Evaluation Summary progress note dated 8/8/24 revealed R203 was admitted into the facility on that day. It was documented that R203's BL (bilateral) heels have necrotic (dead) tissue. On 8/13/24 at approximately 10:30 AM, R203's feet were observed with Wound Care Coordinator, Licensed Practical Nurse (LPN) 'A'. At that time, R203 had heel protector boots on. An observation of R203's right foot revealed a black area to the great toe, a black area on the outer bottom part of the heel, and a second darkened area on the back of the heel. An observation of R203's left foot revealed a black area to the tip of the great toe and a black area described by LPN 'A' as all eschar located on the inner part of the heel. LPN 'A' reported that R203 needed a bed extender. On 8/13/24 at approximately 10:50 AM, an interview was conducted with LPN 'A'. When queried about how often she assessed residents' wounds, LPN 'A' reported she conducted wound assessments every week on Monday. When queried about why there was no documented assessment of R203's pressure ulcers to the heels and toes until 8/9/24, LPN 'A' reported R203 did not have any wounds until he returned to the facility from the hospital on 8/8/24. When queried about the MDS assessment, nursing admission assessment, skin assessment, and treatment orders that indicated R203 had pressure ulcers to his bilateral heels and great toes, LPN 'A' did not offer a response. On 8/13/24 at 1:16 PM, an interview was conducted with the DON. When queried about the facility's process for assessing residents' pressure ulcers, the DON reported they were assessed by LPN 'A' and the wound provider weekly. LPN 'A' reported the wound provider started working in the facility two weeks ago and did not come to the facility on [DATE]. The DON reported any assessment completed by LPN 'A' was documented in the electronic medical record. When queried about why R203's pressure ulcers were not assessed until 8/9/24 when he was admitted with them on 7/22/24, the DON reported he had to look into it. At that time, any evaluations of R203's pressure ulcers conducted by a medical provider was requested. No additional information was provided prior to the end of the survey.

Based on observation, interview, and record review, the facility failed to ensure a thorough and accurate assessment was done upon admission, physician's orders for an indwelling urinary catheter were in place, and the catheter was securely anchored for one (R204) of three residents reviewed for urinary catheters. Findings include: On 8/12/24 at 10:25 AM, R204 was observed sleeping in a chair in the room where his wife resided. R204's was observed with tubing from a urinary catheter exiting the bottom of his long pajama pants. The urinary catheter drainage bag was observed hung on R204's walker which was next to the resident and therefore the tubing was stretched from the pant leg to the walker. On 8/13/24 at 10:25 AM, R204 was observed ambulating with a walker. Tubing from the urinary catheter was observed coming out of the bottom of R204's pant leg and attached to the drainage bag that was attached to the bottom of the walker making contact with the floor. The tubing was observed dragging on the floor as R204 walked. On 8/13/24 at approximately 10:50 AM, an interview was conducted with the Director of Nursing (DON) who was present on the unit during the above observation. When queried about whether R204's catheter was anchored properly, the DON reported he could get a leg bag (a smaller drainage bag that is worn on the leg when you are up out of bed). When queried about what orders and monitoring should be in place for residents admitted with indwelling urinary catheters, the DON reported there should be physician's orders for the catheter. At that time, the DON was asked if the appropriate orders and monitoring were done for R204. The DON reported he would look into it. On 8/13/24 at approximately 11:30 AM, the DON reported R204 did not have an order for the indwelling urinary catheter. A review of R204's clinical record revealed the following: R204 was admitted into the facility on [DATE] for respite care. R204 received hospice services. A review of a Nursing Admission Evaluation for R204 revealed documented vital signs from his previous admission on 5/24/24. The evaluation indicated R204 was continent of urine and did not indicate that R204 had an indwelling urinary catheter. The evaluation was dated 8/11/24, two days after R204 was admitted into the facility. A review of the Certified Nursing Assistant (CNA) task for catheter care indicated R204 received catheter care on 8/13/24. There was no documentation that R204 received catheter care prior to that date. A review of R204's physician's orders revealed no physician's orders for R204's catheter until 8/13/24 which included an order to ensure the catheter was anchored in place. There was no care plan initiated until 8/13/24 for catheter care. A review of R204's progress notes indicated no notes that indicated R204 had an indwelling urinary catheter. A review of R204s CNA task for Urinary Continence revealed CNAs documented R204 was continent of urine twice on 8/10/24 and 8/11/24, and once on 8/12/24 and 8/13/23. The task included a section to check Continence Not Rated due to Indwelling Catheter. In response to the question, What was the toileting bladder activity?, two CNAs documented, Used bed pan/commode/urinal/toilet despite R204 having a urinary catheter. Three CNAs documented R204 toileted himself. A review of a facility policy titled, Catheter Care Procedure - Urinary dated 2/28/23, revealed, in part, the following: .Residents with indwelling catheters will be provided catheter care in accordance with current clinical standards. This may include: .every shift .with each bowel movement .as needed and per request .Leg bags may be utilized for ambulatory residents .Catheters should be secured to prevent pulling and damage to the urethral meatus. This may be accomplished by .utilizing the appropriate drainage device (leg bag or catheter bag) .Catheters should be emptied every shift or as needed .urinary output should be recorded per facility protocol .

Based on observation, interview, and record review, the facility failed to ensure appropriate care was provided to prevent dislodgement of a PEG (Percutaneous Endoscopic Gastrostomy) tube (a tube surgically placed into the stomach to deliver nutrition), physicians orders for nutrition and hydration were in place, and care to the PEG tube site was provided according to physician's orders for one (R203) of one resident reviewed for tube feeding, resulting in the PEG tube being torn from R203's stomach requiring a hospital transfer, the potential for poor nutritional and hydration status, pain, infection and skin breakdown. Findings include: On 8/12/24 at 10:18 AM, R203 was observed lying in bed. R203 was receiving nutrition via a PEG tube. The PEG tube pump was running at 45 milliliters per hour (ml/hr) and the bottle of formula was dated 8/12/24. On 8/13/24 at 9:01 AM, R203 was observed lying in bed. R203 was receiving nutrition via a PEG tube. The PEG tube pump was running at 45 ml/her and the bottle of formula was dated 8/13/24. A review of R203's clinical record revealed R203 was admitted into the facility on [DATE] and readmitted on [DATE] with diagnoses that included: prostate cancer, chronic kidney disease, and ST elevation myocardial infarction (STEMI), and gastrointestinal hemorrhage. A review of an Minimum Data Set (MDS) assessment dated [DATE] revealed R203 had intact cognition and had a feeding tube. A review of a Transition of Care form from the hospital dated 8/8/24 revealed R203 had a primary diagnosis of dehydration and prerenal azotemia (caused by decreased blood flow to the kidneys which can be caused by dehydration or blood loss from a hemorrhage). Instructions for 250 cc (cubic centimeters) of free water flushes every 4 hours was included in the discharge instructions. A review of R203's Physician's orders revealed no order for tube feeding that indicated the prescribed formula, rate, and feeding instructions until 8/13/24, five days after R203 was readmitted into the facility. The orders entered on 8/13/24 indicated R203 was to receive 250 ml (milliliters) of free water, five days after R203 was readmitted into the facility. There was an active order with a start date of 8/9/24 to Cleanse (PEG) tube site with soap and water daily and as needed. Apply drain sponge as needed. site may be left open to air if clean and no drainage. A review of R203's August 2024 Treatment Administration Record (TAR) indicated this order was completed on 8/9/24, 8/10/24, 8/11/24, and 8/12/24 as evidenced by an electronic signature from the nurse who carried out the order. On 8/13/24 at approximately 10:30 AM, an observation of R203's PEG tube site was conducted with the Wound Care Coordinator, Licensed Practical Nurse (LPN) 'A'. LPN 'A' lifted R203's gown and revealed a dressing applied to R203's PEG tube site. The dressing was dated 8/9/24, four days earlier. LPN 'A' removed the dressing which was soiled with thick, caramel colored drainage. On 8/13/24 at approximately 10:50 AM, an interview was conducted with the Director of Nursing (DON). When queried about how often PEG tube sites should be monitored, cleaned, and dressed, the DON reported at least daily. At that time, the DON was asked when R203's tube feeding order was put into place. The DON reported he would look into it. On 8/13/24 at 11:05 AM, the DON followed up and reported the PEG site dressing should have been changed according to physician's orders and the nurse should not have signed out that it was done if it was not. The DON further said the order for R203's tube feeding was not entered until that day, 8/13/24, but the nurse wrote the order in the progress note on admission on 8/8/24. When queried as to how the nurses knew what tube feeding to administer each day since 8/8/24 and how it was known whether or not R203 received daily tube feeding, the DON did not offer a response. A review of R203's progress notes revealed the following: A Nursing Evaluation Summary dated 8/8/24 revealed R203 was readmitted into the facility. It was documented R203 was on peg-tube feeding but only mentioned the type of formula and the rate. A Nurses' Note dated 7/29/24 noted, Therapy was working with resident when peg tube accidentally was torn out. Small trauma to opening noted, stomach contents draining .911 called .transferring to (hospital) for eval and treatment . A progress note written by NP 'G' on 7/30/24 noted, .Chief Complaint .PEG tube traumatically pulled out and replaced .PEG tube traumatically pulled out while working with therapy by accident the other day. Went to the ER (emergency room ) and it was replaced . An Alert Note dated 7/31/24 noted, .CNA (Certified Nursing Assistant) called writer to room because his (R203) peg tube dressing was wet .(R203) c/o (complained of) abdominal pain, abdominal contents coming out of site .transfer to hospital . R203 returned to the facility the same day after the PEG tube was replaced. On 8/13/24 at 9:52 AM, the Administrator and DON were asked to provide any incident reports and/or investigations for R203. The Administrator reported there were no investigations or incident reports for the resident. A review of a Physical Therapy (PT) Treatment Encounter Note dated 7/29/24 revealed, R203 was seen by Physical Therapy Assistant (PTA) 'F'. PTA 'F' documented, .Patient's feeding tube came out of his abdomen after amb (ambulation) . On 8/13/24 at approximately 12:41 PM, an interview was conducted with PTA 'F'. When queried about what happened with R203's PEG tube on 7/29/24, PTA 'F' reported she worked with the resident on ambulation using a gait belt. PTA 'F' reported the gait belt was positioned off of the PEG tube site. PTA 'F' further reported R203 was tired and wanted to lay down. PTA 'F' assisted R203 to sit at the side of the bed and when he laid down she heard a suction and his stomach was wet and the PEG tube was completely out. PTA 'F' reported she did not know what happened. She remembered the tubing was long and that she used a gait belt but was unable to say how it was traumatically pulled out. On 8/13/24 at approximately 12:52 PM, an interview was conducted with the DON. When queried about whether the incident of R203's PEG tube being traumatically pulled out during therapy was investigated, the DON reported he would have to check with therapy. On 8/13/24 at approximately 1:23 PM, the DON followed up and stated, Therapy said they don't think it was anything they did to cause the PEG tube to be traumatically pulled out. The DON reported he did not investigate it from a nursing standpoint. A review of a facility policy titled, Feeding tubes, revised on 6/30/22, revealed, in part, the following: .Feeding tubes will be utilized according to physician orders .

Based on observation, interview and record review the facility failed to ensure a physician and/or physician extender evaluated and assessed a new/worsened pressure ulcer for one (R85) of two residents reviewed for pressure ulcers, resulting in the lack of pressure ulcer assessment by the physician, and the potential for inconsistent and timely documentation of wound status, and/or decline of the wound. Findings include: On 8/12/24 at 12:21 PM, R85 was observed in room appeared to be resting. When R85 was asked how they were doing and stated that their bottom was hurting and could not get comfortable due to the pain, other than that R85 was content. A record review revealed that R85 was admitted to the facility on [DATE] with diagnoses of Parkinson's diseases, pressure ulcers of sacral region and muscle weakness. R85 had a brief interview for mental status score of 15, indicating an intact cognition. A further review of the chart revealed that R85's wound care orders had been updated that morning 8/12/24. A review of the status of the wound, revealed no progress note from a provider since 2/2024. On 8/13/24 at 12:00 PM the Wound care nurse was interviewed and asked what wound care company they used. The Wound care nurse explained they just got a new provider two weeks ago. When further questioned on who was the provider was used prior too two weeks ago, the Wound care nurse stated, We have not had a provider for several months. The doctors were supposed to put in their own notes or assessments of the wounds after we round on their patients weekly. The wound care nurse was then asked about R85 and if they could provide the notes for the wound. The wound care nurse stated she would look and get back with this surveyor. On 8/14/24 at around 10 AM, the Medical director was interviewed by another surveyor and stated that she did not do progress notes on wounds, but put her notes in to follow up with the wound care team. The Medical director was then asked who did the wound care team consist of at the facility. She stated the Wound care nurse since the facility just got a new provider recently. The Medical director was informed of no progress notes or physician follow up with the wound care for R85. The Medical director stated, Correct, there is one now. No additional information was provided by the exit of survey.

Based on interview and record review, the facility failed to ensure labs were obtained timely for one resident (R40) of one resident reviewed for labs, resulting in the potential for unmet medical care needs. Findings include: On 8/12/24 at 1:20 PM, a review of R40's clinical record revealed a note entered into the record on 7/8/24 by Nurse Practitioner (NP) 'G' that read, .Check a CMP (comprehensive metabolic panel, a routine blood test that measures 14 different substances in a blood sample) and CBC (complete blood count, a blood test to look at a wide range of conditions) to monitor fluid volume status . A note entered into R40's record by Nurse 'I' on 7/19/24 at 10:48 AM was reviewed and read, .Resident asked nurse why his blood work from 7/8/24 still hadn't been completed yet, Dr. ('H') in the building at the time and resident asked her about it. Dr. ('H') ordered for blood work to be reordered STAT today . Continued review of R40's record revealed a note entered into R40's record by Nurse 'I' on 7/23/24 at 12:00 PM that read, .Resident stated that he still had not gotten bloodwork <sic> drawn from 7/19/24, nurse saw phlebotomist in building and asked why it was not done yet and to have it completed today. Labs drawn today . A review of R40's physician's orders was conducted and revealed orders dated 7/8/24 and 7/19/24 for a CBC and a CMP. It was noted the orders each had a status of Completed. On 8/13/24 at 2:52 PM, a review of R40's facility provided lab results were reviewed and only included CBC and CMP results collected on 7/22/24 and reported to the facility on [DATE]. No results were provided for labs ordered on 7/8/24 or 7/19/24. On 8/14/24 at 9:30 AM, an interview was conducted with the facility's Director of Nursing and they acknowledged the labs were not drawn and sent on 7/8/24 or 7/19/24. A review of a facility policy titled, Laboratory and Diagnostic Guidelines revised 10/2023 was conducted and read, Policy: This guideline is set up to track the timely completion, reporting and monitoring of laboratory and diagnostic tests, results, and notifications which are used to monitor resident status and/or therapeutic medication levels .

Based on observation, interview and record review the facility failed to follow infection control guidance for one resident (R306) of three residents reviewed for urinary catheters. Findings include: On 8/12/24 at approximately 10:43 a.m., R306 was observed in their room, lying in their bed. R306's catheter draining bag was observed located not below the bladder (indicating a risk for urine to backflow up into the bladder causing infection). R306 was noted not to have any signage on their door that indicated staff were to apply enhanced barrier precautions (EBP) when providing direct care to them. R306 was queired if staff were wearing any protective gowns when caring for them and they indicated nobody had. On 8/12/24 at approximately 3:32 p.m., R306 was observed in their room, lying in their bed. R306's catheter draining bag was still observed high and located not below bladder. R306's door was still noted to not contain any information that staff were to apply EBP. On 8/13/24 at approximately 8:54 a.m., R306 was observed in their room lying in their bed. R306's door was still not observed to have any signage informing staff that they were to don EBP when providing care to R306. On 8/13/24 at approximately 1:13 p.m., Physical Therapy Assistant F (PTA F) was observed providing therapy services to R306 in their room. PTA F was queired if they had used enhanced barrier precautions while doing therapy with R306 and they indicated they did not because they did not see a sign on 306's door. PTA F then reported that R306 should have had an EBP sign on their door because they had a catheter. On 8/12/24 the medical record for R306 was reviewed and revealed the following: R306 was initially admitted to the facility on [DATE] and had diagnoses including Contact with and suspected exposure to Covid-19 and Hemiplegia and Hemiparesis following Cerebral vascular disease affecting right non-dominant side. A Physician evaluation dated 8/9/24 revealed the following: This is an [AGE] year-old admitted to [name of facility] on 8/8/24 from [name of hospital] due to bright red blood per rectum. GI (Gastrointestinal) was consulted. Symptoms improved spontaneously. Lower GIB (gastrointestinal bleeding) suspected due to hemorrhoids, as family reports that patient has had recurrent episodes of bright red blood per rectum and work up found hemorrhoids to be the culprit Hospital course was complicated by large volume urinary retention requiring foley catheter, severe constipation, and E.coli UTI (urinary tract infection). A review of R306's Physician orders did not reveal any orders for enhanced barrier precautions. A review of R306's careplan did not reveal any plan of care for enhanced barrier precautions. On 8/13/24 at approximately 1:16 p.m., Registered Nurse C (RN C) was queried regarding R306's indwelling catheter and then not being provided EBP by the facility staff and they reported that R306 needed to have EBP due to the catheter and that they should have a sign on the door and a Physician's order. At that time, an observation of R306's room was conducted with RN C and they indicated they did not have a sign and would have to put one on the door to alert staff and implement an order in for EBP since R306 had an indwelling catheter. On 8/13/24 a facility document titled Enhanced Barrier Precautions was reviewed and revealed the following: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO) .b. Even if the resident is not known to be infected or colonized with a MDRO, an order for enhanced barrier precautions will be obtained for residents with any of the following: II. Indwelling medical devices (e.g., central lines, urinary catheters .3. a. Make gowns and gloves readily available near or outside of the resident's room .e. Provide education to residents and their visitors about enhanced barriers precautions

This citation pertains to Intake MI 00133995 Based on observation, interview and record review, the facility failed to ensure timely interventions to reduce the risk of pressure ulcer development, perform accurate and timely skin assessments and ensure orders were clarified for one (R38) of four residents reviewed for pressure ulcers, resulting in R38 acquiring a device related pressure ulcer on the spine. Findings Include: R 38 On 9/12/23 at 9:50 AM, R38 was observed lying in bed on her back sleeping. Padded boots were observed in a wheelchair against the wall across from the bed. R38 was asked if they had any wounds or sores on their body. R38's Family Member present in the room explained R38 had a wound on her ankle and a wound on her back from a back brace. When asked about the wound on R38's ankle, R38's Family Member lifted up the bed covers and a flat pillow was observed under R38's lower legs, however her heels were in direct contact with the mattress. R38's Family Member was asked how she got the wound on her back. R38's Family Member explained the staff were putting her brace on when she was in bed, and had left it on all night and the injury is from the brace. Review of the clinical record revealed R38 was originally admitted into the facility on [DATE] and readmitted [DATE] with diagnoses that included: compression fracture of fourth lumbar vertebra, peripheral vascular disease and rheumatoid arthritis. According to her Minimum Data Set (MDS) assessment dated [DATE], R38 had severely impaired cognition and required the assistance of staff for all activities of daily living, (ADL's) including 2 person extensive assistance for bed mobility. The MDS assessment also indicated R38 had no pressure ulcers. Review of R38's pain care plan revealed an intervention initiated 8/28/23 that read, TLSO (thoracic lumbar sacral orthosis - a brace that limits movement in the spine) back brace to be worn at all times while awake. Remove Q (every) shift and check skin integrity. Report any redness or abnormalities to the MD (doctor). On 9/12/23 at 12:39 PM, R38 was observed lying on her back sleeping. The padded boots were still observed in the same spot in the wheelchair, they did not appear to have been moved. Review of R38's progress notes revealed a nursing note dated 9/12/23 at 3:10 PM that read in part, Assessed residents skin today after being notified by staff of new skin issue. Noted medical device related pressure injury to spine stage 2, boggy heels . Skin measurements being entered. Care plan updated to reflect these areas and interventions updated. Residents (Family Member) present at time of assessment. Review of R38's impaired skin integrity care plan revised 9/12/23 read in part, Medical device related pressure injury stage 2 (partial-thickness loss of skin with exposed dermis) . R/t (related to) fragile skin, decreased mobility, back brace. There were no interventions initiated, revised or mentioned with the back brace or the padded boots in the skin integrity care plan. On 9/13/23 at 9:06 AM, R38 was observed lying on her back sleeping, the padded boots were on top of the bedstand next to the bed. On 9/13/23 at 9:10 AM, Licensed Practical Nurse (LPN) E, who served as the wound care nurse, was interviewed and asked about R38's wounds. LPN E explained they had found a stage 2 pressure ulcer from the back brace and boggy heels the day before. On 9/13/23 at 9:24 AM, during observation of R38's wounds with LPN E, R38's right heel was observed to have an approximately 1.5-2 inch diameter of redness on the inner aspect of the heel. LPN E was queried what she would call the redness. LPN E explained she would call it a stage 1 (intact skin with a localized area of non-blanchable redness). When told the padded boots had not been observed on R38's feet on 9/12/23 and that morning, LPN E explained they should be on her feet. Observation of R38's back revealed a linear wound approximately 2-2.5 inches in length by 1 inch in width with eschar (dead or devitalized tissue that is hard or soft in texture, usually black . and may appear scab-like) and slough (non-viable yellow, tan . tissue) obscuring part of the wound. LPN E was queried what stage would she call R38's wound. LPN E explained she would call it an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure ulcer. On 9/13/23 at 9:34 AM, R38's Family Member was asked if they knew how R38 had gotten a wound on her back. R38's Family Member explained he had been told that it was on her all night and that is what caused the injury. On 9/13/23 at 9:51 AM, Therapy Manager G, who was also a Physical Therapist (PT), was interviewed and asked if it was usual to have residents' wear back braces when they were in the bed. Therapy Manager G appeared to look away and did not answer the question. When asked why the back brace had been left on R38 when she was in bed, Therapy Manager G explained the staff would try to educate R38's Family Member, but they would insist it be kept on R38. Therapy Manager G was asked for any documentation that R38 and her Family Member had been educated on the back brace and/or that R38's Family Member had insisted on the back brace while R38 was in bed. No documentation was provided by the end of the survey. On 9/13/26 at 11:01 AM, the Director of Nursing (DON) was interviewed and asked if a resident should ever get a device related pressure ulcer/injury. The DON explained that it should not happen, and it was unfortunate that R38 acquired one. The DON was asked why R38's back brace was kept on her when she was in bed. The DON had no answer. On 9/13/23 at 11:16 AM, Registered Nurse (RN) L, who served as Unit Manager, was interviewed and asked about R 38 wearing the back brace while in bed. RN L explained the hospital discharge orders said to keep the brace on at all time. When asked why R38 would need the back brace while in bed, RN L explained they had thought it was for pain control. RN L was asked if anyone had clarified the back brace order, or scheduled a follow-up appointment for R38. RN L explained neither had been done. Review of the hospital discharge paperwork dated 9/23/23 revealed in part, Recommended Follow Up Information: . Internal Medicine . Follow Up within 3-7 days . Patient to wear back brace at all times . Follow up Within 3-7 days . Neurological Surgery . Follow Up Within 1 to 2 weeks . It should be noted that R38 had been admitted into the facility for over three weeks, or 16 days. On 9/13/23 at 12:39 PM, R38's Family Member was interviewed and asked if they had told staff to keep R 38's back brace on her while she was in bed. R38's Family Member explained they had not told them to put it on her when she was in bed.

This citation pertains to intake #'s MI00131500. Based on observation, interview, and record review, the facility failed to ensure adequate interventions to prevent weight loss for one resident (R90) of five residents reviewed for nutrition, resulting in a 15.69% weight loss from June 2023 to August 2023. Findings include: On 9/13/23 at 8:23 AM, R90's breakfast meal tray was observed on their bedside table in their room. The items on the meal tray were compared to the items on the meal ticket and it was noticed R90 had not been given their Health Shake supplement. It was further noted R90's tray had been set up for them, but R90 was laying at less than a 30-degree angle (almost flat) in their bed attempting to feed themselves some pureed eggs. No staff were observed in the room at that time. On 9/13/23 at 12:21 PM, an observation of R90's lunch meal was conducted. The items on the tray were compared to the meal ticket and it was noted R90 was supposed to receive a Health Shake supplement, however; the Health Shake was not observed to be on the meal tray. No staff were observed in the room at that time. A review of R90's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: femur fracture, stroke, aphasia, hemiplegia, and dysphagia. R90's Minimum Data Set assessment dated [DATE] was reviewed and revealed they had not been assessed for cognition, and at the time of admission R90 required only set-up assistance with dining. It was further documented in the record R90 had a language barrier. It was also noted through skin assessment documentation dated 7/4/23 and 8/9/23 R90 developed two stage two pressure ulcers (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough, may also present as an intact or open/ruptured serum-filled blister usually over a bony prominence), on their sacrum and one on their right heel. R90's documented weights were reviewed and revealed the following: 6/24/23 102.0 lbs. 7/12/23 91.4 lbs. 7/20/23 90.1 lbs. 8/3/23 86.5 lbs. 8/7/23 85.0 lbs. 8/14/23 85.9 lbs. 8/21/23 86.0 lbs. A review of R90's physician's orders was conducted and indicated they were on a pureed diet. A review of a dietary progress note dated 7/7/23 was conducted and read, .adding 4oz HealthShake <sic> TID (three times a day) at meals . Continued review of Dietary progress notes dated: 7/19/23, 7/25/23, 7/27/23, 7/28/23, 8/9/23, 8/17/23, and 8/23/23 was conducted but did not outline any additional interventions such as additional supplements, increased weight monitoring, cueing, or increased assistance with eating. A review of R90's Certified Nursing Aide (CNA) task for amount of meals eaten for a 30-day look-back period was conducted and revealed the following: 8/15/23 documentation for two meals eaten 8/16/23 documentation for one meal eaten 8/18/23 documentation for one meal eaten 8/19/23 no documentation for any meals eaten 8/20/23 documentation for one meal eaten 8/24/23 no documentation for any meals eaten 8/30/23 documentation for one meal eaten 9/2/23, 9/3/23, 9/4/23, 9/5/23, 9/7/23, 9/8/23 and 9/11/23 documentation for one meal eaten. On 09/13/23 at 1:46 PM, an interview was conducted with Registered Dietician (RD) 'N' regarding R90. They were asked when it was identified R90 had a significant weight loss, should weight monitoring have been increased and should the food acceptance records document every meal. RD 'N' said they should have increased weight monitoring and they would have recommended filling out the food acceptance record for every meal. They were asked R90 should have been considered for some additional assistance and cueing and said they could have been. A review of a facility provided policy titled, Nutritional Management revised 1/1/2022 was conducted and read, .The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition.

Based on interview and record review the facility failed to ensure a legally authorized resident representative signed a DNR (do not resuscitate) form (part of an advance directive) for one resident (R72) of one resident reviewed for advance directives. Findings include: On [DATE] the medical record for R72 was reviewed and revealed the following: R72 was initially admitted to the facility on [DATE] and had diagnoses including Adult Failure to Thrive and Congestive heart failure. A review of R72's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] revealed R72 needed extensive assistance with most of their activities of daily living. R72's BIMS score (brief interview for mental status) was five indicating severely impaired cognition. A DNR form titled Do Not Resuscitate Order dated [DATE] was reviewed and revealed that it was signed by R72's daughter as a patient advocate A competency evaluation titled Decision Making Determination Form signed on [DATE] by attending Physician and [DATE] by licensed Psychologist was reviewed and indicated that R72 was incapable of making decisions regarding medical treatment Further review of R72's medical record did not reveal any legal documentation (durable power of attorney or legal guardianship etc .) that provided legal authorization for R72's daughter to be able to make informed medical decisions such as withdrawing CPR (Cardiopulmonary resuscitation). On [DATE] at approximately 1:26 p.m., during a conversation with social worker J (SW J), SW J was queried for any legal paperwork which provided the legal authorization for R72's daughter to sign a DNR form withholding emergency medical treatment. On [DATE] at approximately 2:36 p.m., during a follow-up conversation with SW J, SW J reported they did not have any legal paperwork that provided legal authority to R72's daughter to make advanced directive decisions for R72. On [DATE] a facility document titled Residents' Rights Regarding Treatment and Advance Directives was reviewed and revealed the following: Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Definitions: Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated .4. The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities. 5. The facility will identify or arrange for an appropriate representative for the resident to serve as primary decision maker if the resident is assessed as unable to make relevant health care decisions. 6. The facility will define and clarify medical issues and present them to the resident or legal representative as appropriate. 7. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to any advance directives . No legal documentation that authorized R72's daughter to make advance directive decisions for R72 was provided by the end of the survey.

This citation pertains to intake #'s MI00131529 and MI00138838. Based on interview, and record review, the facility failed to ensure family notification was made for a change of condition for one resident (R104), of two residents reviewed for notification of changes. Findings include: A complaint was received by the State Agency that alleged the family was not made aware of R104's fall. A review of R104's clinical record was conducted and revealed a progress note entered into the record on 7/26/23 at 11:36 PM by Nurse 'M' that read, .Lodger (R104) fell around 9:45 in their room, a CNA (Certified Nurse Aide) saw Lodger on the floor and notified nurse . It was noted the progress note did not indicate the resident's family had been made aware of the fall. A review of an assessment titled, Fall - Initial - V 2 dated 7/27/23 was conducted and also did not indicate family had been made aware of the fall. On 9/14/23 at 10:59 AM, an interview was conducted with the facility's Director of Nursing (DON) regarding R104's fall. The DON indicated the nurse should have notified the family and documented it in the record. A review of a facility provided policy titled, Fall Prevention Program revised 1/1/2022 was conducted and read, .6. When any resident experiences a fall, the facility will: .d. Notify the physician and family .F. Document all assessments and actions .

This citation pertains to intake #MI00138838 Based on interview and record review, the facility failed to document and follow up on family grievances for one resident (R#104) of one resident reviewed for grievances, resulting in feelings of frustration. Findings include: A complaint was received by the State Agency that alleged the facility failed to follow up on grievances after speaking with facility staff regarding multiple concerns. A review of R104's clinical record was conducted and revealed a progress note entered into the record on 7/26/23 at 11:36 PM by Nurse 'M' that read, .Lodger (R104) fell around 9:45 in their room, a CNA (Certified Nurse Aide) saw Lodger on the floor and notified nurse . On 9/14/23 at 11:34 AM, an interview was conducted with Unit Manager 'L' regarding whether they had spoken with R104's family. They said they did, and the family had voiced concerns about not being notified of the fall and R104 experiencing intermittent left and right leg pain. They were asked if they documented any of the family's concerns on a grievance form and said they did not, they reported the concerns to the Director of Nursing, but they should have filled out the form. A review of a facility provided policy titled, Quality Assistance Procedure revised 1/1/22 was conducted and read, .1. Any resident, his or her representative (sponsor), family member, or resident advocate may file a Quality Assistance Form 5. Upon receipt of the Quality Assistance Form/request, the department manager will investigate the allegations and submit a written report of such findings to the administrator .

Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for one (R95), of one residents reviewed for dialysis care plans. Findings include: On 9/12/23 at 10:05 AM, R95 was observed sitting in a wheelchair in her room. R95 was asked if she received hemodialysis. R95 explained she went to the hemodialysis center three times a week, on Monday, Wednesday and Fridays. Review of the clinical record revealed R95 was admitted into the facility on [DATE] with diagnoses that included: end stage renal disease, dependence on renal dialysis and anemia in chronic kidney disease. According to the Minimum Data Set (MDS) assessment dated [DATE], R95 was cognitively intact and required the assistance of staff for activities of daily living (ADL's). The MDS assessment also indicated R95 was on dialysis. Review of R95's care plan revealed no dialysis care plan, or interventions to ensure R95's specialized needs were met. On 9/14/23 at 2:27 PM, the Director of Nursing (DON) was interviewed and asked if R95 should have a dialysis care plan. The DON explained R95 should have a dialysis care plan. When told there was no care plan, the DON explained they would get one. Review of a facility policy titled, Comprehensive Care Plans revised 6/30/22 read in part, .The comprehensive care plan will describe, at a minimum, the following: .The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Any specialized services . the facility will provide .

Based on observation, interview and record review, the facility failed to ensure medications were available for administration for one residents (R59) of one residents reviewed for Nursing standards of practice. Findings include: On 9/12/23 the medical record for R59 was reviewed and revealed the following: R59 was initially admitted to the facility on [DATE] and had diagnoses including Polyosteoarthritis, Dementia and Repeated Falls. A review of R59's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/11/23 revealed R59 needed extensive assistance with most of their activities of daily living. R59's BIMS score (Brief interview for mental status) was five indicating severely impaired cognition. A review of R59's careplan revealed the following: Focus-The resident has/is at risk for acute & chronic pain related to Left Humerus fracture (healing), arthritis, chronic low back pain, Osteoporosis, Hx (history) of Left Femur fracture .Interventions-Administer pain medications as ordered. Give 1/2 hour before treatments or care . A review of R59's Physician ordered medications revealed the following: Lidocaine Pain Relief 4 % Patch Apply to mid back topically in the morning for Pain related to LOW BACK PAIN, UNSPECIFIED. -Start Date-7/13/2023 0700 Aspercreme Lidocaine Patch 4 % (Lidocaine) Apply to L (left) posterior shoulder topically two times a day for Left posterior shoulder pain -Start Date-11/17/2022 0900 A review of R59's progress notes pertaining to R59's lidocaine patch administration to the left posterior revealed the following: 8/23/23-supply n/a (not available), 8/21/23-supply n/a, 8/16/23-supply n/a, 8/15/23-supply n/a, 8/2/23-n/a, 8/1/23-n/a A review of R59's progress notes pertaining to R59's lidocaine patch administration to their mid back revealed the following: 8/23/23-supply n/a (not available), 8/21/23-supply n/a, 8/16/23-supply n/a, 8/15/23-supply n/a, 8/2/23-n/a, 8/1/23-n/a A review of R59's August 2023 Medication Administration Record (MAR) revealed the following dates in which R59's lidocaine patches were not administered on both affected areas: 8/1, 8/2, 8/15, 8/16, 8/21 and 8/23. On 9/14/23 at approximately 10:56 a.m. Nurse Manager E (NM E was queried regarding the missing lidocaine patches for R59 that were not available for administration in August to treat R59's pain and they reported that it is the facility practice of the Nursing staff to notify the Central supply staff member when patches are running low to ensure an uninterrupted supply is available to administer. NM E was queried if the facility should always have medication available for administration and they indicated they should and that the Nursing staff have procedures in place to prevent medication from running out. On 9/14/23 a facility document titled Medications Unavailable was reviewed and revealed the following: Policy: This facility shall use uniform guidelines for unavailable medications. Policy Explanation and Compliance Guidelines: 1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn (as needed), and emergency medications. 2. A STAT supply of commonly used medications is maintained in-house for timely initiation of medications. 3. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. 4. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: a. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. b. Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold. 5. If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication.

Based on observations, interview, and record review, the facility failed to implement interventions to maintain or prevent further decline in range of motion for one (R14) of one Resident reviewed for range of motion and positioning resulting in a potential for further decline in range of motion or worsening of contractures. Findings include: R14 R14 was originally admitted to the facility on [DATE]. R14's admitting diagnoses included poly-osteoarthritis, stroke, joint contractures (limited movement in joints), and loss of vision. R14 was confined to bed and needed extensive staff assistance with their Activities of Daily Living (ADL - mobility in bed, dressing, eating etc.). Based on a Minimum Data Set (MDS) assessment with an assessment reference date of 6/8/23, R14 had a Brief interview for Mental Status (BIMS) score of 8/15, indicative of moderate cognitive deficits. An initial observation was completed on 9/12/23 at approximately 10:30 AM. R14 was observed in their bed. R14 was observed on their back with both shoulders close to their body, both elbows flexed (bent), and both hands with fingers closed. Fingers were in contact with palms with potential to compromise the skin integrity of their hands. R14 was unable to open their fingers on both hands and was able to move their elbow and shoulder minimally on the left side. A follow up observation was completed later that day at approximately 11:45 AM. R14 was observed in their bed, with their fingers closed and arms and elbows flexed (bent) close to their body. On 9/13/23, an observation was completed at approximately 9:30 AM. R14 was observed in their bed, lying on their back. R14 had both shoulders close to their body, both elbows flexed (bent), and both hands with fingers closed. When R14 was asked to open their fingers, R14 was unable to do it. R14 had minimal movement in their elbow and shoulder on the left side. A follow up observation was completed later that day, at approximately 11:00 AM and 11:45 AM. R14 was observed in their bed with their fingers closed. R14 did not have any orthotics (A support, brace, or splint used to support, align, prevent, or correct the function of movable parts of the body) or any intervention such as a rolled wash cloth, hand roll etc. to maintain joint mobility and skin integrity. A review of R14 Electronic Medical Record (EMR) revealed that R14 was originally admitted to the facility on [DATE]. R14 was discharged from the facility on 9/17/22 to the hospital and they were readmitted back to the facility on [DATE]. R14 was a long term resident of the facility. A review of R14's physician orders did not reveal any orders for restorative nursing program to maintain the current range of motion and to prevent further decline. A review of R14's care plan revealed that they were at risk for joint pain due to their diagnoses and comorbidities. The care plan review did not identify R14's risk for further impairment with joint mobility and did not have any interventions in place. A review of Occupational Therapy (OT) evaluation dated 9/14/22, revealed the following range of motion assessment (R14 did not have any recent occupational therapy evaluations on EMR): UE ROM (Upper Extremity Range of Motion): R (Right) UE ROM - Impaired L (Left) UE ROM - Impaired RUE ROM - Shoulder - Impaired; Elbow/Forearm - Impaired; Wrist - impaired; Hand - Impaired; Thumb - Impaired; Index Finger - Impaired; Middle Finger - Impaired; Ring Finger - Impaired; Little Finger - Impaired LUE ROM - Shoulder - Impaired; Elbow/Forearm - Impaired; Wrist - impaired; Hand - Impaired; Thumb - Impaired; Index Finger - Impaired; Middle Finger - Impaired; Ring Finger - Impaired; Little Finger - Impaired A Physical Therapy evaluation dated 9/14/22 (approximately one year ago), revealed the following. R14 did not have any recent physical therapy evaluations on EMR. RLE ROM (Right Lower Extremity Range of Motion) - Impaired LLE ROM (Left Lower Extremity Range of Motion) - Impaired OT evaluation dated 9/14/22 read, Patient has contracture .will trial a hand roll for good skin integrity which clearly indicated that R14 was at risk for further contractures and did not have any interventions in place. An interview was completed with Therapy Manager (Staff member G) on 9/13/23, at approximately 11:20 Am. During the interview staff member G was queried if R14 was receiving skilled therapy services. Staff member G reviewed the EMR and reported that R14 was not receiving any therapy services. Staff member G confirmed that R14 received skilled services in September 2022, prior to their discharge from the facility. Staff member G reported that long-term residents were referred to restorative nursing after the discontinuation of skilled therapy services. Staff member G also reported that if any Residents had contractures, the rehabilitation team would do further ROM assessment after a screen, and make recommendations to the restorative team. Staff member G was requested to provide the restorative referral documentation for R14 and was not received prior to the survey exit. An interview was completed with Director of Nursing (DON) on 9/14/23, at approximately 9 AM. The DON was queried about the restorative program. The DON reported that they were providing oversight to the restorative program, and they had one Certified Nursing Assistant (CNA) providing the restorative services for the residents. The DON was queried specifically on R14's restorative plan. The DON reported that R14 was not currently on a restorative program, and they would follow up and have their therapy team evaluate and follow up. The DON was notified that R14 had no readmission rehabilitation screen. The DON reported that they would follow up. A facility provided document titled Restorative Nursing dated 10/23/20, read in part, The goal of the Restorative Nursing includes improving and/or maintaining independence in activities of daily living and mobility Definition: Level I Restorative Nursing - A reasonable expectation that improvement in function will occur. May need in conjunction with skilled therapy. Level II Restorative Nursing - A reasonable expectation that improvement will continue to occur with resident participation and goal setting. Level III Restorative Nursing - The resident goal(s) or highest level has been achieved. The goal(s) now become the prevention or minimization of functional decline or impact on activities of daily living. Programs based on technique: Range of motion (passive) Range of motion (active) Splint or brace assistance .

This citation pertains to intake #MI 156. Based on interview and record review, the facility failed to identify the development of a pressure ulcer and implement interventions in a timely manner for one (R701) of three residents reviewed for pressure ulcers, resulting in the development of an unstageable (obscured full thickness skin and tissue loss) pressure ulcer. Findings include: A complaint was received by the State Agency that alleged the resident developed a pressure ulcer during their admission to the facility. A review of R701's clinical record revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Section M. Skin Conditions in R701's Minimum Data Set assessment dated [DATE] revealed the resident did not admit with any unhealed pressure ulcers/ injuries, and they were at risk for skin breakdown. A review of R701's weekly skin assessments revealed the following: An assessment dated [DATE] did not indicate R701 had any pressure ulcers. An assessment dated [DATE] did not indicate R701 had any pressure ulcers. An assessment dated [DATE], (14 days after the previous assessment) documented the resident had a UTD (unable to determine) on their right buttock. A review of a nursing progress note dated 9/15/21 at 3:00 PM was conducted and read, .assessed Resident buttocks/sacral/Coccyx area. After removal of foam dressing and cleansing of Right buttock - noted pressure injury UTD stage due to presence of approx. (approximately) 50% necrosis (black tissue) visible in center of the wound .consult for wound nurse placed, low air loss mattress ordered, turning and repositioning task scheduled . A review of R701's record did not indicate why R701 had a foam dressing on their right buttock prior to the 9/15/21 assessment and the first documented discovery of the wound on that date. It was noted there were no other treatments ordered prior to 9/15/21. A review of a progress note documented by the facility's Wound Care Nurse Practitioner on 9/22/21 read, .Patient has a new unstageable pressure ulcer to the right buttock and will need skilled care either here or at home to assist with wound care and will need offloading mattress and cushion for home and visiting home care nurse . The note did not include any measurements of the wound or indication of whether the wound was avoidable or unavoidable. A review of R701's physician orders, CNA care guide, and care plans was conducted and it was noted R701 had no preventative interventions in place prior to the development of the unstageable pressure ulcer on their right buttock. It was noted all interventions were dated 9/15/21 or later, after the development and discovery of the ulcer. It was noted the low air loss mattress intervention was implemented on 9/22/21, seven days after the discovery of the pressure ulcer. On 10/12/21 at 1:30 p.m., an interview was conducted with Wound Care Nurse A regarding skin assessments and interventions implemented to prevent the development of pressure ulcers. Nurse A explained skin assessments were supposed to be performed on admission and weekly thereafter. They further indicated they do not add interventions to the care plan until they are in place. It was noted R701's pressure reducing mattress had been implemented on 9/22/21 after the identification of the development of the unstageable pressure ulcer on 9/15/21. Nurse 'A' was asked why it was not added to the care plan and explained it had not been put on the bed until 9/22/21, so was not added until then. A review of a facility provided policy titled, Pressure Injury Prevention and Management dated 1/1/21 was conducted and read, .Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit staging, wound characteristics). ' c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); 11. Minimize exposure to moisture and keep skin clean, especially of fecal contamination· iii. Provide appropriate, pressure-redistributing, support surfaces; ' iv. Maintain or improve nutrition and hydration status, where feasible .

This citation pertains to intake #MI 786. Based on interview and record review, the facility failed to properly administer an opioid (narcotic) pain medication for one (R704) resident of one resident reviewed for use of a transdermal patch (a medicated adhesive patch that is placed on the skin to deliver a specific dose of medication through the skin and into the bloodstream), resulting in an overdose which required the use of [MEDICATION(S)] (a medication used to treat narcotic overdose in an emergency situation), fall with a skin tear, and hospitalization . Findings Include: Review of the clinical the clinical record revealed R704 was initially admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, R704 was hospitalized on [DATE], readmitted on [DATE], hospitalized on [DATE] and remained out of the facility as of this review. Review of R704's Emergency Treatment Note dated 6/17/21 revealed, in part: .This patient comes to the emergency department after she was found to be less responsive at (Facility Name). She was found on the floor. There was no witnessed fall. She does have left superficial laceration of her elbow without deformity .She apparently had 2 [MEDICATION(S)] patches and and <sic> only supposed to have one. She also takes oxycodone Patient presents after apparently receiving too much [MEDICATION(S)] with 2 patches on. They were removed at the nursing home, and she was given [MEDICATION(S)] and she became awake after that. She is here for further evaluation. She does have a skin tear .will admit the patient for observation in light of her overdose .Final Impression(s)/Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] According to the facility's Medication-Narcotic Pain Patch policy which was revised after this incident on 6/30/2021: .The nurse will apply the narcotic patch and document where the narcotic patch was placed on the resident on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R704's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] Patch 72 Hour 25 MCG/HR (Micrograms per hour) Apply 1 patch transdermally every 72 hours for pain and remove per schedule. Per the MAR, this was applied on 6/16/21 at 11:03 AM. Oxycodone HCl (Hydrochloride) 5 MG Tablet Take 1 Tablet by Mouth Every 6 Hours as needed ordered 6/9/21. Per the MAR, this was administered on 6/16/21 at 9:46 PM. [MEDICATION(S)] HCl ([MEDICATION(S)]) Solution Cartridge 0.4 MG/ML Inject 1 dose intramuscularly one time only for overdose for 1 Day. Per the MAR, this was administered on 6/17/21 at 1:47 PM. Review of R704's facility incident report dated 6/17/21 at 1:13 PM documented, in part: .Resident has mental status changes, hallucinations, nausea, dizziness, [MEDICATION(S)] patch removed from L (Left) arm. [MEDICATION(S)] administered per MD (Doctor of Medicine), second patch found on R (Right) chest near port .Results of Investigation: 79 y.o. (year old) with H/O (History Of) endometrial CA (Cancer) admitted with orders for [MEDICATION(S)] 25 mcg/H change Q 72 (every 72 hours), Oxycodone 5 mg Q6 (every six hours), prn (as needed). On 6/15/2021 [MEDICATION(S)] patch was not available and old patch was not removed. MD was notified. On 6/16/21 nurse applied new patch and wrote new order to coincide with new order. On 6/17/21 resident was noted to be hallucinating and called 911. Patch was removed and [MEDICATION(S)] admin (administered), (R704) c/o (complained of) nausea and patch was noted on R Chest, which was also removed. Resident was transferred to the hospital. Review of a Performance Improvement Form dated 6/17/21 for Registered Nurse (RN 'EE') documented, in part: .(RN 'EE') documented that he removed the [MEDICATION(S)] patch from R arm and then applied a new patch to the R arm. The newer-appearing patch was removed from L arm after Resident had mental status changes. Patch placement was documented incorrectly. A second old-appearing patch was removed from R chest . Review of a Medication Discrepancy Report documented, Date of Discrepancy 6-17-21 Time of Discrepancy 13:13 PM .[MEDICATION(S)] patch was applied per MD orders, but the previous patch was not removed .Resident given [MEDICATION(S)] and transferred <sic> via 911 ambulance to [name of local hospital] ED (Emergency Department). Resident treated at hospital .Performance improvement form filled out for Nurse administering medication .Nurse one on one education regarding safety. Proper documentation and pharmacy documentation clarification .(Physician 'FF') ordered [MEDICATION(S)] due to Resident's mental status changes and ordered transfer via 911 to [name of local hospital] .Name of Nurse Responsible for Medication Discrepancy (RN 'EE') . On 6/30/21 at 11:55 AM, and interview with the Director of Nursing (DON) was conducted. When queried about the documentation and events of an overdose for R704, the DON reported the same information and events as reflected in the above documentation. The DON also reported that currently, there were no residents in the facility that had transdermal patches ordered. When asked what the facility's process was for nursing to apply/remove transdermal patches, the DON reported the nurses were to follow their policy to identify and document where patches were placed and/or removed from and to document they had monitored the placement as well.

This citation pertains to intake# MI 575 Based on interview and record review the facility failed to ensure interventions/treatments were put in place in a timely manner to prevent skin breakdown for one resident (R#604) of three residents reviewed for pressure ulcers, resulting in R#604 developing multiple unstageable pressure ulcers (full thickness skin or tissue loss with unknown depth). Findings include: On 11/30/20 an allegation that was submitted to the State Agency pertaining to R#604 was reviewed that indicated R#604 developed pressure ulcers during their stay at the facility. On 11/30/20 the medical record for R#604 was reviewed and revealed the following: R#604 was initially admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of R#604's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/25/20 revealed R#604 needed extensive assistance from facility staff with most of their activities of daily living. R#604's BIMS score (brief interview of mental status) was five indicating severely impaired cognition. A Nursing admission evaluation dated 8/19/20 was reviewed and revealed the following: Section C-Skin .A. Does the resident have any identified skin conditions/wounds (No) was marked indicting no identified skin conditions. A Weekly Summary dated 8/25/20 revealed the following: 11. Skin conditions-A. Skin Ulcers (No) was marked indicating no identified skin conditions. A skin assessment dated [DATE] revealed the following: Skin Evaluation-1. 1. Are there any new abnormal skin areas? (No) was marked .6. List cites of any existing abnormal skin areas. 32. Left buttock. MASD (moisture associated skin damage) . 31. Right buttock. MASD. Further review of the medical record revealed no added skin interventions when the MASD was identified, nor was there any documentation that the Physician was called regarding the change in condition or any new treatments/orders to prevent further breakdown on 8/26/20. A Physician Assistant note dated 8/31/20 revealed the following: Chief Complaint / Nature of Presenting Problem: Resident seen in regards to coccyx wound . History Of Present Illness: Resident is a gentleman with history of [MEDICAL CONDITION], seen today per staff request regards to coccyx wound. He is lying comfortably in bed in no acute distress denying chest pain, shortness of breath, nausea, and vomiting. Resident states he does have some discomfort on his buttock. He states he transfers into his motorized chair a few times during the day .Skin: Multiple areas on buttock/coccyx noted per staff picture .Wound care specialist to assess tomorrow for further instruction, in the interim proceed with pressure-point offloading and frequent turns . A Nurse Practitioner note dated 9/1/20 revealed the following: Chief Complaint / Nature of Presenting Problem: Unstageable pressure ulcer right buttock, unstageable pressure ulcer left buttock History Of Present Illness: Today's initial wound consult requested by medical physician for evaluation and treatment of [REDACTED].Patient was admitted to facility on August 19, 2020. Unfortunately, he is developed concerning unstageable pressure ulcers to both buttocks. The right buttock unstageable pressure ulcer measures 8 cm (centimeters) in length by 3 cm in width with a depth UTD (Unable to Determine). Wound base has approximately 50% fragile granular tissue with 50% moist necrosis (premature tissue death) and minimal serosanguineous drainage (wound drainage). Periwound area (tissue surrounding a wound) is moist, no odor, no signs of infection. Left buttock large unstageable pressure injury site noted which measures 14 cm in length by 4 cm in width with a depth UTD. Wound base has 100% moist necrosis which is dark in color with surrounding periwound moisture and mild induration (hardening) . A Nurse Practitioner note dated 9/10/20 revealed the following: Skin: Patient had developed unstageable pressure ulcers to her bilateral buttocks recently. Today he states the pain to these regions have improved since I seen him last. Both wound sites are still concerning especially the large unstageable pressure injury site to left buttock. Wounds are located at distal buttock regions close to perirectal area, patient has been incontinent of loose stools today. The right buttock unstageable pressure ulcer shows improvement and can today be noted as a stage III pressure injury site (full thickness skin loss involving damage or necrosis of subcutaneous tissue). This wound measures 7 cm in length by 3.5 cm in width with a depth of 0.2 cm. The wound base now has 90% pink granular tissue with only 10% pale necrosis and minimal serosanguineous drainage. Surrounding induration and [DIAGNOSES REDACTED] (skin rash) have improved, no maceration (softening of the skin) noted but moist skin. Left buttock unstageable pressure injury site is the more concerning wound. This wound is larger in size than the right buttock wound and measures 14 cm in length by 5 cm in width with a depth UTD. Wound base has 100% moist necrotic tissue with edges beginning to separate, no tunneling (wound that has channels extending from the central injury into the surrounding tissue) no undermining (erosion under the wound edges) or signs of infection. Periwound region [DIAGNOSES REDACTED] and induration shows improvement since last week. Today there is no maceration but periwound area is moist due to the location of the wound and patient's incontinence. Minimal to moderate serosanguineous drainage noted . On 12/1/20 the medical record for R#604 was reviewed with the Director of Nursing (DON), the DON was queried what the practice was when newly identified changes of skin breakdown are identified such as the MASD on both of R#604's buttocks that was identified on the 8/26/20 skin assessment and the DON indicated that the Physician should have been called for notification of the change in condition and that new interventions should have been put into place such as an air pressure mattress or an ordered barrier cream and possible additional treatment. The DON was queried if the facility had put any new treatments/interventions into place when the MASD was identified and the DON indicated that nothing was done at that time. The DON further indicated that they had only been made aware of R#604's wounds after they had developed the pressure ulcers. The DON indicated that they had identified actions that needed to be corrected in systemic process regarding R#604's skin breakdown and that education was completed for all nurses on skin assessment and identification of wounds/skin breakdown and the interventions that were needed as they had identified their own noncompliance in regards R#604's wounds. On 12/1/20 a facility document titled Pressure Ulcers/Skin Breakdown Clinical Protocol. was reviewed and revealed the following: Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing . On 12/1/20 a facility document titled Facility Past Non-Compliance Checklist pertaining to R#604's wounds dated 9/8/2020 was reviewed and revealed the following: 1. Description of quality concern (why and how did it happen): Nursing staff failed to put preventative measure in place resulting in PI (pressure injury) to resident .Further review of the document revealed the facility put systemic changes in place that included reviewing all residents in the facility that had pressure ulcers or were at high risk of breakdown to ensure that proper interventions to prevent breakdown were in place. Audits were to be completed to ensure ongoing compliance and the results will be reported at the facility QAPI (quality assurance and performance improvement) meeting.

Based on observation, interview and record review, the facility failed to ensure the provision of care per professional standards of practice and health care provider recommendations, to implement planned interventions to prevent the development and worsening of facility acquired pressure ulcers, to operationalize policies and procedures to ensure clear and concise skin assessment/wound care documentation, and failed to ensure the application of infection control techniques during wound care for one (Resident #88) of four Residents reviewed for pressure ulcers resulting in pressure ulcer worsening, unnecessary pain, and the potential for the development of infection, delayed healing, and decline in overall health status. Findings include: On 4/2/19 at 11:01 AM, Resident #88 was observed in their room in the facility. The Resident was lying in bed, positioned on their back with their eyes closed. An interview was completed with Nurse A at 11:03 AM on 4/2/19. When queried regarding facility procedures related to wound care for Residents with pressure ulcers, Nurse A indicated the facility does not have a wound care nurse but does have a wound care physician. Nurse A also revealed the nurse managers on each unit round with the wound care physician and the staff nurses' complete wound treatments. On 4/2/19 at 12:15 PM, observation occurred of Resident #88 in their room. The Resident was lying in bed, positioned on their back with their eyes open. Resident #88 was pleasant and answered questions with one- word responses. The Resident was observed to tighten his hands and display facial grimacing with any movement. The Resident's legs were noted to be elevated on a pillow with their heels pressing directly into the mattress. An interview was conducted with Witness Q at 12:20 PM on 4/2/19. When queried regarding Resident #88, Witness Q stated, I have known (Resident #88) for over [AGE] years. Witness Q further indicated they frequently visit the Resident at the facility. When queried regarding the Resident's pressure ulcers, Witness Q stated, (Resident #88) developed a pressure sore here. Record review on 4/2/19 at 1:00 PM revealed Resident #88 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was severely cognitively impaired, required supervision to extensive assistance to perform Activities of Daily Living (ADL's), and did not have any pressure ulcers/injuries or other alterations in skin integrity. Review of Resident #88's care plans on 4/2/19 at 1:10 PM revealed a care plan entitled, The resident has potential impairment to skin integrity of the coccyx r/t (related to) Fragile skin, Immobility (Date Initiated: 1/28/19; Revised: 2/1/19). Care plan interventions included: -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. (Initiated: 2/1/19) -Encourage good nutrition and hydration in order to promote healthier skin. (Initiated: 2/1/19) -Identify/document potential causative factors and eliminate/resolve where possible. (Initiated: 2/1/19) -Keep skin clean and dry. Use lotion on dry skin. Do not apply on skin impairment area(s). (Initiated: 2/1/19; Revised 2/1/19) -Monitor/document location, size and treatment of [REDACTED]. to physician/provider. (Initiated: 2/1/19) -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. (Initiated: 2/1/19) Further review of a care plan entitled, The resident has and/or is at risk for pressure ulcer development to the following areas (bony prominences) related to decreased mobility. (Initiated: 2/1/19; Revised: 2/14/19). Care plan interventions included: -Educate resident/family regarding the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. (Initiated: 1/31/19) -Inform the Physician/resident/family/caregivers of any new area of skin breakdown (Initiated: 1/31/19) -Skin inspections by CNA (Certified Nursing Assistant) during care and showers/baths. Report changes to licensed nurse immediately. (Initiated and Revised: 2/14/19) Review of Resident #88's Treatment Administration Record (TAR) revealed wound treatment for [REDACTED]. In (MONTH) 2019, five of 13 ordered coccyx wound care treatments were not completed. Review of the TAR also revealed the treatment for [REDACTED]. In (MONTH) 2019, seven of the 57 ordered treatments were not completed. Record review of wound care documentation on 4/2/19 at 1:25 PM, revealed wound healthcare provider documentation entitled Wound Care Progress Note: Skilled Nursing Facility Visit notes. Documentation dated 3/21/19 revealed the following: -Wound #1: Coccyx Stage Two partial thickness (pressure ulcer) . Length 2.0 (cm), Width 1 (cm), Depth 0.2 (cm) . Drainage: minimal . Wound bed: slough . Size: Decreased . Tissue quality: Improved . Plan: Medi-honey (prescription wound treatment) . Border Foam . every day and PRN (as needed). -Wound #2: Left Heel Blister . Length 3.0 (cm), Width 4.0 cm . Size: Decreased . Tissue quality: Unchanged . Plan: Skin Prep every day and PRN. -Wound #3: Right Heel UTD (Unable to Determine) . Length 3.0 (cm), Width 3.0 (cm), Size: Increased . Tissue quality: Unchanged . Plan: Skin Prep every day and PRN . Preventative Care: Foam boots . Air Mattress . Rotation. Wound Care Progress Note: Skilled Nursing Facility Visit note dated 3/29/19 revealed: -Wound #1: Coccyx Stage Two . 5.0 (cm), Width 2.0 (cm), Depth 0.2 (cm) . Drainage: minimal . Eschar 60 percent . Surrounding Skin: Maceration . Size: Increased .Tissue quality: Worsened . Plan: [MEDICATION NAME] . Border Foam . every day and PRN (as needed) -Wound #2: Left Heel Blister . Length 0.8 (cm), Width 10 cm . Size: Decreased . Tissue quality: Improved .Plan: Skin Prep every day and PRN. -Wound #3: Right Heel UTD . Length 3.0 (cm), Width 3.0 (cm), Eschar 100 percent (thinned), Size: Unchanged . Tissue quality: Unchanged . Plan: Skin Prep every day and PRN . Preventative Care: Foam boots . Air Mattress . Rotation. On 4/2/19 at 1:42 PM, an interview was conducted with Nursing Assistant F. When queried regarding Resident #88 not having got out of bed, Nursing Assistant F stated, (The Resident) doesn't got up anymore because they don't sit up straight in the wheelchair. With further inquiry Nursing Assistant F indicated the Resident had been trying to lean forward in their wheelchair before when they had got them up to get off of the sore on their bottom. When queried regarding how often Resident #88 is turned and repositioned in their bed, Nursing Assistant F stated, I turn them as often as I can. When queried if the Resident was turned and repositioned every two hours, Nursing Assistant F stated, Not really. When queried if the Resident had any other interventions in place to prevent pressure ulcers, Nursing Assistant F indicated no. Wound care observation was attempted to be completed on 4/2/19 at 2:48 PM with Nurse N. When queried regarding scheduled wound care observation, Nurse N indicated they did not have time due to upcoming shift change. On 4/2/19 at 03:37 PM, observation occurred of Resident #88 in their room. The Resident was laying in their bed, positioned on their back. The Resident's heels were not elevated and were directly on the mattress. An interview was conducted with Nursing Assistant G on 4/2/18 at 3:48 PM. When queried regarding interventions for Resident #88 related to pressure and skin, Nursing Assistant G indicated they recently transferred to the facility and would need to look at the Resident's Kardex (care guide). Nursing Assistant G proceeded to review Resident #88's Kardex in the Electronic Medical Record (EMR). After reviewing the Kardex, Nursing Assistant G stated, There isn't anything specific. On 4/2/19 at 3:54 PM, an interview was conducted with Nursing Assistant G and Nursing Assistant H. Nursing Assistant H reviewed Resident #88's Kardex and care orders in the EMR and stated, I don't see any skin orders. Nursing Assistant H further stated, I don't see any positioning orders. Nursing Assistant H proceeded to go to the Resident's room and stated, No yellow dot (beside name outside of door) so (Resident #88) is not a skin precaution. When queried regarding what the yellow dot next to a Resident's name outside their door means, Nursing Assistant H stated, The yellow dot means turn every two hours. When queried if Resident #88 was being turned every two hours, Nursing Assistant G and Nursing Assistant H did not provide a response. On 4/3/19 at 9:17 AM, Resident #88 was observed in their room, laying on their back with their eyes open and the lights in the room dim. The Resident's heels were directly on the bed with no pillow or pressure reduction device. When queried how they were, Resident #88 stated, It hurts. The Resident then pulled back their blanket and pointed at their back and buttocks. At 9:49 AM on 4/3/19, Resident #88 observed in their room, with the room lights dim. The Resident was laying on their back with their eyes open. The Resident's heels were positioned directly on the bed with no pillow or pressure reduction device. Observation of peri-care for Resident #88 occurred on 10:22 AM on 4/3/19 with Nurse A and Nursing Assistant F. Prior to beginning care, Resident #88 was noted to be positioned on their back in bed with their eyes open and their heels positioned directly on the bed with no pillow or pressure reduction device in place. The front of the Resident's brief was noted to be saturated with urine. The Resident began crying out in pain stating, Oww, Oww, Oww when moved. Upon rolling the Resident to place a new brief under them, a foul, pungent odor was noted. A dressing was in place over the Resident's coccyx area. The dressing and brief were saturated with a light brown/gray colored drainage. The dressing was dated 4/1/19. When queried regarding the saturated dressing, Nurse A and Nursing Assistant F indicated the wound had leaked through the dressing onto the brief. Nurse A and Nursing Assistant F proceeded to place a new brief on the Resident with the saturated dressing in place. Resident #88 was positioned on their right side. As Nursing Assistant F was preparing to exit the room, Nurse A stated, Oh, we need to elevate their heels. A pillow was placed under the Resident's heels at this time. Throughout care, Resident #88 displayed non-verbal signs of pain including facial grimacing, making a fist with their hand, patting at the bed, and yelling out, Oww, oww, oww and it hurts. On 4/3/19 at 10:34 AM, an interview was conducted with Nurse A. When queried regarding the Resident's dressing being saturated, saturating the prior brief, and a new brief being placed on the Resident, Nurse A stated, I think it is due to be changed today. I will ask the nurse. Resident #88 was observed laying in their bed, positioned on their right side with their eyes closed on 4/3/19 at 11:23 AM. An interview was conducted with the ADON on 4/3/19 at 11:30 AM. When queried regarding health care provider documentation for Resident #88 dated 3/21/19 and 3/28/19 indicating pressure ulcer interventions including an air mattress and foam boots to both feet, the ADON stated, Those are the recommendations. I remember Unit Manager R asking me and we looked into it because we have some in house, but the pump did not match the bed. Unit Manager R was supposed to follow up on that. Further review of Resident #88's wound and skin documentation occurred with the ADON at this time. When queried if heel boots should have been implemented, the ADON stated, Yes. When asked about additional interventions implemented to prevent further breakdown, the ADON stated The boots may take longer to get but the air mattress should have been done by now. The ADON further stated, (Resident #88) should not be laying in their bed all day. When queried regarding why the Resident did not have a yellow dot outside their door until today for turning, the ADON was unable to provide an explanation. The ADON then stated, They do have an order for [REDACTED]. On 4/3/19 at 12:29 PM, Resident #88 was observed in their room, laying in their bed and positioned slightly on their right side. The Resident's eyes were closed. Record review on 4/3/19 at 1:35 PM of Resident #88's Admission and Skin Integrity documentation revealed the following: -1/28/19: Nursing Admission/Readmission Assessment: . C. Skin: . Scab Rear, Right Lower Leg -2/5/19: Nursing Admission Evaluation: . C. Skin: Does the Resident have any identified skin conditions/wounds: No. -3/4/19 at 11:47 PM: Nursing Admission Evaluation: . C. Skin: Does the Resident have any identified skin conditions/wounds: No. -3/18/19 S[NAME] Skin: Left heel blister 4.0 cm x 4.0 cm; Right heel blister 3.0 cm x 2.5 cm; Coccyx 3.0 cm x 2.0 cm with slough . -3/25/19 S[NAME]- Skin: Coccyx stage 2 readmitted with from hospital; bilateral heels left heel blister 3.0 x 4.0; Right blister 3.0 x 3.0 . -4/1/19 S[NAME] - Skin: Coccyx wound stage 2, 5.0 cm x 2.0 cm; Right heel blister 3.0 cm x 3.0 cm; Left Heel blister 0.8 cm x 1.0 cm . Resident #88 was observed lying in bed, positioned slightly on their right side with their heels directly on the bed on 4/3/19 at 2:07 PM. On 4/3/19 at 2:11 PM, wound care observation occurred with Nurse B and Nursing Assistant F. Nurse B was observed washing their hands and then gathering the equipment to complete the dressing change. Upon repositioning the Resident to complete the dressing change, Resident #88 began yelling out Ouch, it hurts repeatedly. The dressing was noted to be saturated with a light brown/gray colored drainage, was dated 4/1/19, and had a foul, pungent odor. The wound drainage was also observed on the Resident's brief. Nurse B removed the soiled dressing. Upon removal of the dressing, the foul odor increased. The prior dressing was completely saturated with light brown/gray colored purulent drainage with an extremely foul odor. Nurse B then cleansed the wound with wound cleanser. The wound bed was observed to have white colored slough covering the base of the wound bed with a scant amount of red tissue noted directly in the center of the wound and gray colored tissue around the edges of the wound bed. The area surrounding the wound was dark red in color. Wound measurements were obtained by Nurse B at this time. The coccyx wound was 4 centimeters (cm) by 3.75 cm and the depth of the wound was unable to be measured by Nurse B at this time due to equipment. Nurse B then proceeded to measure the dark red area surrounding the wound bed and indicated the area was 10 cm X 10 cm. Nurse B then changed their gloves and applied [MEDICATION NAME] ointment and a foam dressing to the pressure ulcer. When queried regarding the stage of the pressure ulcer, Nurse B replied, Stage three because the bed is covered in slough. Nurse B then changed their gloves and proceeded to complete the treatment for [REDACTED]. Resident #88's right heel was observed to have a dark black colored area. When queried, Nurse B stated the heel wound was mushy to touch. The wound measurements were 5.5 cm by 3 cm. The Resident's left heel was observed to have a dark black, circle shaped area on the outside of the heel which measured 1.5 cm X 2 cm and another area around the other area of the heel, measuring 4 cm by 6 cm which was dark red/purple in color with areas of gray. When queried regarding the Resident's heel wound, Nurse B stated, Deep Tissue Injury (DTI) so unstagable. Nurse B applied skin prep to both of the Resident's heels. After completing the wound care treatment, Nurse B washed their hands and exited the Resident's room. Throughout the wound care treatments, Resident #88 displayed non-verbal signs of pain and yelled out, Oww, Ouch, and It hurts. When queried regarding pain management for Resident #88, Nurse B stated, We got new orders today for [MEDICATION NAME] and to increase the [MEDICATION NAME] (non-narcotic, controlled substance for pain relief). After the dressing change, an interview was completed with Resident #88. When queried if they were having pain, the Resident indicated they were but were unable to rate their pain utilizing a standardized pain scale. On 4/3/19 at 2:39 PM, an interview was completed with Nurse B. When queried regarding wound care and hand hygiene after removal of soiled dressing, application of new dressing, and between each area, Nurse B stated No, I didn't (perform hand hygiene) but I know I should have. An interview was conducted with the ADON on 4/3/19 at 2:53 PM. When queried regarding observations of wound care for Resident #88, the ADON stated, Okay. No further explanation was provided. On 4/3/19 at 3:53 PM, an interview was completed with Senior Nursing Director Nurse P. When queried regarding interventions not implemented to prevent pressure ulcers, observations of Resident #88, and inconsistent documentation of the Resident's pressure ulcer and interventions, Nurse P did not provide further explanation. Record review on 4/3/19 at 5:05 PM of facility policy entitled, Pressure Ulcers/Pressure Injury Prevention and Treatment- Clinical Protocol (Reviewed/Revised: 11/28/17) revealed, Prevention: 1. The at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent PU/PI (Pressure Ulcer/Pressure Injury) 3 . The assessment also helps identify the resident . who is refusing care and treatment. If the resident is refusing care, an evaluation of the basis for the refusal and the identification and evaluation of potential alternatives is indicated . Assessment and Recognition . h. The facility should have a turning and reposition program which allows staff to know Residents individual intervention and monitoring . i. Yellow Dot- Residents who are at high risk for the development of PU/PI . will have a yellow dot on door/nameplate of the resident's room and wheelchair . 7. Plan of Care: a. The plan of care for prevention and/or treatment of [REDACTED]. i. Support Surfaces, ii. Turning schedule/ off-loading, iii. Moisture Management, iv. Incontinence Management, v. Managing friction and sheer, vi. Nutritional/hydration management, vii. Pain Management . Change of Condition/New skin alteration: a. Complete Head to Toe Assessment, document in medical record . g. Update plan of care . 10. The pressure ulcer treatment program should focus on the following strategies: a. assessing the resident and the pressure ulcer (s) . c. PU/PI care/treatment . d. Managing bacterial colonization and infection .

This citation has two deficient practices. Deficient practice #1 Based on observation, interview and record review, the facility failed to ensure fall interventions were implemented based on their assessed needs for two residents (R#45 and R#68) of seven residents reviewed for accidents/hazards, resulting in R#45 sustaining a raised quarter-size hematoma on their right frontal scalp, acute hospitalization and subsequent anterolisthesis with PLC damage (Posterior Ligamentous Complex), and the increased likelihood of injury from falling for R#68. Findings include: Resident #45 On 4/1/19 at approximately 10:12 a.m., R#45 was observed in their room lying in their bed. R#45 was observed to have a neck brace on. R#45 was queried why they needed the neck brace and they stated, I fell out of bed and went to the hospital for surgery. R#45 was queried how they fell and they stated I can't remember. On 4/2/19 the medical record for R#45 was reviewed and revealed the following: R#45 was initially admitted to the facility on [DATE] was last admitted on [DATE], and had [DIAGNOSES REDACTED]. A review of R#45's MDS (minimum data set) with an ARD (assessment reference date) of 2/8/19 revealed R#45 needed supervision from staff with most of their activities of daily living. A review of R#45's comprehensive care plan revealed the following: Focus-The resident is at risk for falls related to deconditioning and history of falls .Goal-the risk of major injury will be reduced through next review .Interventions-Anticipate and meet the residents needs based on nursing assessments (initiated 5/31/18) .bed against wall per lodger request (initiated 12/30/18) .bed in lowest position as appropriate for residents height when not providing care (revised 6/12/18) .The resident needs a safe environment with: floors free from spills and/or clutter; adequate glare-free light; A working and reachable call light, bed in low position at night, personal items with (revised 12/30/18) . An incident and accident report with an incident date of 12/30/18 revealed the following: Time of incident: 6:30 AM .has confusion lodger sitting on floor facing bed. Lodger was placed back in bed . A review of the facility Quality Assessment & Assurance Investigation Report pertaining to R#45's fall on 12/30/18 and signed as completed on 12/31/18 revealed the following: Results of Investigation: Resident found on floor facing her bed injury noted to eyes, and bilateral arms, skin tears, ice applied and skin tears dressed. Continue to encourage the use of call light. Resident request to move bed against the wall as she fell out while sleeping and is not sure how. Care plan updated. Injuries will continue to be monitored. An incident and accident report dated 3/12/19 for R#45's fall on the morning of 3/13/19 revealed the following: Time of Incident: 6:40 AM . Memory Impaired- (box checked) .Incident Type-Fall (box checked) .Brief Description-Kitchen staff notified nurse, lodger was on the floor. Observed lodger sitting on side of bed facing BR (bathroom) wall with knees bent and drawn up to her. C/O (complaint of) hitting her head. Noted quarter size hematoma (not opened) to R (right) forehead above eyebrows Bed height-knee height .up (box checked) .Treatment (ice pack), assessment and neurocheck Action Taken-Care Plan Update (box checked), Staff-Re-education (box checked )-make sure 02) (oxygen) is on .Resident Education (box checked)-To wear 02 at night, bed in lowest position .Place of fall/accident-Lodger sitting on floor with back to bed facing BR (bathroom) door .List Care Plan Interventions Prior to Fall/Accident-Anticipate needs, call light in right, bed at preferred height, enc (encourage) to be careful when turning in bed to know where edges are, remind lodger not to sit up at side of bed while sleeping or while wearing pressure relief boots, bed against wall lodger request .Were planned interventions in place: No (box checked) .If no list reasons: bed not against wall .Residents explanation of incident-I rolled out of bed and hit head on over bed table .Level of assistance resident requires-1 PA (person assist) for transfers .List staff/witnesses that were present at time of incident-Roommate heard her yell for help .Any other information that is important to know?-POX 85% (oxygen saturation rate) .Immediate Interventions Implemented-Educated pt (patient) and staff on importance of wearing 02 at hs (night) and keep bed at low ht (height) . A progress note dated 3/13/19 at 8:40 (military time) revealed the following:Date of Fall: 3/13/19. Situation Details: Observed sitting on floor with back against bed and facing BR (bathroom) wall, with knees bent and pulled up to her. Stated she hit her head on over bed table .Assessment: Noted a quarter size hematoma, no break in skin observed. Ice applied and Neuros started .Mitigating factors: Pox was 85 percent on room air was not wearing 02. Stated she rolled out of bed .Environmental Factors: Bed was at knee height .Interventions: Lodger instructed on the importance of wearing O2 (oxygen) and keeping bed at knee height or lower. Staff also educated on 02 and bed height . A progress note dated 3/13/19 at 9:32 (military time) revealed the following: Resident to (Name of local hospital) for CT (Computerized Tomography Scan) as ordered by (Name of attending doctor) transported by EMS. A progress note dated 3/13/19 at 16:40 revealed the following: Resident has been hospitalized . A hospital history and physical record dated 3/13/19 for R#45 was reviewed and revealed the following: History of Present Illness- (R#45 demographic information) .who present from group home due to right scalp hematoma after fall. Pt stated that this occurred around 7 this morning and she was trying to get out of bed. She sat on floor less than 30 min before getting up off floor. Pt states that she hit her head against the stand. Denies L[NAME] (loss of consciousness) on daily aspirin 81 mg. Denies dizziness, nausea/emesis, lightheadedness after incident. Unsure when she took her last dose. Last meal was this morning. On examination, c-collar in place. Right frontal scalp hematoma, tenderness to thorax spine, right hip small bruise nontender. Reports HA (headache) and discomfort to right scalp hematoma. Pt (patient) denies any dizziness, lightheadedness, SOB (shortness of breath) .CT head cervical spine neg (negative) for acute intracranial process; however, cervical spine revealed new grade 1/2 anterolisthesis of C4 on C5. Left: C4-C5 moderate to severe neural foramen narrowing is worse from prior study .Physical Exam-HEENT (head, eyes ears, nose and throat)-right frontal lobe hematoma (2x3cm) .CT Spine Cerv (cervical)/head w/o (without) contrast-Impression-There is hematoma in the soft tissues overlying the right forehead. New grade 1/2 anterolisthesis of C4 on C5. Consider MRI (magnetic Magnetic resonance imaging) cervical spine for further evaluation .MRI Spine Cervical w/o Contrast-There is new anterolisthesis seen of C4 with respect to C5 .There is increased signal around the right facet joint compatible with ligamentous injury. There is increased signal between the C5 and C6 spinous process with widening compatible with ligamentous injury .4 mm anterolisthesis is seen of C4 with respect to C5 which is new compared to prior study. Increased note is also made of signal seen in the disc space at C4-5 suggestive of ligamentous injury .Note is also made of increased signal and the interspinous space between the C5 and C6 spinous process compatible with ligamentous injury .Impression- .There is new anterolisthesis seen of C4 with respect to C5 .There is increased signal between the C5 and C6 spinous process with widening compatible with ligamentous injury .Cervical spondyiosis as described above resulting in mild cord impingement see at C4-5 and C5-6 . ASSESSMENT-Accidental fall 3/13/2019 .CT/head/cervical spine remarkable for acute cervical abnormality .New Anterolisthesis seen of C4 with respect to C5 & suspected Ligamentous injury C4-C5, C5-C6, neurosurgery consulted .3/13/2019 MRI completed showed ligamentous injury .Possible surgical intervention later in week right frontal scalp hematoma-Ice pain management . A cardiology progress note from the hospital dated 3/18/19 was reviewed and revealed the following: Assessment/Plan-Acute mechanical fall with anterolisthesis of C4 on C5 w/ PLC damage on MRI-s/p ACDF on Saturday, pain management. A nursing progress note dated 3/18/19 revealed the following: Resident arrived via (specify) per (specify): Resident arrived to the facility for readmission by PM via EMS ambulance. Transferred to bed via (specify how and how many staff): Transferred to bed with 2-person extensive assist Accompanied by (specify/family/ambulance/etc): Accompanied by 2 ambulance transporters and daughter. Comments: admitting [DIAGNOSES REDACTED]. Resident had a cervical anterior Spinal Fusion on 3/15/19. She has a brace on her neck on arrival. MD notified of patient return. On 4/3/19 at approximately 2:25 p.m., R#45's fall investigation for their fall on 3/13/19 was reviewed with Unit Manager (UM) R. UM R was queried if all of R#45's fall interventions were in place when they fell , and they indicated they weren't. UM R indicated that R#45's bed should have been against the wall and should have been in the lowest position. UM R stated, the care plan says bed against the wall and bed in the low position. The bed should not have been at knee height either, knee height isn't in the care plan. UM R was queried if it was their expectation that all fall interventions be in place to prevent falls and injury from falls and they indicated that it was. On 4/3/19 at approximately 3:10 p.m., staff member X was queried regarding R#45's fall on 3/13/19. Staff member X was queried if they were the nurse that was caring for R#45 the morning that they fell , and they indicated that they were. Staff member X was queried where R#45 fell and they stated, they fell between the bed and the bathroom wall and hit their head on the overbed table. Staff member X was queried if R#45's bed was against the wall per their care plan when they fell and they indicated that it wasn't and that it was 3-4 feet from the wall. Staff member X was queried if the bed was in the lowest position when they found R#45 on the floor and they indicated that it wasn't and that it was at about knee height. Staff member X was queried if R#45's bed should have been against the wall to prevent them from falling out on that side of the bed and they indicated that it should have been. Staff member X stated, when she came back from the hospital, we made sure her bed was against the wall. R#68 On 4/01/19 at approximately 9:38 a.m., R#68 was observed in their room. R#68 was observed to be restless, moving their legs. A fall mat (a large rectangular cushion used to prevent injury from falling) was observed to be on the floor next to R#68's bed. On 4/02/19 at approximately 2:10 p.m., R#68 was observed in their room sleeping in their bed. R#68 was observed to not have their fall mat in place next to their bed. R#68's fall mat was observed underneath their bed. On 04/02/19 at approximately 4:05 p.m., R#68 was observed in their room sleeping in their bed. R#68 was observed to have no floor mat next to their bed. R#68's fall mat was observed underneath their bed. On 04/03/19 at approximately 9:15 a.m., R#68 was observed in their room lying in their bed. R#68 was observed moving legs in restless motion. R#68's fall mat was observed underneath their bed in the same position as the two observations on 4/2/19. On 4/2/19 the medical record for R#68 was reviewed and revealed the following: R#68 was initially admitted to the facility on [DATE] was last admitted on [DATE], and had [DIAGNOSES REDACTED]. A review of R#68's MDS (minimum data set) with an ARD of 3/1/19 revealed R#68 needed extensive assistance from facility staff with most of their activities of daily living. R#68's cognition was documented as severely impaired. An incident and accident report with an incident date of 8/21/18 revealed the following: Location-Resident room .Incident Type-Fall .Brief Description-Lodger observed on floor mat next to bed Any other information that is important to know?-Resident is S/P (status [REDACTED]. Fall mat in place per CPlan (care plan). A review of R#68's comprehensive care plan revealed the following: Focus-The resident is at risk for falls related to: History of falls and right side weakness .Goal-To reduce the risk of serious injury in the event of a fall .Interventions-bed in lowest position when not providing care .Bed moved up against the wall at families request .The resident utilizes a fall mat to minimize injury should the resident attempt transfers without assistance or roll out of bed .The resident requires the following: frequent hourly visual checks . On 04/03/19 at approximately 11:01 a.m., staff member Y was queried regarding R#68's need for a fall mat next to their bed. Staff member Y stated, she has had some falls where she fell out of bed and hospice brought in the mat for her. Staff member Y was queried why R#68's fall mat was observed on multiple times to be underneath their bed and they stated, yeah, I saw that today and I had to move it back. It shouldn't be under the bed. She needs it in case she falls again. On 4/3/19 at approximately 2:51 p.m., during a conversation with the Assistant Director of Nursing (ADON), the ADON was queried if it was their expectation that all fall interventions that are included on the residents plan of care are implemented and they indicated that it was. On 4/3/19 a facility document titled Falls-Clinical Protocol (last reviewed/revised 6/2018) was reviewed and revealed the following: Assessment and Recognition .1 . As part of an initial and ongoing resident assessment, the staff will help identify individuals a history of falls and risk factors for subsequent falling. This will be accomplished by the following task; a. The Falls Risk Evaluation is completed upon admission, quarterly, and with significant change in status. 1. Based on the assessment a care plan will be developed and implemented to address risk. This will be revised as necessary. 2. The Minimum Data Set (MDS) and subsequent CAAs (care area assessments) will be utilized to develop the comprehensive plan of care to minimize falls and injuries from falls. 3. Goals of the plan of care may include the interdisciplinary team, physician, resident and responsible party when possible. a. Goals may include, but not limited to reduction of falls, minimize injury from falls, and/or prevent falls while maintaining and/or improving resident abilities and quality of life. 4. Interventions should be developed and implemented per the assessed needs. 5. In addition, interventions for direct care givers should be placed on the KARDEX or similar format. 6. The care plan and KARDEX should be updated as interventions change. Cause Identification/Response- 1. For an individual who has fallen, staff should attempt to define possible causes within 24 of the fall. a. Causes refer to factors that are associated with or that directly result in a fall; for a balance problem caused by an old or recent stroke. b. Often, multiple factors in varying degrees contribute to a falling problem. c. Once a fall occurs it is important to gather as much information as possible; i. Observe for evident trauma ii. Observe to determine what the resident was attempting to do if possible iii. Observe for environmental hazards which may have contributed. iv. If the resident is able, what does he/she state happened. v. Staff present and responders, what did they see/hear. d. Provide emergency care and assessment/s as indicated. e. Residents who have fallen and have been witnessed to hit their head or suspected hit their head should have neurochecks per MD orders or resident's conditions un-witnessed falls should have neurochecks completed, regardless of resident's status, per MD orders or residents' condition. f. The Physician and Responsible party should be notified as soon as the resident is stabilized. g. Document findings in the resident's medical record per standard protocol. h. An accident/incident report will be completed and forwarded to the DON as part of the facility's internal Quality Assessment and Assurance Program. Post Fall Analysis/Treatment/Management- Post fall analysis will review (not all inclusive); a. The A/I. b. The nurses notes. c. Review any recent medication changes. d. Review previous lab findings if applicable. e. Review for other acute clinical changes. f. Review staff and resident statements. g. Observe the resident's room or area of fall. 2. Analysis of the causative factors and rationale for interventions developed and implemented should be documented in the Standards of Care notes. Update the plan of care with the new or revised interventions. Update the KARDEX or similar format with new or revised interventions. Provide ongoing report at shift change regarding updates to the plan/s of care. Make referrals to therapy or restorative nursing as needed. Monitoring and Follow Up- 1. The staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. 2. Residents will be reviewed through Standards of Care at a determined time frame after new interventions are implemented to determine if effective or revision is necessary. 3. If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention (for example, dizziness or musculoskeletal pain) has resolved. If the individual continues to fall, the interdisciplinary team should re-evaluate the situation and consider possible reasons for the resident's falling (besides those that have already been identified) and re-evaluate the continued relevance of current interventions. Deficient Practice #2: Based on observation, interview, and record review, the facility failed to ensure a resident was transferred in a safe manner per assessed needs for one (R#56) of six residents reviewed for falls, resulting in complaints of pain. Findings include: On 4/1/19 at 9:06AM, R#56 was observed in bed. R#56 stated that she had fallen on Friday, when the resident was in a rush to get to the resident council meeting. The resident stated that she was transferring from the toilet to the chair, and said I should have been using my gait belt. The resident said she fell and hurt her ankle. When asked how many people were present for transfer, the resident said there was one person present. Review of the clinical record for R#56 revealed the resident was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of R#56's minimum data set (MDS) assessment dated [DATE] the resident scored 15 out of 15 on a brief interview for mental status (BIMS) assessment, which indicated the resident was cognitively intact. Also per this assessment it was documented the resident had experienced falls since admission, entry, re-entry or prior assessment, and required the extensive assistance of two plus persons physical assistance for toilet use. Review of an Incident/Accident (I/A) report for R#56 dated 3/29/19 at 12:57PM, revealed the following brief description of the incident: I was holding onto the grab bar, went to grab the WC (wheelchair) to sit down and missed. CNA (Certified Nursing Assistant) lowered resident to the floor. Per the injury section of the report it was documented the resident complained of right ankle pain. Review of the investigation report pertaining to this incident revealed, in part, the following: Gait belt was not in use @ (at) time of incident. Immediate interventions implemented documented the following: Educated staff (and) resident re: importance of using gait belt @ all times re: transfers. Review of progress notes for R#56 documented, in part, the following: 4/1/2019 3:14PM: IDT-Interdisciplinary Progress Note Note Text: Resident had fall on 3-29-19 @1257 in her bathroom during transfer to toilet. I was holding onto the grab bar and going to grab the WC to sit down and I missed. CNA lowered resident to the floor. C/O pain and swelling in right ankle. X-Ray negative for any orthopedic injury, soft tissue swelling. CNA educated on the use of gait belt during transfers. PT (physical therapy) evaluated. Transfer status changed to 2PA with air boots on at all times . Review of an I/A report for R#56 dated 9/21/18 at 9:20AM, revealed the following brief description of the incident: During bed to W/C transfer resident was lowered to ground after legs became weak and could not sustain standing position. Per the investigation report the resident required the assistance of two people. One staff member was documented as being present at the time of the incident. Immediate interventions to address this incident were noted to have been left blank. Review of an I/A report signed 6/26/18 revealed the following brief description of the incident: Lodger was being transfer from toilet to W/C lodger knees buckled lodger assisted to ground. Review of the level of assistance required section of the form documented the following: 2 PA (person assist) ex c (with) gaitbelt. Staff/witnesses present at the incident was noted to state one name. Per the immediate interventions implemented section of the form it was documented, educated cena for 2 person transfer. Review of a progress note for R#56 documented the following: 6/26/2018 5:23PM: Pertinent Charting-Falls Note Text: Date of Fall: 06/26/2018 Situation Details: Lodger was being transfer from toilet to wheel chair. Lodger knees buckled and CENA gently lower lodger to ground. Assessment: full assisted Range of motion to upper and lower extremities noted. No c/o pain. No apparent injury Mitigating Factors: Environmental Factors: Interventions: educated CENA on proper transfer techniques. Review of a plan of care for R#56 dated 10/8/17 and revised on 4/1/19 revealed the following: The resident needs activities of daily living assistance related to MS and deconditioning. Per an intervention dated 5/15/18 and revised on 2/15/19 it was documented, TOILET USE 1PA ext. The resident prefers to use bed pan when in bed. Per an intervention dated 6/28/18 and revised on 4/1/19 it was documented, The resident is a 2PA for stand pivot transfers. Resident should wear air casts on both legs during transfers. Per a plan of care for R#56 dated 1/18/19 the following was documented: The resident is at risk for falls related to generalized weakness, deconditioning, debility, MS, poor muscle control of lower extremities, administration of narcotics, anti-[MEDICAL CONDITION] medications, and [MEDICAL CONDITION]. Review of an intervention dated 1/18/19 it was documented, 2 PA extensive assist for toilet transfers. Per an additional intervention dated 1/18/19 documented, Use gait belt for transfers/walking. On 4/03/19 at 1:39 PM the facility's Assistant Director of Nursing (ADON) was queried in regard to R#56's transfer status, and explained the resident's transfer status had varied. When queried as to where a nurse would get information pertaining to resident transfer status, the ADON explained the nurse would obtain this information from the care plan. When queried as to how it could be determined on the date of each incident what the resident's transfer status had been, the ADON did not provide further information. On 4/3/19 a facility document titled Falls-Clinical Protocol (last reviewed/revised 6/2018) was reviewed and revealed the following: Assessment and Recognition .1 . As part of an initial and ongoing resident assessment, the staff will help identify individuals a history of falls and risk factors for subsequent falling. This will be accomplished by the following task; a. The Falls Risk Evaluation is completed upon admission, quarterly, and with significant change in status. 1. Based on the assessment a care plan will be developed and implemented to address risk. This will be revised as necessary. 2. The Minimum Data Set (MDS) and subsequent CAAs (care area assessments) will be utilized to develop the comprehensive plan of care to minimize falls and injuries from falls. 3. Goals of the plan of care may include the interdisciplinary team, physician, resident and responsible party when possible. a. Goals may include, but not limited to reduction of falls, minimize injury from falls, and/or prevent falls while maintaining and/or improving resident abilities and quality of life. 4. Interventions should be developed and implemented per the assessed needs. 5. In addition, interventions for direct care givers should be placed on the KARDEX or similar format. 6. The care plan and KARDEX should be updated as interventions change. Cause Identification/Response- 1. For an individual who has fallen, staff should attempt to define possible causes within 24 of the fall Post Fall Analysis/Treatment/Management- Post fall analysis will review (not all inclusive); a. The A/I. b. The nurses notes. c. Review any recent medication changes. d. Review previous lab findings if applicable. e. Review for other acute clinical changes. f. Review staff and resident statements. g. Observe the resident's room or area of fall. 2. Analysis of the causative factors and rationale for interventions developed and implemented should be documented in the Standards of Care notes. Update the plan of care with the new or revised interventions. Update the KARDEX or similar format with new or revised interventions. Provide ongoing report at shift change regarding updates to the plan/s of care. Make referrals to therapy or restorative nursing as needed. Monitoring and Follow Up- 1. The staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. 2. Residents will be reviewed through Standards of Care at a determined time frame after new interventions are implemented to determine if effective or revision is necessary. 3. If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed if the problem that required the intervention (for example, dizziness or musculoskeletal pain) has resolved. If the individual continues to fall, the interdisciplinary team should re-evaluate the situation and consider possible reasons for the resident's falling (besides those that have already been identified) and re-evaluate the continued relevance of current interventions.

Based on observation, interview and record review, the facility failed to operationalize policies and procedures to recognize, assess, monitor, evaluate, promptly treat, and provide effective pain management for one (Resident #88) of two Residents reviewed for pain, resulting in inconsistent pain documentation, a lack of non-pharmacological interventions, ineffective and non-administered pharmacological interventions, ineffective pain management, and the potential decline in overall health status for a severely cognitively impaired Resident expressing verbal and non-verbal signs and symptoms of pain and discomfort. Findings include: An interview was conducted with Witness Q at 12:20 PM on 4/2/19. When queried regarding Resident #88, Witness Q stated, I have known (Resident #88) for over [AGE] years. Witness Q further indicated they frequently visit the Resident at the facility and stated, (Resident #88) has been having pain and it is not being treated appropriately. With further inquiry, Witness Q stated, It's like the (primary) Doctor and the pain Doctor don't talk to each. The nurses don't seem to know either. (Resident #88) has always had pain in their back. When asked about pain management, Witness Q indicated what they are giving the Resident does not seem to help and that the medications get changed without anyone being made aware. With further inquiry, Witness Q stated, I don't think that's right, they (facility) just change them (medications) and don't let anyone know. Record review on 4/2/19 at 1:00 PM revealed Resident #88 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessments dated 2/11/19 and 3/11/19 revealed the Resident was severely cognitively impaired, required supervision to extensive assistance to perform Activities of Daily Living (ADL's), and frequently experienced pain. Review of Resident #88's care plans on 4/2/19 at 1:10 revealed one care plan related to pain. The care plan was entitled, The resident has/is at risk for chronic pain related to chronic back pain (Initiated: 2/1/19; Revised: 2/8/19). The care plan goal stated, The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date (Initiated: 1/28/19; Target: 4/28/19) and included one intervention, Monitor/record/report to Nurse any signs or symptoms of non-verbal pain (Initiated: 1/28/19). Review of Resident #88's orders and Medication Administration Records (MAR's) on 4/2/19 at 1:15 PM revealed the Resident was receiving the following medications for pain: -[MEDICATION NAME] (medication to treat nerve pain) 300 mg (one capsule) by mouth at bedtime for [MEDICAL CONDITION] (disease effecting the peripheral nerves) (Start Date: 3/5/19) -[MEDICATION NAME] (medication to treat moderate pain) 50 milligram (mg) by mouth every eight hours (Start Date: 3/27/19) -Aleve Tablet 220 mg (one tablet) by mouth every eight hours as needed for pain (Start Date: 3/25/19 Review of the MAR's revealed Resident #88 had received one dose of as [MEDICATION NAME] 3/26/19 since ordered on [DATE]. Additional review revealed the following discontinued orders: --Tylenol 1000 mg by mouth every 6 hours (Start: 3/5/19; Discontinued: 3/5/19). Resident #88 received two doses of the medication. -[MEDICATION NAME] 25 mg by mouth every 12 hours as needed (Start: 3/4/19; Discontinued: 3/27/19). Resident #88 received two doses of the medication. -Tylenol 650 mg by mouth every 6 hours as needed for pain (Start: 3/5/19; Discontinued: 3/25/19). Resident #88 received the medication five times. On 4/2/19 at 1:42 PM an interview was conducted with Nursing Assistant F. When queried regarding Resident #88 not having got out of bed, Nursing Assistant F stated, (The Resident) doesn't got up anymore because they don't sit up straight in the wheelchair. With further inquiry Nursing Assistant F indicated the Resident had been trying to lean forward in their wheelchair the last time they sat in their wheelchair to get off the sore on their bottom (pressure ulcer). When queried further, Nursing Assistant F indicated the Resident has a lot of pain and that is why they lean forward in their wheelchair and were no longer being assisted to get out of bed. When asked about interventions in place to reduce the Resident's pain, Nursing Assistant F indicated they let nursing staff know if the Resident complained of pain. No further explanation was provided. On 4/2/19 at 3:37 PM, observation occurred of Resident #88 in their room. The Resident was laying in their bed, positioned on their back. The Resident's bed was positioned directly against the wall. Nurse A and Nursing Assistant K were in the Resident's room to obtain the Resident's weight utilizing a Hoyer lift (mechanical lift). Nurse A and Nursing Assistant K did not move the Resident's bed away from the wall. When the facility staff moved the Resident, the Resident began yelling out stating, Oww and It hurts. Resident #88 was observed hitting his hand on the bed and displaying facial grimacing while Nurse A and Nursing Assistant K turned and positioned the Resident to place the Hoyer lift sling under them. When asked if they were having pain, Resident #88 stated, Yes. After being positioned on their back in the sling, Resident #88 grabbed Nurse A's hand. When queried, Nurse A stated Resident #88 was squeezing their hand and further indicated Resident #88 had behaviors. After obtaining the Resident's weight, Nurse A and Nursing Assistant K rolled the Resident on their right side and pulled the sling out from underneath of them. When Nurse A and Nursing Assistant K pulled the sling, the Resident was rolled further onto their side and hit their head on the wall. Nurse A and Nursing Assistant K looked at Resident #88's head and indicated they were okay. Resident #88 continued to cry out and display non-verbal signs of pain throughout the time staff were present in the room. After Nurse A and Nursing Assistant K exited the room, an interview was conducted with Resident #88. When asked if they were having pain, Resident #88 stated, Yes but was unable to provide a numeric value to rate their pain. On 4/3/19 at 9:17 AM, Resident #88 was observed in their room, laying on their back with their eyes open and the lights in the room dim. An interview was conducted with the Resident at this time. When queried, Resident #88 stated, It hurts. When asked where their pain was located, Resident #88 pulled back their blanket and pointed at their back and buttocks. The Resident was unable to rate their pain utilizing a numeric pain scale but stated, It hurts and displaced facial grimacing with movement. On 4/3/19 at 10:02 AM, an interview was conducted with Activities Staff E. When queried regarding Resident #88, Activities Staff E stated, (Resident #88) used to come (to activities) quite frequently then quit. When queried if Resident #88 had complained of pain during activities, Activities Staff E stated, Yes, and I would just tell the nurse. Activities Staff E was unable to provide specific dates and/or times of nursing staff notification of Resident #88's complains of pain. Observation of pericare for Resident #88 occurred on 10:22 AM on 4/3/19 with Nurse A and Nursing Assistant F. Prior to beginning care, Resident #88 was noted to be positioned on their back in bed with their eyes open and their heels positioned directly on the bed. Throughout care, the Resident displayed non-verbal signs of pain including facial grimacing and clenching their hands. Resident #88 also cried out, Oww, Oww, Oww and that hurts me throughout pericare provided by Nurse A and Nursing Assistant F. On 4/3/19 at 10:34 AM, an interview was conducted with Nurse A when queried regarding Resident #88's pain during care, Nurse A stated, Yeah, (Resident #88) seems to be in a ton of pain. I will go let the nurse know. When queried regarding non-pharmacological interventions for pain, Nurse A indicated there were not aware of any non-pharmacological interventions in placed or ordered for the Resident. On 4/3/19 at 11:00 AM, record review of documentation related to pain revealed the following: -Nursing Readmission Evaluation (Dated: 3/4/19): No documentation of pain assessment. Resident's acceptable level of pain: 2 (2 out of 10 on pain scale) -Skilled Daily (Dated: 3/21/19): Pain . No . No non-verbal signs of pain . -Skilled Daily (Dated: 3/23/19): Pain . Occasionally Numeric Rating Scale: 3/10 .Moderate . No non-verbal signs of pain . -Skilled Daily (Dated: 3/24/19): Pain . Occasionally Numeric Rating Scale: 3/10 . Moderate . No non-verbal signs of pain . -Skilled Daily (Dated: 3/25/19): Pain . Occasionally Numeric Rating Scale: 3/10 . Moderate . No non-verbal signs of pain . -Skilled Daily (Dated: 3/26/19): Pain . Frequently Numeric Rating Scale: 5/10 . Moderate . No non-verbal signs of pain . -Skilled Daily (Dated: 3/27/19): Pain . No . No non-verbal signs of pain . -Skilled Daily (Dated: 3/30/19): Pain . Occasionally Numeric Rating Scale: 3/10 . Mild . No non-verbal signs of pain . -Skilled Daily (Dated: 3/31/19): Pain . Occasionally Numeric Rating Scale: 5/10 . Moderate . Non-verbal signs of pain: Facial grimacing and tensing of muscles when repositioning . An interview was conducted with the ADON on 4/3/19 at 12:17 PM. When queried regarding Resident #88's pain, the ADON reviewed the Resident's medical record and stated, The medication dosage was changed on 3/27/19. With further inquiry regarding observations including non-verbal signs of pain, Resident verbalization of pain, and why the Resident's pain level has not been addressed further if medication change on 3/27/19 was ineffective, the ADON indicated the Resident may start Hospice services as a referral was ordered. When queried why the Resident's pain had not been addressed at this time, the ADON stated, It should have been. I will contact the Doctor now. On 4/3/19 at 2:11 PM, wound care observation occurred with Nurse B and Nursing Assistant F. Upon repositioning and throughout the dressing change, Resident #88 was repeatedly yelling out Ouch, it hurts and displayed non-verbal signs of pain. An interview was conducted with Resident #88 following the completion of the wound care treatment. When queried if they were having pain, the Resident indicated they were but were unable to rate their pain utilizing a standardized pain scale. An interview was completed with Nurse B on 4/3/19 at 2:39 PM. When queried regarding Resident #88's pain and pain management, Nurse A indicated the ADON spoke to Resident's Doctor today and stated, There are new orders today for [MEDICATION NAME] as needed and to increase the [MEDICATION NAME] dose. When asked why the Resident's pain was not assessed prior to and after the wound care treatment/dressing change, Nurse A did not provide and explanation. When queried regarding the Resident crying out and displaying non-verbal signs of pain, Nurse A indicated Resident #88 displays those behaviors during dressing change. When queried if Resident #88 received pain medication prior to the wound care treatment/dressing change, Nurse B indicated they had not given the Resident pain medication prior to completing wound care. When queried regarding the last time Resident #88 received something for pain prior to the dressing change, Nurse B reviewed the Resident's medical record and stated, 11:27 (AM) today. When asked if Resident #88 is normally given pain medications prior to wound care treatment/dressing change, Nurse A stated, No because it is scheduled, and I do the dressing change at the end of my shift. With further inquiry regarding Resident #88's pain management, Nurse A stated, Even after getting medication (Resident #88) still complains of pain. When queried if they had given the Resident an as needed medication or notified the Resident's Doctor that Resident #88 was crying out in pain and displaying non-verbal signs of pain while receiving the current ordered pain medications, Nurse A replied, No, I think they are of aware of it. When asked if they would normally contact a Resident's Doctor if a pain medication was not effectively treating a Resident's pain, Nurse A stated, Yes, I would. When asked why they did not contact Resident #88's Doctor, Nurse A stated, I thought they were aware and looking into it. I assumed they were. An interview was completed with Nurse A on 4/3/19 at 3:20 PM. When queried regarding Resident #88's pain management, Nurse A stated, We have scheduled and PRN (as needed) meds. With further inquiry regarding the Resident's pain and pain management, Nurse A stated, We recently changed the one PRN med to scheduled. When queried regarding assessment of the Resident's pain, Nurse A stated, Well, all the nurses don't see (Resident #88) when they are being moved so they don't really see (the Resident) in pain because their pain is highest when they are moving around. When queried further regarding their role, Nurse A indicated they help in many areas but do not give medications. When queried regarding Resident #88's as needed pain medications, Nurse A stated, We weren't utilizing the PRN (as needed medications). When asked why the as needed pain medications were not being administered, Nurse A stated, I think the nurses forget. No further explanation was provided. On 4/3/19 at 3:53 PM, an interview was completed with Senior Nursing Director Nurse O. When queried regarding Resident #88's pain levels and pain management, Nurse O did not provide an explanation. Review of facility policy entitled, Pain- Clinical Protocol (Reviewed/Revised: 3/22/11) on 4/3/19 at 4:25 PM revealed, 1. The Physician and stall will identify individual who have pain or who are at risk for having pain . b. It also included a review for any treatments that the resident current is receiving for pain, including all complementary (non-pharmacologic) treatments. c. Such assessment should occur on admission to the facility, at each quarterly; review, whenever there is a significant change in condition and at any time pain is suspected . 2. The staff and physician will identify the nature and severity of pain including characteristics location, intensity, frequency, duration, etc.). a. Staff should use a standardized pain assessment instrument appropriate to the resident's cognitive level. b. The staff and physician will evaluate nonverbal individuals for nonspecific signs and symptoms that could reflect pain . 3. The staff and physician will also evaluate how pain is affecting mood, activities of daily living . The policy further revealed, Treatment/Management: 1. With input from the resident and/or advocate, the physician and staff will establish goals or pain treatment . 2. The physician will order appropriate non-pharmacological and medication interventions . 3. The staff will evaluate and report how much and how often the individual ask for PRN pain medication . 4. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions . Monitoring: 1. The staff will reassess the individuals pain and consequences of pain at regular intervals, at least each shift for acute pain . 3. The staff will discuss significant changes in levels of comfort with the Attending Physician who will adjust interventions accordingly .

This citation has two deficient practices Deficient Practice #1 Based on observation, interview and record review, the facility failed to promptly address and treat an identified alteration in skin integrity for one (#35) of three residents reviewed for catheters (tube that drains urine from the bladder through the urethra), resulting in pain and continuing laceration of the urethra. Findings include: On 4/1/19 at 3:39 PM, R#35 was observed lying in bed, a catheter drainage bag was noted hanging from the bed. R#35 was asked if the catheter was anchored (a device used to secure the catheter tubing in place). R#35 stated, Yes, here on my leg. An anchor device was noted high on R#35's right thigh. R#35 was asked if he had any problems with the catheter. R#35 stated, I don't know how to put it, the tube doesn't come out of the end anymore, it is down on the side (of the penis). R#35 was asked how long this problem had been going on. R#35 stated, For a while, a month or so ago, I can't remember when it happened. R#35 was asked if the tubing had been pulled, causing the problem. R#35 stated, I don't remember it getting pulled, I don't know how it happened. R#35 was asked what anyone had done about it. R#35 stated, The doctor hasn't seen it yet. R#35 was asked what staff were saying about it. R#35 stated, Every time someone sees it, they say, 'That looks like it really hurts', I'm not going to argue with them. It hurts! Review of R#35's clinical record revealed R#35 was admitted into the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. According to the most recent admission MDS assessment dated [DATE], R#35 scored 15/15 on the Brief Interview for Mental Status (BIMS) exam, indicating intact cognition. The MDS (Minimum Data Set) assessment indicated R#35 required extensive assistance of staff for all Activities of Daily Living (ADL's). A continued review revealed a nursing progress note written by RN 'R', dated 12/12/18 that read, Resident urethra skin being pulled on by catheter. Re-educated CNAS (Certified Nursing Assistants) regarding catheter anchors in place and being gentle when moving catheter bag when turning resident. No pain or irritation reported from patient regarding skin around urethra. Continue to monitor and report to physician. A further review of R#35's clinical record revealed a nursing progress note dated 3/30/19 that read, Lodger urethra is torn from catheter. Informed Physician New order to see DR (name redacted) in out patient setting. Apply [MEDICATION NAME] (antibiotic ointment) tid (three times a day) noted. Review of R#35's care plan revealed a goal initiated 10/11/18 that read, The resident's risk of significant skin injury will be reduced/minimized. An intervention dated 10/11/18 read in part, Monitor/document/report PRN (as needed) any changes in skin status . On 4/2/19 at 12:40 PM, R#35's catheter site was observed with RN (Registered Nurse) 'N'. It was noted the catheter tubing's exit site was approximately 1 3/4 inches below the tip of the the penis on the right side. The shaft of the penis above the exit site appeared to lay flat with the progression of the torn urethra visible. R#35 appeared to grimace and flinch each time the penis was moved or touched. On 4/2/19 at 4:00 PM, Medical Records Staff 'Z' was interviewed and asked if R#35 had an appointment to an urologist. Medical Records 'Z' stated, Not yet, we weren't sure if (R#35) needed to go on a stretcher or wheelchair. On 4/2/19 at 4:11 PM, CNA 'AA' was interviewed and asked about R#35's catheter site. CNA 'AA' stated, I haven't had him since last week, but it's looked like that for a while. On 4/2/19 at 4:14 PM, CNA 'K' was interviewed and asked about R#35's catheter site. CNA 'K' stated, It's been like that for a couple months, it started with just a small tear, now it's ripping down. We keep telling the nurses. On 4/3/19 at 9:34 AM, RN 'R' was interviewed and queried about R#35's catheter site. RN 'R' stated, I think he came with it (torn urethra). RN 'R' was asked about the progress note she had written on 12/12/18. RN 'R' made no comment. RN 'R' stated, I know he has an appointment with the urologist on Monday. On 4/3/19 at 9:53 AM, the Assistant Director of Nursing, (ADON) was interviewed and queried about R#35's catheter site. the ADON indicated she had not seen the site, and that it was a recent tear. The ADON was questioned about the progress note from 12/12/18 and CNA's stating the tear had happened months ago, and was getting worse. The ADON did not have an explanation, and stated, We have a new treatment plan in place, to help keep it from continuing to rip (down the penis). On 4/3/19 at approximately 11:00 AM, several nurses, including the Senior Director of Nursing Services (SDONS) were observed to enter R#35's room to put the new treatment plan in place to keep the catheter from continuing to tear the urethra. On 4/3/19 at approximately 4:00 PM, The SDONS was interviewed and queried about R#35's catheter site. THE SDONS stated, Once we saw it (the catheter site), I knew the treatment plan wouldn't work. I called and got a new treatment plan that will hopefully keep it from tearing more. We also educated the resident to hold his penis up against him whenever ADL care is being done to keep it from tearing. The SDONS was asked if she thought the tear had happened on 3/30/19. The SDONS stated, No. The SDONS indicated R#35 had an appointment with an urologist on Monday (4/8/19) and stated, I would think they would put in a SP (Supra Pubic) catheter. A review of a facility provided Wound and Skincare Guidelines sheet read in part, Care is based upon individual resident needs . Assess all wounds for pain . The facility was asked if they had any additional information, none was provided by the end of the survey. Deficient Practice #2 Based on observation, interview and record review, the facility failed to ensure treatments for identified skin tears were completed for one resident (R#96) of one resident reviewed for skin tears, resulting in the increased likelihood of skin tears reopening and infection. Findings include: On 4/1/19 at approximately 10:08 am., R#96 was observed in their room. R#96's right forearm was observed to contain a raised scab. No dressing was observed to be protecting the scab. R#96 was queried how they got the scab and they stated, I don't remember. On 04/02/19 at approximately 9:15 a.m., R#96 was observed in their room lying in their bed. R#96 was observed to have a raised scab on their right forearm and a red area on their left forearm. No dressings were observed on either arm. On 4/3/19 at approximately 1:05 p.m., R#96's right and left forearms were observed with staff member C. Staff member C was queried if they observed any dressings on either of R#96's arms and they stated that they didn't. On 4/01/19 the medical record for R#96 was reviewed and revealed the following: R#96 was initially admitted to the facility on [DATE], was last admitted on [DATE], and had [DIAGNOSES REDACTED]. R#96's MDS (minimum data set) with an ARD (assessment reference date) of 3/15/19 revealed R#96 needed extensive assistance from facility staff with most of their activities of daily living. R#96's BIMS score (brief interview of mental status) was three indicating severely impaired cognition. A skin assessment completed on the nursing admission evaluation dated 3/8/19 revealed the following: Skin tear-rt (right) fore arm and Skin tear-Left forearm. A physician's orders [REDACTED]. Change Q day (every day). Monitor for heaking <sic> No scheduling was indicated. A second physician's orders [REDACTED].<sic>. Border foam covering. Change Q day. Monitor for healing. No order scheduling was indicated. A review of R#96's comprehensive care plan revealed the following: Focus-the resident has a (skin tear) of the (right forearm) .Goal-The residents risk of significant skin injury will be reduced/minimized .Interventions-Encourage good nutrition and hydration in order to promote healthier skin .If skin tear occurs treat per facility protocol .Keep skin clean and dry. Use lotion on dry scaly skin. A review of R#96's TAR (treatment administration record) for (MONTH) and (MONTH) 2019 revealed no documentation that R#96's dressings for their skin tears on their forearms had been completed. On 4/3/19 at approximately 12:57 p.m., the Physician orders [REDACTED].#96's forearm dressings were reviewed in the medical record with staff member C. Staff member C was observed reviewing the orders and indicated that the orders for both of the forearm dressing changes were not written into the electronic medical record correctly and that there should have been a schedule indicated on the order. Staff member C stated, some education will need to be given to this nurse, thank you for bringing this to my attention. Staff member C was queried if they could provide any documentation that R#96's dressing changes were completed as ordered and they indicated they could not because an appropriate schedule was not entered with the orders and due to the orders not containing an appropriate schedule, the treatments did not show up in the the TAR for the nurses to complete. On 4/3/19 at approximately 2:51 p.m., during a conversation with the Assistant Director of Nursing (ADON), the ADON was queried if it was their expectation that all treatments are completed per the physician's orders [REDACTED]. On 4/3/19 a facility document titled Wound and Skincare Guidelines (undated, page 1) was reviewed and revealed the following: Note: Care is based upon individual resident needs and physician orders.

This Citation refers to Intake #MI 577 Based on observation, interview and record review the Facility failed to ensure a Resident with a known medical history of [REDACTED].#901) out of three Residents reviewed for anticoagulant medication administration out of a total sample of three, resulting in Resident #901 sustaining multiple blood clots, a [MEDICAL CONDITION] embolism, extended Hospital stay, loss of appetite, vomiting and weight loss. Findings include: On 5/23/18 the Complainant reported to the State Agency that the Facility doctor discontinued Residents (#901) life long anticoagulant medication ([MEDICATION NAME]) causing severe blood clots resulting in a Hospital stay. On 6/12/18 at approximately 11:55 AM a phone interview was conducted with the Complainant. The Complainant reported that Resident #901 had been receiving the drug [MEDICATION NAME] ([MEDICATION NAME] - an anticoagulant medication) for a number of years due to a chronic blood clotting disorder. The Complainant stated, Resident #901 was taking [MEDICATION NAME] when she entered the Facility in (MONTH) (YEAR) and continued until sometime in April. For some reason the treating physician (name redacted/Physician C ) decided to discontinue the medication. I believe he based his decision a nurse's phone call recommendation. Resident #901 then ended up in (name redacted) Hospital with numerous blood clots leading to a [MEDICAL CONDITION] embolism (PE). She spent five days at the Hospital including time in the ICU (intensive care unit). Now that she is back in the Facility, she is not herself. She refuses to eat at times, sometimes throws up, she lost twenty pounds since she returned and has been bumping into things and falling. She is now being seen by a different doctor (Physician D). On 6/12/18 at approximately 11:00 AM a review of Resident #901's electronic clinical record was conducted. and documented that the Resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #901's MDS (minimum data set) dated 5/31/18 revealed that the Resident had a BIMS (brief interview for mental status) score 7/15 (cognitively impaired) and required one person extensive assist for bed mobility, transfers, dressing and bathing. Medical documents received by the Facility from outside medical providers (Hospital) upon Resident #901's admission, (2/8/18) documented, in part, the following: History of PE/[MEDICAL CONDITION] ([MEDICAL CONDITION] with APLA. Continue [MEDICATION NAME] 80 mg q24hrs .Home dose is 100 mg q24 hours. Continued review of Resident #901's clinical record revealed a care plan created (2/9/18) that documented, in part, the following: Description: The Resident is receiving anticoagulant therapy ([MEDICATION NAME]) r/t disease process .administer medications as ordered .monitor side effects .report to MD (physician) adverse reactions of anticoagulant therapy . A document submitted from (name redacted) Hospital Hematology Clinic/Cancer Center to the facility on [DATE] documented, in part, the following: Order Information: Anti-Xa ( a laboratory procedure designed to measure plasma [MEDICATION NAME] levels and to monitor anticoagulant therapy) ([MEDICATION NAME]) low muscular weight [MEDICATION NAME] - Routine blood monthly .draw 4 hours after [MEDICATION NAME] dosage monthly A progress note dated 3/29/18 documented, in part, the following: Resident daughter return with new orders from (name redacted) Hospital Anti-Xa to be drawn monthly 4 hours after [MEDICATION NAME] ([MEDICATION NAME]) dosage . Continued review of the Resident #901's medical record documented a discontinue order (D/C) dated 4/11/18 (authored by physician C) [MEDICATION NAME] Solution 100 MG/ML (Enoxaperin sodium) inject .85 ml .D/C A review of Resident #901's Medication Administration Record [REDACTED]. Progress notes dated 4/30/18 documented, in part, the following: 16:14 .change in condition change identified: respiratory difficulties, abnormal VS (vital signs), vomiting .Assessment: unstable .nursing interventions: started on O2, elevated head of bed (HOB), EMS for transport . Lodger sent to (name redacted) Hospital 4:10 PM via 911 .respiratory distress . Hospital Discharge documents documented, in part, the following: admitted : 4/30/18 discharge date : 5/4/18 16:43 PM .Discharge Diagnosis: [REDACTED].Your home medication list .enoxaprin 80 mg subcutaneous .no record of levonox on medication record sent by Facility (name redacted). A progress note dated 5/4/2018 documented, in part, Resident arrive via EMS at 19:50, .Physician D notified with arrival of resident, all medications are approved. Physician D request do not stop [MEDICATION NAME], resident is on medication indefinitely for the rest of Resident's life, do not stop [MEDICATION NAME] A physician progress notes [REDACTED].female .presented to ER from (name redacted) Facility .on (MONTH) 30, (YEAR) .The patient has had antiphospholipid antibody syndrome and had multiple prior [MEDICAL CONDITION]'s and [MEDICAL CONDITION] emboli .She has been on lifelong [MEDICATION NAME], but apparently was not receiving therapy in (name redacted) Facility. Her last injection of [MEDICATION NAME] being in mid (MONTH) CT (cat scan) for [MEDICAL CONDITION] embolism revealed bilateral massive [MEDICAL CONDITION] emboli with right heart strain, right-sided cardiac enlargement. She was admitted and placed on anticoagulant with [MEDICATION NAME]. She restarted enoxaprarin .She has remained on [MEDICATION NAME] at doses prescribed by her (name redacted) Hospital oncologist. The patient was noted to have right and left lower extremity [MEDICAL CONDITION]'s Reason for visit physician transfer. On 6/12/18 at approximately 12:15 PM a phone interview was conducted with Physician C. Physician C was queried as to the care and treatment provided to Resident #901, specifically, medication orders pertaining to [MEDICATION NAME], Physician C stated, I remember the Resident. I believe I only saw her one time when she first came in. A nurse at the Facility, (name redacted) maybe Nurse E called me late at night like 7:00 or 8:00 PM, I can't remember the date. The Nurse wanted to let me know that the Resident was on [MEDICATION NAME] injection and had been on since admission. The Nurse was concerned that the Resident was being poked two times a day with the medication. I asked the Nurse if the Resident was being bridged. Nurse E didn't know. I knew the Resident didn't [MEDICAL CONDITION]. Generally those are the people who are on [MEDICATION NAME] for long periods. I asked Nurse E if she had recent [MEDICAL CONDITION]'s. Nurse E did not believe she did, so I discontinued the medication. It was only after the Resident was at the Hospital that I found out that she had been on life long [MEDICATION NAME]. When she came back to the Facility she was assigned to a different doctor. Physician C was read Hospital documents, including the document received by the Facility on 2/8/18 that indicated History of PE/[MEDICAL CONDITION] ([MEDICAL CONDITION] with APLA. Continue [MEDICATION NAME] 80 mg q24hrs .Home dose is 100 mg q24 hours. and document dated 3/29/18 for Hospital Hemotology Center Order Information: Anti-Xa ([MEDICATION NAME]) low muscular weight [MEDICATION NAME] - Routine blood monthly .draw 4 hours after [MEDICATION NAME] dosage monthly . Physician C responded, The problem is nobody gave me the reports that the Resident was being seen by Hospital (name redacted) Hematology. Usually I would get a note in my box. If I had received a note, I would have known she had a clotting disorder. On 6/12/18 at approximately 1:00 PM an interview and record review was conducted with the Director of Nursing (DON) regarding Resident #901's treating physician and how they obtain Resident information. The DON reported that the Facility has three physicians that work in the building and when a Resident enters the building they are automatically assigned a physician. When queried as to how treating physicians are able to obtain medical/treating information about the Resident's who reside in the building, the DON stated, The physician assigned has access to all of our Resident's medical records online or if they do not like to view online documents that can provide paper documents that we receive and scan into the electronic record. The DON was queried as to the D/C order of [MEDICATION NAME] on 4/11/18, the DON stated, I believe another Nurse may have told Nurse E that Resident #901 had been receiving Levonox injections for a long period of time. Nurse E contacted Physician C via phone to express concern about Resident #901's medication. When queried as to whether there was any documents that detailed the conversation, the DON stated, No. When queried as to the Facility Policy as to whether Nursing staff is able to place or discontinue orders, the DON stated, No, only the physician can make or discontinue an order. On 6/12/18 at approximately 1:15 PM a phone interview was conducted with Nurse E regarding the care and treatment of [REDACTED]. Nurse E was queried as to whether she knew Resident #901's diagnosis, Nurse E responded, I can't remember. When queried as to whether she had ever contacted Physician C regarding Resident #901's order for [MEDICATION NAME]. Nurse E stated, I called Physician C because I assumed that he would not want the Resident on [MEDICATION NAME] for such a long time. He asked me if she had had a [MEDICAL CONDITION], I told him no. He then D/C'd the order. When queried as to whether she knew why the Resident was taking [MEDICATION NAME], Nurse E stated, I do not recall. When queried as to whether Resident #901 was showing any reactions that she believed were caused by the [MEDICATION NAME], Nurse E stated, No. When queried as to whether she initiated a note in the Resident's record pertaining to the phone call and subsequent discontinuation of the medication, Nurse E stated, No. When queried as to whether Physician C asked for or discussed any other documentation pertinent to Resident #901, Nurse E stated, No. On 6/12/18 at approximately 4:35 PM, an interview and record review was conducted with the Administrator regarding the care and treatment of [REDACTED]. The Administrator was queried as to the discontinuation of Resident #901's [MEDICATION NAME] on 4/11/18. The Administrator reported that Nurse E contacted Physician C and following the discussion the [MEDICATION NAME] was discontinued. When asked for the protocol used by staff nurses for non-emergency communication, the Administrator reported that the Facility has a box where Nurse's can leave questions or concerns with the physician. The Administrator also reported that Facility Physician's have access to all of the Resident's electronic and paper records at all times and can view the records outside of the Facility. On 6/12/18 at approximately 4:50 PM, Resident #901 was observed sitting in a wheelchair in the main dining room. The Resident was alert, but not able to answer questions about medical care provided. When queried about the food being provided, Resident #901 stated, I'm not very hungry. On 6/12/18 at approximately 5:10 PM a review of the Facility Policy titled, Physician Services (revised 10/7/2010) was conducted and documented, in part, the following: Policy Statement: the medical care of each resident is under the supervision of a Licensed Physician .Policy interpretation .the resident's Attending Physician participates in the resident's assessment and care planning .is responsible for conducting required routine visits delegating and supervising follow-up visits .to ensure that the resident receives quality care and medical treatments . A second Policy titled, Administering Medication (5/2018) was reviewed on 6/12/18 at 5:15 PM and documented, in part, the following: Policy Statement: Medications shall be administered in a safe and timely manner and as prescribed .the Director of Nursing services will supervise and direct all nursing personnel who administer medications .medications must be administered in accordance with the orders .if a dosage is believed to be inappropriate or excessive .or is suspected of being associated with adverse consequences the person preparing or administering the medication shall contact the facility's Medical Director to discuss the concerns .

Based on observation, interview and record review the Facility failed to ensure the proper transfer of one (#701) Resident out of two residents reviewed for falls from a total sample of four, resulting in Resident #701 sustaining a closed [MEDICAL CONDITION] femur, continued pain and a hospital stay. Findings include: On 4/16/18 the Facility reported to the State Agency that Resident #701 sustained a supracondylar femur fx (fracture) of the right leg. On 5/10/18 at approximately 9:47 AM, Resident #701 was observed lying in bed. Her leg was elevated and she appeared to be wearing a brace. The Resident was crying and screaming out, I am in pain - my leg, my leg, why do I have so much pain. The Resident was not able to answer any questions asked regarding the cause of the pain. Staff member C entered the room and attempted to talk with the Resident and contacted a nurse to assist the Resident. On 5/10/18 at 10:45 AM a review of the Resident's clinical record was conducted. Resident #701 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS (minimum data set) dated 2/26/18 documented the Resident had a BIMS (brief interview for mental status) score of 14 (cognitively intact). Further review indicated that the Resident required extensive two person assist for all transfers. A review of the Resident's ADL (activity of daily living) Care Plan (initiated 12/16/16) documented, in part, the following: The resident has an ADL self-care performance deficit r/t/impaired balance, Interventions .TRANSFER: The resident required extensive 2 person assistance with transfers (date initiated 12/19/16 - revision on 8/22/17). Bathing/Showering: The resident is a 2 person expensive for assistance (date initiated 12/19/16: Revision date 4/16/18 .The Resident is a one person extensive for assistance (date initiated 12/19/16) A review of the Facility Incident and Accident ( I&A) report documented, in part, the following: Date of Incident: 3/26/18 Location: Bathroom Incident Type: Fall Incident Type: Observed Brief Description: Resident was in the bathroom being showered by the CNA (certified nursing assistant). Resident had a BM (bowl movement) and stood up, CNA instructed( word struck out) attempted to assist resident to sit down in shower chair, but resident refused. Her legs then became weak and CNA lowered her to the floor List Care Planned Interventions Prior to Fall/Accident: 1 person assist Residents explanation of Incident: Resident stated that she is unable to stand for that long. 9. With respect to interviews conducted in investigating the incident, identify the following: Interviews of residents (BLANK) Interviews of staff: Individual Interviewed (CNA D - name redacted) Continued review of the Resident's medical record, including progress notes, documented, in part, the following: 3/26/18: Tylenol given 4PM- RT (right) knee pain swelling x-ray 8:30 PM. 3/26/18: x-ray shows no evidence of fracture . 3/27/18: continues right leg swelling . 4/8/18: Lodger complains of pain to right knee .elevated with ice pack bruising to knee and lower leg . 4/11/18: New onset .unrelieved pain . 4/14/18: .stated she was in pain R leg was touched .knee swollen .Dr. notified .(name redacted) from Radiology called said recent fracture . On 5/10/18 at approximately 12:00 PM an interview with CNA D was conducted. CNA D reported that she received her CNA license approximately two months ago and started working for the Facility at that time. When queried as to the incident involving Resident #701 on 3/26/18 and the Resident's transfer status, CNA D reported that she needed to give Resident #701 a shower and stated, When I looked on the Kardex (summary of patient's care plan and assessments) it stated that the Resident was a one person assist, later I learned from the DON (director of nursing) that the Resident was actually a two person assist. I went into the shower and put her on the shower bench and then the Resident stated, get my butt and she moved forward, but started to slide and I was going to pull the call light for help and CNA E came in and the Resident complained of leg pain and said her arm hurt. CNA E went to get Nurse F to help. On 5/10/18 at approximately 12:30 PM an interview was conducted with CNA E. CNA E was queried as to the incident involving Resident #701. CNA E stated, I remember that CNA D told me that she would need help with Resident #701's shower. We were going to meet in Resident's room and CNA D told me that she would come and get me. When she did not come to get me I went to check to see where she was and Resident #701 was on the floor in the shower. I knew she needed help and I went to get a nurse and we lifted her up and put her in bed. I remember after that when I worked with her she was very verbal about her pain. She would yell and say, 'I hurt all over.' On 5/10/18 at approximately 2:15 PM an interview was conducted with Nurse F. Nurse F was queried about the incident on 3/26/18 and reported that she was not in the room when Resident #701 fell , but was called for assistance by CNA E. Nurse F stated, An x-ray was ordered that day because the Resident was complaining of pain, but the x-ray results showed that nothing was wrong. The Resident kept complaining of pain and about two weeks later it was still swollen and she was still in pain, the doctor told me to order a Doppler and when I called with the order, (name redacted) told me that there was a second report that indicated a fracture so there was no need for the Dopler and then the Resident was sent to the Hospital. I think she came back a few days later. She is really not herself, I believe she might be Hospice. On 5/10/18 at approximately 4:00 PM an interview and record review was conducted with the DON regarding the incident involving Resident #701. When queried as to the Resident's transfer status, including transfers for showers, the DON stated, On the Resident's Kardex it indicated that the Resident was a one person assist for transfers, but the Resident's Care Plan and the MDS indicated that Resident #701 was a two person assist, the proper transfer information was never properly indicated on the Kardex. When queried as to whether an interview was ever conducted with Resident #701 regarding the incident, the DON reported that she did not interview the Resident and did not believe that any interview statements were available for review. No interview documents were provided by the Facility prior to exit. When queried as to the delay in determining that the Resident had a fractured femur, the DON reported that the Facility ordered an x-ray on 3/26/18 and the radiology report indicated that Resident did not have a fracture. The DON reported that on 4/14/18, the Resident was still complaining of pain and when attempting to get an ultrasound for the Resident, it was reported to the Facility that a second review of the initial 3/26/18 x-ray showed that Resident #701 had sustained an acute fracture to the right femur and the Resident was sent to the Hospital and returned on 4/18/18. On 5/10/18 at 3:30 PM a review of the Facility's Accidents and Incidents - Investigation and Reporting (Policy revised 12/1/2017) was conducted and documented, in part, the following: All accident or incidents involving residents, employees ., occurring on our premises must be investigated and reported to the Administrator. Investigation Action in Incident Report: The Nurse Supervisor/Change Nurse and/or department director or supervisor must conduct and immediate investigation of the accident or incident. b. The following data, as it may apply, must be included on the Report of Incident/Accident: .6. the injured persons account of the accident or incident

This citation pertains to MI 513: Based on observation, interview, and record review the facility failed to promptly identify alterations in skin integrity, consistently perform and document skin assessments, implement and revise interventions for pressure ulcers, and provide prompt treatment to prevent the development and worsening of pressure ulcers for 6 (#601, #604, #606, #607, #609, #613) of 12 residents reviewed for pressure ulcers/wounds from a total sample of 14, resulting in the development of multiple avoidable facility acquired pressure ulcers, a compromise of health status, and the potential for pain and infection. Findings include: Resident #601: On 7/18/17 at 12:00pm the clinical record for Resident #601 was reviewed and revealed the resident had been admitted into the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's quarterly minimum data set (MDS) assessment dated [DATE] Resident #601 scored 1 out of 15 on a brief interview for mental status (BIMs) exam, which indicated that the resident was severely cognitively impaired. Per this MDS assessment, Resident #601 was not noted to have any unhealed pressure ulcers at the time of the assessment. On 7/18/17 at 12:08pm a review of weekly skin assessments for Resident #601 revealed the following dates that skin assessments had been completed between May 2017 and June 2017: 5/5/17, 5/26/17, 6/2/17, 6/22/17. On 7/18/17 at 12:15pm the skin assessments for Resident #601 dated 6/2/17 and 6/22/17 were reviewed and revealed the following abnormal areas that had been identified: Per a weekly skin assessment dated [DATE] Resident #601 was noted to have a left knee scab and a scabbed wound to the right knee. Per a weekly skin assessment dated [DATE] it was documented that Resident #601 had abormal skin areas noted to the right hand (palm) described as a red/blanchable area measuring 4.5 x 5.7 , left hand (palm) area described as wrist: red/blanchable area: 2.5 x5.0, an area to the left ear described as an open area beneath the outer fold, an area to the left outer ankle described as an unstageable (full thickness ulcer) measuring 0.6 x1.5cm, an area to the sacrum described as a stage 2 (partial thickness) wound measuring 3.0 x 3.5cm, unstageable wounds to the left foot measuring 1.0 x 0.5cm and 1.2 x 1.0cm, red and blanchable areas observed to all bony prominences, and an unstageable wound to the right foot measuring 0.5 x 1.0cm. On 7/19/17 at 12:20pm the facility's Director of Nursing (DON) was queried concerning the development of multiple wounds between the time period of the resident's two skin assessments completed in June 2017. The DON responded that the resident's family and physician had been notified when the resident's wounds had been discovered. The DON stated that the hospice company that was involved in the resident's care had not identified the resident's wounds. On 7/20/17 at approximately 9:00am continued review of Resident #601's clinical record revealed the resident had been assessed as being at high risk for skin breakdown related to pressure per a pressure ulcer assessment dated [DATE]. Per a careplan dated 12/5/16 and revised on 6/23/17 Resident #601 had been identified as being at Risk for impaired skin integrity. r/t (related to) braden (scale which assesses the risk for pressure ulcer development) 17. Resident #604 On 7/19/17 at 2:42 P.M., Resident #604's clinical record was reviewed and revealed the following: Resident #604 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #604 required limited physical assistance from one staff member for bed mobility and transfers and did not have any pressure ulcers. A 5 day MDS assessment dated [DATE] documented that Resident #604 did not have any pressure ulcers. On 7/20/17 at 10:45 A.M., the DON was interviewed. The DON indicated that she began working as the DON in the facility on 7/14/17. When asked if there was any other staff that would be able to answer questions pertaining to wounds prior to that date, the DON indicated that the unit managers and former DON no longer worked in the facility and she would be the person to talk to. Resident #604's clinical record was reviewed with the DON. The DON indicated that in addition to the progress notes, documentation of wounds could be in the Skilled Daily nursing notes. Skilled Daily nursing notes for Resident #604 were reviewed with the DON and revealed the following: A Skilled Daily nursing note dated 5/30/17 that documented, Does the resident have any wounds? Yes .#, type and location: scrotum area; tx in place. Skilled notes dated 5/31/17, 6/1/17, 6/2/17, and 6/3/17 documented Resident #604 did not have any wounds. Skilled notes dated 6/4/17 and 6/5/17 documented, Resident has stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister) to posterior side of scrotum, 4 x 2 x .1 cm. A skilled note dated 6/6/17 documented, Open area to testicles. The DON was queried about the documented pressure ulcer to Resident #604 and was asked to provide any information regarding any treatment or interventions prior to and after the open area to Resident #604's scrotum was identified. All skin assessments since Resident #604's readmitted on 5/18/17 were requested at that time. On 7/20/17 at 1:30 P.M., skin assessments for Resident #604 were reviewed and revealed the following: On 5/25/17, Groin - redness from moisture/incontinence, tx in place. On 6/1/17, Groin and testicles red. The next skin assessment was completed on 7/19/17 (48 days after the last skin assessment) and documented, Blanchable redness. The DON was interviewed on 7/20/17 at 2:14 P.M. and queried about any additional information regarding the open area to Resident #604's scrotum. The DON stated, I didn't see anything else other than what was documented in the skilled note and skin assessment. When queried about what should be done when an alteration in skin is identified, the DON stated, They should have notified their manager, put a treatment in place, update the care plan, and notify the physician. Progress notes, physician's orders [REDACTED].#604's scrotum. Resident #606 On 7/19/17 at 9:00 A.M., Resident #606's clinical record was reviewed and revealed the following: Resident #606 was admitted into the facility on [DATE], readmitted on [DATE], and discharged from the facility on 6/1/17. Resident #606's [DIAGNOSES REDACTED]. An admission MDS assessment dated [DATE] documented Resident #606 required extensive physical assistance from at least two staff members for bed mobility and transfers, was not ambulatory, did not have any pressure ulcers or venous/arterial ulcers, and had surgical wounds. A review of the Nursing Admission assessment dated [DATE] documented Resident #606 had the following skin conditions: A stage one pressure ulcer (Intact skin with non-blanchable redness of a localized area usually over a bony prominence) to the right knee, and undocumented conditions/description to the front and rear of the right and left lower legs (the type, measurements, and stage were left blank). An admission progress note dated 4/13/17 documented, .Traumatic [DIAGNOSES REDACTED] of BLE (bilateral lower extremities), pressure ulcer of right knee and DM (diabetes mellitus) .open wounds on both legs .Has wound vac (a vacuum dressing to remove blood or fluid and promote healing of complicated wounds) . Skin Assessments from 4/13/17 though 6/1/17 were reviewed at that time and they revealed the following: A skin assessment dated [DATE] (17 days after the admission skin assessment mentioned above) that documented, Site - Coccyx (tailbone). Description - area has discolored, blanchable skin measuring approx(imately) 12-13 cm (centimeter) in diameter with open area approx. 2 cm in diameter. Barrier cream applied. It also documented both sides of right and left leg had a wound vac. A second skin assessment dated [DATE] documented the following abnormal skin areas: Coccyx 11.5 cm x 8.5 cm area red area, Right buttock 1 cm x 0.5 cm, Left buttock 1.5 cm x 2 cm (there was no description of the condition of the right and left buttock), and a wound vac to the right and left lower legs. A skin assessment dated [DATE] documented, Coccyx red/tender . A admission skin assessment completed after Resident #606 was readmitted on [DATE] documented, Site - Other (specify) .Type - Other (specify) .coccyx red . A skin assessment dated [DATE] documented, Coccyx - Open area, discolored non-blanchable skin; New treatment in place .Right heel - Fluid filled (bubble); Tx in place. A skin assessment dated [DATE] documented, Coccyx - open area measuring approx. 3 cm x 5 cm, with 2 cm x 2 cm darkened area, hard in middle of coccyx wound, 2.5 cm x 1 cm deep tissue damage at top of coccyx wound . There was no documentation regarding the right heel documented the day prior. There were no notes in the facility's wound care system according to the DON. physician's orders [REDACTED].M. and the revealed the following orders: An order on 4/30/17 for Barrier cream mixed with vitamin D ointment to coccyx/buttocks - every shift for redness AND as needed for redness Q (every) shift and PRN (as needed) with brief changes/bed pan use. An order on 5/1/17 for (brand name for an orthotic device to decrease pressue to the foot and ankle) boots when in bed and at night every shift to prevent foot drop. An order on 5/24/17 for Coccyx wound care QD (every day) and PRN - Cleanse coccyx area w/ wound cleaner apply skin prep to wound borders and apply 6 x 6 border foam dressing to wound QD and PRN until resolved. An order on 5/25/17 for Coccyx wound care QD and PRN - cleanse with wound cleaner, apply dry alginate dressing, cover with dry while islan dressing. Change QD and PRN. Every day and evening shift for coccyx. Check on evening shifts to make sure dressing is still on. SOC-Skin notes were reviewed from 4/13/17 through 6/1/17 and they revealed the following: A note written on 4/21/17 documented, Resident admitted with incisions to bilateral l/e (lower extremities) r/t (related to) [DIAGNOSES REDACTED] . A note written on 5/19/17 contained documentation regarding the surgical wounds. There was no documentation regarding Resident #606's coccyx, buttocks, or right heel. There were no other SOC-skin notes after 5/19/17. On 7/19/17 at 12:05 P.M., the DON was interviewed regarding the development of a coccyx wound and heel blister on Resident #606. The above mentioned skin assessments and documentation of abnormal areas on Resident #606's coccyx, buttocks, and right heel were reviewed with the DON. The DON stated, The descriptions on the skin assessments are not consistent. When queried about how the treatments were determined for pressure ulcers when the assessments are inconsistent, the DON stated, I don't know. When queried about the lack of skin assessments for Resident #606 between 4/13/17 and 4/30/17, the DON reported that skin assessments should be done weekly. The DON was asked for any information that explained when and how Resident #606 acquired the open area to the coccyx and the heel blister and what interventions were in place to prevent the development of pressure ulcers. The DON indicated she would look into it. No additional information was provided prior to the end of the survey. On 7/20/17 at 8:30 A.M., Resident #606's clinical record was further reviewed and revealed the following: There were care plans that addressed the surgical wounds on Residents #606's bilateral lower extremities. However, there were no care plans that addressed the open areas on Resident #606's coccyx or right heel. Norton Plus Pressure Ulcer Scale forms from 4/13/17 through 6/1/17 were reviewed and documented Resident #606 was at moderate risk for development of pressure ulcers on admission (4/13/17), high risk on 4/20/17 and 4/27/17, moderate risk on 5/4/17 and 5/12/17 (after the development of a right heel blister and an open area to the coccyx). Resident #607: On 7/18/17 at approximately 2:30pm the clinical record for Resident #607 was reviewed and revealed the resident had been admitted into the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Per an admission MDS assessment dated [DATE] the resident scored 12 out of 15 on a BIMs assessment, which indicated that the resident was moderately cognitively impaired. Per this MDS assessment, Resident #607 was not noted to have any unhealed pressure ulcers at a stage one or greater. On 7/18/17 at 2:35pm skin assessments for Resident #607 completed for the time period of May 2017 and June 2017 were reviewed and revealed the following: Per a weekly skin assessment dated [DATE], Resident #607 was not noted to have any abnormal areas on the skin. Per a weekly skin assessment dated [DATE], Resident #607 was noted to have a 2.5cm open wound to the coccyx, an incisional wound with staples present to the right hip, and a deep red area approximately 5cm x 3cm to the left buttock. Per a weekly skin assessment dated [DATE], Resident #607 was noted to have a small open area to the coccyx which measured 0.6cm x 0.5cm and a healing incision to the right hip. Per a weekly skin assessment dated [DATE], Resident #607 had been identified as having a 1.5x2cm scabbed area to the left elbow with the surrounding skin intact, an excoriated, red coccyx described as a stage 2 pressure ulcer measuring 2 x 2 x .1cm, and a right heel wound measuring 4cm x 4cm, described as a deep tissue injury (boggy with surrounding skin intact). Per a weekly skin assessment dated [DATE], Resident #607 was noted to have a small, healing pressure sore to the coccyx, a blackened area to the right heel measuring approximately 1cm x 1cm, and a blackened area to the right great toe which measured 0.3cm x 0.3cm. Per a weekly skin assessment dated [DATE], Resident #607 was noted to have a wound to the coccyx which measured 0.4 L x 0.2 W x 0 D with no drainage and a dark tan base, a wound to the right heel which measured 3cm L x 3cmW x 0D with a closed-necrotic base, and an area to the tip of the right great toe which measured 0.9cm L x 1.0cm W x 0D described as dark purple in color with no active drainage. On 7/18/17 at 4:32pm a careplan dated 5/2/17 for Resident #607 was reviewed and revealed the following: The resident has a pressure ulcer related to immobility. Per the goal of the careplan dated 5/3/17 and revised on 5/11/17, it was documented, The resident's Pressure injury to coccyx will progress through the healing process and remain free from infection by/through review date. It was noted that last date when this careplan was revised was on 5/11/17, prior to the resident being assessed as having a right heel wound and a right great toe wound. On 7/20/17 at approximately 1:20pm continued review of the resident's clinical record noted that per a transcribed physician note dated 5/22/17 at 5:06pm, wounds/alterations in skin integrity to the resident's right great toe were not noted. Per a SOC (standard of care) nutrition/hydration note dated 5/26/17 at 9:47am it was documented that the resident had a pressure ulcer to the right great toe, coccyx, and right heel. Review of physician orders [REDACTED]. On 7/19/17 at approximately 12:20pm the facililty's DON was queried in regards to the development of a wound to Resident #607's toe, and was unable to provide an explanation pertaining to the cause of the wound. Resident #609: On 7/18/17 at approximately 12:40pm the clinical record for Resident #609 was reviewed and revealed the resident had been admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the resident's admission MDS assessment dated [DATE], Resident #609 was rarely to never understood, and was noted to have no unhealed pressure ulcers, no diabetic ulcers, and no open [MEDICAL CONDITION] of the foot. Per this assessment, Resident #609 was noted to have open [MEDICAL CONDITION] other than ulcers, rashes, or cuts. On 7/18/17 at 12:44pm and 12:53pm, Resident #609's Admission Nursing Evaluation Data dated 6/12/17 and a skin assessment dated [DATE] were reviewed and revealed the following: Per Resident #609's Nursing Evaluation Data, Resident #609 was noted to have redness to the coccyx, groin, and to the back of the resident's left hand. No other areas of the skin had been identified as having wounds or skin abnormalities. A skin assessment for Resident #609 dated 6/22/17 was reviewed and revealed the following abnormal areas identified per the skin assessments, which noted the following descriptions: -Left ankle (outer) Stage 2 Pressure Ulcer, 1.5cm L x 1.5cm W x 0 D Dark purple wound base -Right heel fluid filled blister, 3.4cm Lx 4cm w x 0 cm D. Base is dark yellow with shades of dark green. Dark purple edges -Blister: Right lower lateral side of leg. 8.5 cm L x 3 cm W x 0D -Bruising on left upper inner thigh. On 7/18/17 at 2:08pm careplans were reviewed for Resident #609, which revealed, in part, the following: Per a careplan dated 6/14/17, it was documented, The resident has potential impairment to skin integrity r/t fragile skin. This careplan contained the following goal, also dated 6/14/17: The resident will maintain or develop clean and intact skin by the review date (target date 6/30/17). Interventions per the plan of care were dated 6/14/17 and 6/25/17. Per a careplan dated 6/25/17, it was documented, The resident has a stage 2 blister on the right heel and a stage 2 on the left outer ankle r/t Bilateral Lower extremities [MEDICAL CONDITION]. This careplan contained the following goal, also dated 6/25/17: The resident's Pressure ulcer will progress through the healing process and remain free from infection by/through review date (target date 6/30/17). It was noted that all interventions per this plan of care were implemented on 6/25/17, three days after the resident's skin assessment on 6/22/17. On 7/20/17 at 11:22am further review of the clinical record for Resident #609 revealed the resident had been assessed as being at high risk for skin breakdown related to pressure per a pressure ulcer assessment completed on 6/12/17 and on 6/22/17. On 7/20/17 at 1:30pm review of an SOC-LACE (Standard of Care-readmission assessment note) note dated 6/15/17 revealed documentation that Resident #609 had a large fluid filled blister to the right heel. Per a nurses note dated 6/19/17 at 5:04am, it was documented that Resident #609 had a right heel blister with white skin in the center, surrounded by a thin darkened/pink area 4.5cm x 3.5cm. Also noted was a blistered area to the lateral portion of the right lower extremity, which measured 8.5 (cm) x 2.5 (cm) at the widest point. Review of physician orders [REDACTED]. 6/12/17-skin protective cream every 1 hours as needed for as needed for skin redness 6/19/17-Apply skin prep to blister on right heel and side right lower leg. FLOAT HEELS AAT (at all times) AND KEEP TUBING, ETC OFF OF RIGHT LEG, every shift for WOUND CARE. 6/20/17-Pt (patient) to wear (B) Bilateral ankle AFO (braces) while in bed with regular skin checks thoroughly to avoid skin breakthrough, every shift Physician orders [REDACTED]. Also, no orders were observed pertaining to the care and treatment of [REDACTED]. On 7/20/17 the facility's DON was queried in regards to Resident #613's left lateral ankle wound, and stated that she believed the wound may have not been related to pressure. Additional information pertaining to whether the wound had been identified as a non-pressure wound was not provided prior to the exit of the survey. Resident #613: On 7/19/17 at 5:00pm the clinical record for Resident #613 was reviewed and revealed the resident had been admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of Resident #613's quarterly MDS assessment dated [DATE] the resident scored 14 out of 15 on a BIMs assessment, which indicated that the resident was cognitively intact. Also per this assessment dated [DATE] it was noted that the resident had one unstageable pressure ulcer with eschar (dead tissue). It was noted that per Resident #613's initial admission MDS on 12/29/17, the resident did not have any venous or pressure ulcers upon admission into the facility. On 7/20/17 at 9:35am wound care was observed being performed by Nurse 'H' to a wound located on Resident #613's right heel. Resident #613 was observed to be laying in bed, and was observed to have a dressing present to the right heel and part of a roll of gauze wrapped around the resident's right foot. Upon removal of the soiled dressing, Nurse 'H' was queried as to a description of the wound present to the resident's right heel. Nurse 'H described the wound to the resident's heel as having eschar in the middle of the wound bed, and was noted to have some purulent drainage with an odor present. During this observation, the area of eschar tissue was observed to be black in color. When Nurse 'H' was observed to touch the area of eschar on the resident's right heel, Resident #601 said,Ouch ouch .ouch! On 7/20/17 at approximately 9:45am Resident #613 was queried regarding the development of the wound to her right heel. When queried as to whether the resident entered into the facility with the wound or developed the wound while at the facility, Resident #613 responded that the wound had developed after the resident entered the facility. When queried as to whether the resident was in any pain, the resident indicated that her heel hurt. On 7/20/17 at 10:11am further review of Resident #613's clinical record revealed the resident had been assessed as being at moderate risk for skin breakdown related to pressure per a pressure ulcer assessment completed on 5/2/17, and had been reassessed as being at high risk on evaluation per assessments completed on 6/15/17, 6/22/17, 6/29/17, and 7/6/17. It was also noted that between the assessments completed on 5/2/17 and 6/15/17, the resident's risk level for skin breakdown related to pressure had been documented as Not Changed. On 7/20/17 continued review of the clinical record for Resident #613 revealed the following documentation and description of Resident #613's right heel wound per weekly skin assessments dated May 4, 2017 through July 6, 2017: 5/4/17-eschar wound 5/11/17-eschar wound to right heel 5/18/17-unstageable 2.0 x 3.0 cm eschar, skin prep applied 5/25/17-red/mushy 6/1/17-boggy 6/8/17-existing unstageable wound, 2.5 x 2.5, 100% eschar. Surrounding skin pink and blanchable. 6/15/17-existing unstageable wound 2.5 x 2.5, 100% eschar skin prep applied 6/22/17-no abnormal skin areas observed 7/6/17-existing wound 2.0 x 2.2 eschar, surrounding skin red/boggy/blanchable. Per review of documentation completed by the facility's wound care consultant dated 7/6/17, Resident #613's right heel was assessed as an acquired wound related to pressure. Per this documentation the wound to Resident #613's heel measured 2.0 cm (centimeters) L (length) x 2.2 cm W (Width) x UTD (unable to determine), and was noted to be an unstageable wound, have necrotic tissue present, and have a 100% necrotic wound bed. Per this assessment, no odor and no pain was noted to the resident's right heel. Review of a skin assessment dated [DATE] revealed, in part, the following: 7/13/17-existing wound, necrotic center surrounded by pink/blanchable skin. Foul smelling drainage-tx (treatment) and ABT (antibiotics) in progress Review of a physician order [REDACTED]. Review of a careplan for Resident #613 dated 2/2/17 with a revision date of 4/2/17 revealed, The resident has a stable unstageable wound to the right heel related r/t vascular insufficiency. The goal of this careplan (dated 2/2/17 and revised 7/7/17) noted, The resident will be free from infection or complications related to arterial ulcer through review date. Per the interventions noted in the careplan, it was observed that no new interventions had been added to the careplan following the date of 2/2/17. The Director of Nursing (DON) was interviewed on 7/19/17 at 12:05 P.M. regarding the facility's process for preventing, identifying, monitoring, and treating pressure ulcers. The DON reported she began working as the DON on 7/14/17. When asked if there was another staff member to discuss wounds prior to 7/14/17, the DON did not identify another staff member. The DON stated, From March until last week when I started, we noticed problems .As of this morning, everything is up to date. We have been working to get everything up to date this week. The DON reported that the unit manager was responsible for bringing any information about wounds to the SOC meeting (morning meeting). Floor nurses were responsible for completing weekly skin assessments on all residents and would report any abnormalities to the unit manager who would then assess the resident, document their findings in a progress note, determine the appropriate treatment using the facility's wound protocol, and notify family and the physician. When queried about who determined the treatment for [REDACTED]. On 7/19/17 at 3:38pm the facility's Medical Director (MD) 'E' was queried via telephone regarding the process for the identification of wounds. MD 'E' stated that the nurses will inform the doctor about wounds, and also stated that there were standing orders at the facility for wound care. When queried regarding the staging process for discovered wounds, MD 'E' responded that the nursing department was involved in the process, and said that the nursing staff were well versed in staging wounds. When queried as to whether he was aware of multiple residents having newly acquired wounds at the facility, MD 'E' responded that he was aware of patients who had established wounds, and was not aware on interview of multiple new wounds having been acquired at the facility. On 7/20/17 at 2:00pm a facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 3/23/11 was reviewed and revealed, in part, the following: The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of presssure ulcer(s) .3. The Physician and staff will examine the skin of a new admission for ulcerations or indications of a Stage I pressure area that has not yet ulcerated at the surface .4. The physician will help the staff define the type (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of the wound bed, etc.) of an ulceration 1. The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and the application of topical agents .

This citation refers to Intake # MI 513. Based on interview and record review, the facility failed to monitor a surgical incision for one (#604) of eleven residents reviewed for wounds, from a total sample of 14, resulting in an infected wound that required hospitalization , surgical treatment, and intravenous antibiotics. Findings include: On 7/19/17 at 2:42 P.M., Resident #604's clinical record was reviewed and revealed the following: Resident #604 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. An admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #604 required limited physical assistance from one staff member for bed mobility and transfers and did not have any pressure ulcers or surgical wounds. A 5 day MDS assessment dated [DATE] documented Resident #604 had a surgical wound and required extensive physical assistance from two staff members for bed mobility and was totally dependent on two staff members for transfers. A review of Resident #604's progress notes on 7/19/17 at 3:24 P.M. revealed the following: A nurse's note dated 5/19/17 at 2:13 A.M. that documented Resident #604 was readmitted into the facility and had, .intramedullary nailing of left hip (a surgical procedure where a metal rod is used to treat a broken bone) and left [MEDICAL CONDITION] from a fall .incisions open to air . A nurse's note dated 6/6/17 documented, .Sent to hospital for left hip infection. Large amount of bloody purulent (containing pus) drainage noted, area red and swollen . A care plan initiated on 5/19/17 documented, (surgical wound) Impaired skin integrity R/T surgical wound to left hip and thigh. Interventions documented, Medications/Treatments as ordered - see MAR/TAR for specific instructions. Observe efficacy and for adverse effects .Observe for sxs (signs and symptoms) of pain .Observe wound for condition. Observe for redness, [MEDICAL CONDITION] (swelling), drainage. Notify MD PRN (as needed) .Standard precautions . A care plan initiated on 6/13/17 documented, Resident has infection of surgical wound left hip . physician's orders [REDACTED].#604's surgical incision. There were no nurse's notes that documented the surgical site between 5/22/17 and 6/6/17 when it was documented the incision was infected and Resident #604 was transferred to the hospital. On 7/20/17 at 10:45 A.M., the Director of Nursing (DON) was interviewed. The DON indicated that she began working as the DON in the facility on 7/14/17. When asked if there was any other staff that would be able to answer questions pertaining to wounds prior to that date, the DON indicated that the unit managers and former DON no longer worked in the facility and she would be the person to talk to. The DON was queried about the facility's process for a resident admitted with a surgical wound. The DON reported the surgical site would be observed and assessed during the admission assessment and a description of the site would be documented that included measurements and if there were staples or sutures. When queried about how the surgical site was monitored the DON stated, It's standard of care to monitor the surgical site, but it's expected that the nurse documents in the progress notes or skilled daily notes. The DON reported if the surgical site had abnormalities or signs of infection, the physician would be notified. The DON was asked if there would be a physician's orders [REDACTED]. The DON reported that there would be a physician's orders [REDACTED]. At that time, Resident #604's clinical record was reviewed with the DON. The DON confirmed that the only documentation in the progress notes of Resident #604's surgical wound was on 5/19/17 on admission and 5/22/17. The DON indicated that additional documentation of the surgical wound site could be in the Skilled Daily nursing notes, which were requested that that time from 5/19/17 through 6/6/17. All skin assessments since Resident #604's readmitted on 5/18/17 were requested at that time. On 7/20/17 at 12:22 P.M., Transcribed physician progress notes [REDACTED].#604. On 6/13/17, Physician E documented, .He (Resident #604) started developing drainage, significant purulent drainage at the surgical wound site that was noticed by nursing staff .Sent patient immediately to (local hospital) .It was determined that the patient had a superficial wound infection of the left hip secondary to E. coli with recurrent hematoma formation. The patient had irrigation and debridement (a surgical procedure to clean an infected wound to remove any infected and dead tissue) on the left intramedullary nail wound. Incision site with a drain placed with irrigation and debridement and wound reclosure .Will need to continue with (antibiotic) with the PICC (peripherally inserted central catheter) line (a catheter inserted into a vein for use to administer intravenous (IV) medications). physician's orders [REDACTED].M. and revealed an order for [REDACTED]. On 7/20/17 at 1:30 P.M., Skilled Daily nursing notes were provided by the DON and reviewed. On 5/21/17, 5/22/17, 5/23/17, 5/24/17, 5/25/17, 5/26/17, 5/27/17, 5/31/17, 6/1/17, 6/2/17, and 6/3/17 the Skin/Wound section documented that Resident #604 did not have any wounds. The section to comment about any changes in skin integrity was left blank. On 5/30/17, 6/4/17, 6/5/17, and 6/6/17 documented Resident #604 had wounds, but not related to the surgical incisions. There were no skilled daily notes for 5/20/17, 5/28/17, and 5/29/17. Skin Assessments since Resident #604's readmitted on 5/18/17 were reviewed and revealed the following: A Nursing Admission assessment dated [DATE] documented that Resident #604 had three surgical incisions on the front of the left thigh that measured 1.0 centimeters (cm), 2.0 cm, and 3.5 cm. A Skin assessment dated [DATE] did not document the surgical incisions on the thigh. The form asked, Are there any abnormal skin areas? .Describe all abnormal skin areas. Include length, width, and depth of each area and stage of each pressure area. A Skin assessment dated [DATE] did not document the surgical incisions on the thigh. The next skin assessment was completed on 7/19/17 (48 days later). There were no skin assessments between 6/1/17 and 6/6/17 when Resident #604 went out to the hospital for an infected left hip. The DON was asked if there was any further documentation to indicate monitoring of Resident #604's surgical incisions of the thigh. The DON reported that the only documentation she could find is what was provided. A policy regarding assessment, monitoring, and treatment of [REDACTED]. A policy was not provided prior to the end of the survey.

This Citation Pertains To Intake # MI 322 Based on interview and record review, the facility failed to follow a physician's order and appropriately transfer one sampled resident (#902) of one resident reviewed for improper transfer out of a total of 3 sampled residents, resulting in the resident requiring emergency hospitalization , actual injury, pain and distress. Findings include: A review of Resident #902's clinical record was conducted on 4/6/17 at 11:20 AM. Resident #902 was initially admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #902 was alert and orientated times 2-3. Resident #902 required 2 person assist with mechanical lift for transfers. A telephone interview was conducted with certified nursing assistant (CNA) 'A' on 4/6/17 at 2:30 PM. CNA 'A' indicated that on 3/27/17 she was assigned to Resident #902. CNA 'A' stated: When I got my report from another CNA, I was informed that physical therapy was doing a slide board transfer. I got my male co-worker (referring to CNA 'B') to help me transfer. I stood behind her while she was in the wheelchair and CNA 'B' was in front of Resident #902 and lifted Resident #902 to do the pivot transfer. When CNA 'B' was getting her on the bed, Resident #902 screamed ouch. CNA 'A' indicated that that the resident was laid on the bed and when the boot worn on the right ankle/leg area was removed, blood was observed on the resident's leg. CNA 'A' indicated that she had not checked Resident #902's care plan and kardex (a card-filing system that allows quick reference to the particular needs of each patient for certain aspects of nursing care) prior to the transfer which indicated that the resident was a two person assist with mechanical lift for transfers. An interview was conducted with CNA 'B' on 4/6/17 at 3:15 PM. When queried regarding transfer technique used for Resident #902, CNA 'B' stated: CNA 'A' asked me to come help her transfer Resident #902. Resident #902 was sitting in wheelchair and I didn't see any mechanical lift, so we moved her close to the bed in wheelchair then I took her under her armpits and CNA 'A' grabbed Resident #902's pants from behind. It was a quarter turn from wheelchair to bed. CNA 'B' indicated that the resident started crying. CNA 'B' stated: We laid Resident #902 on the bed. Resident #902 had a boot on the right leg and when I opened the boot, I saw that Resident #902 was bleeding and the scar opened. I think it was an old scar, so we called the nurse. When further queried regarding if Resident #902's care plan had been checked prior to transfer, CNA 'B' responded: No. I just wanted to help out and go to my unit. A review of Resident #902's care plan date initiated: 3/20/17 was conducted on 4/6/17 at 3:30 PM. Resident #902's care plan documented: Transfer: The resident requires a Hoyer lift (a type of mechanical lift that is used to transport people with mobility impairments) with 2 staff to move between surfaces, bed, and wheelchair and as necessary. A review of Resident #902's hospital report for EXAM: Xray, right tibia and fibula dated 3/27/17 was conducted on 4/6/17 at 3:45 PM. The Xray of the right tibia and fibula documented: Findings: There is a new [MEDICATION NAME] nondisplaced [MEDICAL CONDITION] malleolus (inside part of the tibia/ankle fracture). An interview was conducted with the Administrator and Director of Nursing (DON) on 4/6/17 at 4:30 PM. When queried regarding Resident #902's injury sustained from transfer by 2 CNAs on 3/27/17, the DON indicated that Resident #902's transfer orders are entered into the care plan and triggered to the kardex. The Administrator stated: They (referring to CNA 'A' and 'B') did not verify the care plan. The Administrator further explained that physical therapy had worked with Resident #902 one time with the slide board to determine if the resident was ready. The Administrator further stated: The care plan still said Hoyer lift and they should have verified by checking the care plan and nurse. A review of the facility's policy and procedure titled Safe Lifting and Movement of Residents Revised 4/2015 was performed on 4/6/17 at 4:45 PM. The facility's policy and procedure titled Safe Lifting and Movement of Residents documented: Each resident is assessed through the Resident Assessment Instrument (RAI) and interdisciplinary team to determine lifting and movement assistance needs. At times, it is necessary to include the use of mechanical lifts to protect the safety and well-being of staff and residents, and to promote quality care. #10- Resident transferring and lifting needs shall be documented in the care plan.

Based on observation, interview, and record review, the facility failed to assess and provide adequate supervision for one Resident (#608) at risk for falls out of 13 residents reviewed for falls from a total sample of 19, resulting in a head laceration, bleeding, and emergency hospital treatment for [REDACTED]. Findings include: On 10/19/15 at 9:10 a.m., during an initial tour of the Facility, Resident #608 was lying in bed. When queried about life in the Facility, Resident #608 stated, things are generally okay. I came her because I fell and broke my pelvis. The other night I fell in the bathroom and hit my head, there was blood everywhere. I had to go to the hospital. I got six staples in my head. It is very uncomfortable and it hurts. When further queried as to what happened that night, Resident #608 stated, it happened about 3:00 a.m., the aide left me on the toilet and told me she would be right back. I pulled the call light for her to come back. I waited a long time and she still did not come. I was very tired and it was so late at night. She said she would be back and I just wanted to get back to bed so I stood up to go back to bed and fell . I kept yelling for help. Finally she came back. Approximately six staples were observed on the center/right portion of the back of the head. On 10/19/15 at 2:30 p.m., Resident #608's clinical record was reviewed and revealed the following: Resident #608 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted that the resident had a Brief Interview for Mental Status (BIMS) score of 12 (moderately impaired) and required extensive one person assist with for toileting. There was no Fall/Safety care plan found in the clinical record prior to the fall on 10/18/15. On 10/20/15 at 9:30 a.m., a review of the Resident's clinical record and the incident/accident (I/A) report dated 10/18/15 revealed, in part, the following: CENA (certified nursing assistant) stated she assisted Lodger to the bathroom, Lodger was sitting on the toilet, lodger said she was fine. CENA left to get something. Suddenly she heard a noise, she quickly ran to the bathroom, saw blood on lodgers head, pajamas and bathroom floor. Lodger was sitting upright. CENA quickly called for help. Nurse on 500 hall and writer quickly ran to lodger's room, found lodger sitting upright, assessment was done, writer called 911. EMS (emergency medical system) came at 3:20 a.m., lodger was transported to hospital. Further review of the I/A report revealed a copy of the Facility call light log record for 10/18/15 that indicated the following: 10/18/15: 2:57 a.m., (Response time column)- 7:15 (seven minutes/fifteen seconds) On 10/20/15 at 4:10 p.m., an interview was conducted with CNA I regarding the incident that occurred on 10/18/15. CNA I stated, I do remember that night. I worked a double that night. I usually work the afternoon shift on the 500 unit. That night I was asked if I would work the midnight shift on the 100 unit. I started at 11:30 p.m., after the shift change. I remember that around 3:00 a.m., Resident #608 pulled her call light because she had to go to the bathroom. I had never worked with her before so I asked her if she could walk to the bathroom. She said she could walk, so I used my gait belt and took her to the bathroom. I think she did have a walker in her room, but I don't remember using it. Once she was on the toilet, she asked for some privacy. I left the the Resident's room to go talk to CNA N because I know she works on that floor and I wanted to get some information about the Resident. CNA N was in the staff bathroom and I remember talking to her through the bathroom door about whether or not the Resident could walk back to the bedroom on her own. I remember CNA N told me that she usually uses a walker. At some point I heard her calling for help, so I ran back to the room and she was on the floor. There was a lot of blood on the floor and I ran to the 500 unit hall to get some help. CNA I was further asked whether she was aware that call light response time log indicated a seven minute and fifteen seconds response time. CNA I stated, I didn't think it took me that long to get back to her room, but if that's what the records say, that's what it is. Records don't lie. CNA I was then asked why she did not receive information about the Resident's fall risk and care assistance prior to working with her. CNA I stated, Usually I would get the low-down from the staff on the prior shift, but that night I was moved over to the unit at 11:30 p.m., so the afternoon shift was gone. When asked if she could receive information about the Resident in another way, CNA I stated, well, we can look at the electronic record and the care plan, however, that night I just thought I could get the information from CNA N. On 10/21/15 at 8:51 a.m., a record review and interview was conducted with Assistant Director of Nursing (ADON) J regarding the incident that occurred on 10/18/15 as well as the Resident's care plan. ADON J stated, CNA's are supposed to check the Resident's care plan at the beginning of a shift to see what they are supposed to do with respect to care. Resident #608's care plan does not specify that she can't be left alone on the toilet, however it does state that she needs extensive assist for transferring to and from the toilet and with walking. For instance, I helped her to the bathroom today and I waited outside the door until she was done. ADON J was further queried as to whether Resident #608 had a fall care plan in place at the time of the incident. ADON J stated that Resident #608 did NOT (emphasis added) have a Fall Safety Plan in place at the time of the incident, despite the fact that she was admitted to the facility for rehabilitation following a fall with a fracture. When asked why, ADON J stated, we only do a (fall/safety) care plan when the Resident's Fall Risk Assessment score is 10 or higher. ADON 'J was asked to review the Facility's Fall-Risk assessment dated [DATE]. The Assessment score was six 6, however portion (E) titled Gait/Balance and included 7 questions, as indicated below, was left blank. · Gait/Balance Normal · Balance problem while standing · Balance problem while walking · Decreased muscular coordination · Change in gait patter when walking through doorway · Jerking or unstable when making turns · Requires use of assistive devices ADON J was asked why portion E was left blank. ADON J stated, I don't know why it was left blank. ADON J was further asked if that portion had been completed, would it be possible that the Resident's score would have scored 10 or higher. ADON J stated, yes, maybe. I'm not sure why that section was not completed. I do know sometimes the indication that a Resident should not be left alone on the toilet is often done by physical therapists, you can talk with them. On 10/21/15 at 9:35 a.m., an interview and record review was conducted with Physical Therapist Manager (PTM) K regarding the Fall Assessment, specifically, Portion E- Gait Balance. PTM K stated at the time of assessment, I would have scored that section a 6 thus making total of 12. A review of the PT (physical therapy) Evaluation and Plan of Treatment dated 9/26/15 revealed, in part, the following: Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for falls. On 10/21/15 at 12:00 p.m., Resident #608's accident was discussed with the Director of Nursing. The DON agreed that the Resident's fall risk was not fully assessed and that if CNA I had reviewed the Resident's record before performing care instead of leaving the resident and trying to get information from CNA N, the incident may have been prevented. On 10/21/15 at 3:00 p.m., the Facility's Falls-Clinical Protocol (revised February 2013) was reviewed and revealed, in part, the following: Assessment and Recognition: As part of an initial and ongoing resident assessment, the staff will help identify individuals with a history of falls and risk factors for subsequent falling. This will be accomplished by the following task: b. The falls section (fall risk evaluation) is inclusive of: ii. History of falls: cognitive status/behavioral symptoms, visual status, continence, mobility, balance, and medications. Staff will ask the resident and the caregiver or family about a history of falling. IPOC/Comprehensive Care Plan: 1. Based on the assessment an initial plan of care (IPOC) will be developed and implemented to address identified risks. This will be revised as necessary. 3. Goals of the plan of care may include the interdisciplinary team, physican, resident and responsible party when necessary. a. Goals may include, but not limited to reduction of falls, minimize injury from falls, and/or prevent falls while maintaining and/or improving resident abilities and quality of life. 4. Interventions should be developed and implemented per the assessed needs. 5. In addition, interventions for direct care givers should be placed on the CNA care card or similar format. 6. The care plan and CNA care card should be updated as interventions change. ( )

Based on interview and record review, the facility failed to implement appropriate safety measures to prevent falls/accidents for one (#611) of nine sampled residents reviewed for falls, out of a total sample of 15, resulting in injury requiring surgical (left hip fracture) and the potential for additional falls. Findings include: Clinical record review on 12/12/13 at 9:15 am revealed Resident #611 was readmitted on [DATE], from the hospital with history of Right Hemiarthroplasty on 11/21/2013 and Left Hemiarthroplasty on 12/07/13. Resident #611 also had a [DIAGNOSES REDACTED].#611 was assessed as having a Brief Interview for Mental Status) score of 9/15 indicating impaired cognition, required extensive 2 person assistance for activities of daily living including bed mobility, transfer, and toilet use. Resident #611 was frequently incontinent of bowel and bladder. According to the facility's incident/accident reports, reviewed on 12/12/13 at 10:00 am, Resident #611 had fallen twice prior to the Left Hemiarthroplasty procedure on 12/07/13. According to Fall Incident Report #1 dated 11/26/13 at 7:00 pm, "(Resident #611) rolled out of bed on the floor on his left side. S/P (status [REDACTED]." According to Fall Incident Report #1, there were no witnesses to this fall. According to Fall Incident Report #2, dated 11/28/13 8:55 am, Resident #611 was found by Certified Nurse Aide (CNA) "D", lying on the floor. Again, there was no witness to this fall. An interview was conducted with CNA "D" on 12/12/13 at 11:30 am. CNA "D" stated that on 11/28/13, he was supposed to sit and watch Resident #611 from outside the room, keeping visible contact with Resident #611 to maintain safety and prevent him from getting out of bed unassisted. CNA "D" stated that he (CNA "D") left to respond to a call light in another room. CNA "D" explained that he was gone for only 2 or 3 minutes, but when he came back, Resident #611 was already on the floor. According to CNA "D", "He (Resident #611) complained of pain on the left side." CNA "D" admitted that he was not supposed to leave until relieved by another staff member. When Unit Manager "B" was interviewed on 12/12/13 at 1:45 pm, she stated that Resident #611 "was confused and disoriented due to dementia and prescribed narcotics from recent surgery. My (Unit Manager "B") instructions to the staff was to have 1 person sit on the chair in the hallway just outside his room, keeping him visible for staff to monitor his movements and attempts of unassisted and unsafe transfers." According to Unit Manager "B", the care plan for Resident #611 reflected this instruction effective as of 11/27/13, after Resident #611's first fall on 11/26/13. Resident #611 was to have a staff to visibly monitor him 24/7 and the designated staff member was not to leave the chair without anyone else relieving him/her. Unit Manager "B" went on to day that CNA "D" had left to answer a call light and found Resident #611 on the floor on 11/28/13. Resident #611 complained of left hip pain which was the opposite of the most recent right hip repair. According to Unit Manager "B", the staff failed to follow the care plan to monitor Resident #611 by visual contact. It was not until 12/5/13, that x-ray verified a fracture of the left hip. When CNA "C" was interviewed on 12/12/13 at 2:00 pm, she stated that on 11/28/13, Thanksgiving Day, she was the CNA assigned to Resident #611. Resident #611 was confused and was a high fall risk. Resident #611 did not use his call light. CNA "C" recalled that she asked CNA "D" to watch Resident #611 so she would be able to give another resident a shower. Staff was told that Resident #611 was to be in "constant watch" and that staff should watch him from outside his room and not leave until a replacement came. During an interview with Physical Therapist (PT) "E" on 12/12/13 at 12:00 pm, Physical Therapist "E" stated that Resident #611 was extremely confused and not oriented to time, place and person. Resident #611 had very poor safety awareness. Resident #611 had previous right hip surgery with pain on the right hip. However, after the Thanksgiving weekend, Resident #611 was observed to be in extreme pain but on the left side (which was the unaffected hip) and was unable to move his left extremity at all. According to PT "E", when she asked the staff, she was told that Resident #611 fell during Thanksgiving Day. A repeat x-ray was requested on 12/05/13 and it did clarify a fracture found on the x-ray dated 11/29/13. According to the Administrator on 12/12/13 at 1:30 pm, the x-ray taken after the fall on 11/28/13, showed no fracture. However, the repeat x-ray done on 12/5/13, clarified that the x-ray from 11/29/13 was misread and noted a fracture from the 11/29/13 X-ray film. The administrator denied reporting the incident to the State. According to the Radiology (X-ray) Report dated 12/5/2013, specified in the ADDENDUM: "11/29/13, (Pertaining to Left Hip, Femur) Image reveals a lucent line across the proximal head of left femur which is obscure by greater trochanter. Appears undisplaced. Suspicious in nature." However, according to the 12/5/13 X-ray Report, "There is evidence of an impacted, slightly angulated and slightly displaced fracture in the subcapital region of the neck of the proximal femur, appearing to be recent." ( )

THIS CITATION PERTAINS TO INTAKE NUMBER #MI 623 BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION, ASSESSMENTS AND INTERVENTIONS TO PROTECT ONE (#501) OF THREE SAMPLED RESIDENTS WITH SAFETY RISKS FROM A TOTAL SAMPLE OF FOUR RESIDENTS, FROM ACCIDENTS, RESULTING IN hospitalization WITH AN ACUTE RIGHT IMPACTED FEMORAL NECK FRACTURE. FINDINGS INCLUDE: RESIDENT #501 DID NOT RESIDE IN THE FACILITY AT THE TIME OF THE INVESTIGATION. REVIEW OF HOSPITAL EMERGENCY TREATMENT NOTE REVEALED THAT ON 09/07/2012, RESIDENT #501'S "X-RAY OF HER RIGHT HIP AND PELVIS...SHOWS AN ACUTE RIGHT IMPACTED FEMORAL NECK FRACTURE. AT THIS POINT PATIENT APPEARS TO HAVE ANOTHER HIP FRACTURE..." REVIEW OF THE CLINICAL RECORD AND THE MINIMUM DATA SET (MDS) assessment dated [DATE] REVEALED THAT RESIDENT #501 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT WAS CODED AS HAVING MODERATELY IMPAIRED COGNITION AND REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS AND ACTIVITIES OF DAILY LIVING. ON 09/19/2012 AT 4:30 P.M., AN INTERVIEW WAS CONDUCTED WITH THE FACILITY SOCIAL WORKER (SW) #5 WHO DESCRIBED THE RESIDENT'S MENTAL STATUS AND LEVEL OF CONSCIOUSNESS AS "DISCONNECTED, IT WAS LIKE SHE WAS IN A CLOUD. SHE WAS INTERMITTENTLY CONFUSED. SHE DID NOT SPEAK FOR HERSELF, LOOKED TO HER HUSBAND TO SPEAK FOR HER." ACCORDING TO THE HISTORY AND PHYSICAL (SEEN ON 08/07/12, COMPLETED ON 08/10/12) RESIDENT #501 WAS admitted INTO THE FACILITY BECAUSE SHE "...HAD A MECHANICAL FALL OVER A STEP AND WAS UNABLE TO GET UP. SHE WAS TAKEN TO THE ER (emergency room ) AND NOTED TO HAVE CLOSED LEFT HIP FRACTURE..." REVIEW OF THE FALL RISK assessment dated [DATE] REVEALED A TOTAL SCORE OF 4, NOT AT RISK FOR FALLS (A TOTAL SCORE OF 10 OR GREATER WAS CONSIDERED HIGH RISK FOR POTENTIAL FALLS). HOWEVER, FURTHER REVIEW OF THE FALL RISK ASSESSMENT REVEALED THAT THE ASSESSMENT WAS INACCURATELY COMPLETED. THE ASSESSOR DOCUMENTED THAT RESIDENT #501'S LEVEL OF CONSCIOUSNESS WAS ALERT AND ORIENTED TIMES THREE. HOWEVER, SW #5 ASSESSED RESIDENT #501 AS BEING INTERMITTENTLY CONFUSED. HER AMBULATION STATUS WAS ASSESSED AS AMBULATORY. HOWEVER, ON ADMISSION THE RESIDENT WAS status [REDACTED]. IN ADDITION THE RESIDENT WAS ASSESSED AS NOT HAVING TAKEN ANTI-HYPERTENSIVE MEDICATION AND NARCOTICS IN THE PREVIOUS 7 DAYS, WHEN IN FACT REVIEW OF PHYSICIAN ORDERS [REDACTED]. IF THE ASSESSOR HAD TAKEN THESE FACTORS INTO CONSIDERATION, RESIDENT #501 WOULD HAVE RECEIVED A SCORE OF 12 ON HER FALL RISK ASSESSMENT. ALL INCIDENT REPORTS FOR RESIDENT #501WERE REQUESTED FROM THE FACILITY ON 09/19/2012. REVIEW OF PROGRESS NOTES REVEALED THE FOLLOWING: SOCIAL WORKER NOTE, ON 8/15/12 AT 4:34 P.M., DOCUMENTED "...RESIDENT WAS hospitalized for [REDACTED]. HUSBAND REPORTED THAT RESIDENT WAS SEEING CHILDREN IN THE ROOM WHEN THERE WERE NO CHILDREN PRESENT. HE STATES THAT THIS BEHAVIOR IS NEW. THE HOSPITAL ALSO IDENTIFIED SOME SIMILAR BEHAVIORS PRESENT...HUSBAND IS CONCERNED WITH SAFETY PRECAUTIONS..." ON 08/24/12, NURSING DOCUMENTED "DX LEFT HIP ORIF. LODGER IS CONFUSED. MAXIMUM 2 PERSON ASSIST..." ON 08/25/12, NURSING DOCUMENTED "8/24: DURING THERAPIES THIS DAY, RESIDENT REPORTED TO HAVE INCREASED PAIN AND UNABLE TO AMBULATE AS MUCH AS USUAL. LEFT HIP, LEFT KNEE X-RAYS ORDERED. RESULTS SHOW NO EVIDENCE OF FRACTURE." ON 08/27/2012, NURSING DOCUMENTED "...RESIDENT IS A TWO MAX ASSIST FOR AMBULATION..." ON 08/29/2012, DOCUMENTED BY THE INTERDISCIPLINARY CARE TEAM, "CARE CONFERENCE HELD WITH RESIDENT, FAMILY MEMBERS...PHYSICAL THERAPY STATED...25 - 50% ASSISTANCE (WITH MOBILITY) AT PRESENT...BALANCE REMAINS AN AREA OF CONCERN-SAFETY..." 08/31/2012, NURSING DOCUMENTED, "...AT 11 A.M., RESIDENT WAS OUT OF HER WHEELCHAIR AND STANDING BY HERSELF, HOLDING ON TO THE BEDSIDE TABLE...RESIDENT STATED, "I HAVE TO USE THE RESTROOM..." 09/02/2012, NURSING DOCUMENTED, "LODGER FOUND ON FLOOR BY BED BY CNA (CERTIFIED NURSING ASSISTANT) AT 2140 THIS EVENING. SHE STATED, I HAD TO GO TO THE BATHROOM. I JUST ROLLED OUT. WHEN ASKED IF SHE HIT HER HEAD SHE STATED YES...PATIENT HAS HISTORY OF FALLS AND CONFUSION..." REVIEW OF INCIDENT REPORTS REVEALED THAT NO INCIDENT REPORT PROVIDED BY THE FACILITY FOR THIS FALL. ON 09/04/ , AT 9:05P.M., NURSING DOCUMENTED "RESIDENT FOUND AT HER DOORWAY LOOKING FOR THE BATHROOM. WAS TAKEN TO THE TOILET AS REQUESTED..." ON 09/05/2012, AT 9:17 A.M., NURSING DOCUMENTED "RESIDENT AWAKE AT 11 P.M., SITTING NEAR FIREPLACE. UP BEING WATCHED BY STAFF UNTIL 2:30 A.M. ATTEMPTING TO STAND ON OWN NUMEROUS TIMES...RESIDENT WOULD OFFER $5 OR $20 BY GESTURING IN EFFORT TO HAVE STAFF 'TAKE ME HOME'...AT 6:20 A.M. STAFF FOUND RESIDENT WALKING IN ROOM WITH BRIEF OFF. ASKED STAFF NUMEROUS TIMES TO TAKE HER HOME." 09/05/12 AT 12:05 P.M., NURSING DOCUMENTED "...RESIDENT IS A TWO PERSON PIVOT TRANSFER ...CONFUSED AT TIMES AND IMPULSIVE. RESIDENT IS A 1:1 FOR SAFETY." ON 09/06/2012, AT 12:42 P.M., NURSING DOCUMENTED "...RESIDENT WITH 1 ON 1 CAREGIVER. CAREGIVER REPORTS THAT RESIDENT TRYING TO GET OUT OF BED MULTIPLE TIMES..." ON 09/06/2012, AT 10:58 P.M., NURSING DOCUMENTED "...RESIDENT IS A 2 PERSON ASSIST FOR AMBULATION." ON 09/07/2012 8:44 A.M., NURSING DOCUMENTED "RESIDENT WENT TO SLEEP AT 3 A.M. AWOKE AT 6:30 A.M. WHILE AWAKE, RESIDENT WATCHED BY STAFF ON 1:1 BASIS." 09/07/2012 AT 12:51 P.M., NURSING DOCUMENTED "...RESIDENT IS A 1:1 FOR SAFETY." 09/08/2012, NURSING DOCUMENTED "9/7 AT 2140 KNOCKING HEARD COMING FROM ROOM 202. RESIDENT FOUND ON BATHROOM FLOOR, LYING ON LEFT SIDE, COMPLAINED OF PAIN IN RIGHT HIP AND RIGHT ELBOW. RESIDENT STATED SHE HAD FALLEN ON RIGHT SIDE BUT DID NOT KNOW HOW SHE GOT ON HER LEFT SIDE. RIGHT HIP AREA BEGINNING TO BRUISE. RIGHT ELBOW WITH LARGE HEMATOMA. RESIDENT RELUCTANT TO MOVE HER ELBOW, WOULD NOT MOVE HER HIP. RESIDENT ROLL ONTO A FOLDED BLANKET AND WAS TRANSFERRED TO BED WITH FOUR ASSIST...TRANSPORTED TO HOSPITAL..." IT WAS UNCLEAR HOW RESIDENT #501 WALKED TO THE BATHROOM UNATTENDED WHEN SHE WAS TO BE SUPERVISED "ONE TO ONE" FOR SAFETY. ACCORDING TO THE "SAFETY" CARE PLAN FOR RESIDENT #501 DATED 08/07/2012, RESIDENT #501 HAD THE FOLLOWING INTERVENTIONS IN PLACE: IMPLEMENT SAFETY EQUIPMENT AS NEEDED, ASSESS FOR NEED FOR SAFETY EQUIPMENT, BED IN LOWEST POSITION, PLACE IN HIGHER VISIBILITY AREAS, REFER TO THERAPY AS NEEDED, ASSESS TOILETING PATTERNS, COMPLETE SAFETY AWARENESS/PROBLEM SOLVING TASKS WITH THERAPY. AN INTERVIEW WAS CONDUCTED WITH NURSE #9 ON 09/19/2012 AT 5:45 P.M. NURSE #9 EXPLAINED THAT SHE WAS THE NURSE ASSIGNED TO CARE FOR RESIDENT #501 ON THE DAY OF HER INJURY. NURSE #9 EXPLAINED THAT SHE FOUND THE RESIDENT ON THE BATHROOM FLOOR ON 09/07/2012, AND ALTHOUGH THE FALL WAS NOT WITNESSED, THE RESIDENT WAS ABLE TO TELL HER (#9) THAT SHE HAD FALLEN. THE NURSE FURTHER STATED, "THE FACILITY DID NOT USE ALARMS SO STAFF ARE NOT ALERTED BEFORE RESIDENTS ATTEMPT TO TRANSFER OR AMBULATE." THE NURSE DID NOT EXPLAIN WHY THE 1:1 SUPERVISING STAFF MEMBER WAS NOT PRESENT IN THE ROOM WITH THE RESIDENT TO ASSIST THE RESIDENT OUT OF BED AND PREVENT THE FALL. ON 09/09/2012 AN INTERVIEW WAS CONDUCTED WITH CNA #2 WHO EXPLAINED THAT "THE RESIDENT HAD THE TENDENCY TO GET UP AND DOWN OFTEN AT NIGHT." ON 09/19/2012 AT 4:50 P.M., INTERVIEWS WERE CONDUCTED WITH TWO STAFF MEMBERS WHO WISHED TO REMAIN ANONYMOUS. ACCORDING TO THESE TWO ANONYMOUS STAFF MEMBERS, AT NIGHT, NURSING STAFF HAVE ASSIGNMENTS ON MORE THAN ONE HALLWAY. THE HALLWAYS ARE LONG AND IT TAKES TIME TO GET FROM ONE HALLWAY TO THE NEXT. THE FACILITY WAS NOT USING ALARMS OF ANY KIND TO ALERT STAFF WHEN LODGERS (RESIDENTS) ATTEMPT TO AMBULATE WITHOUT ASSISTANCE. ACCORDING TO ONE OF THE ANONYMOUS STAFF MEMBERS, "IT IS DIFFICULT TO MAKE SURE EVERYBODY IS SAFE BECAUSE STAFFING IS LIMITED AND STAFF ARE GOING AROUND CORNERS TO ATTEND TO LODGERS ON ONE HALL, AND LODGERS WHO RESIDE ON THE OTHER HALL ARE NOT SUPERVISED. SAFETY OF THE LODGERS IS IMPORTANT TO ME AND WE DON'T HAVE ALARMS, THIS IS A CONCERN TO ME." AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSES (DON) #8 ON 09/19/2012 AT 5:15 P.M. DON #8 WAS QUERIED ABOUT SAFETY INTERVENTIONS THAT WERE IN PLACE FOR RESIDENT #501. DON #8 STATED, "SHE HAD A LOW BED, AND WAS ROUNDED ON. WE DON'T DO ALARMS OR SEAT BELTS HERE. THAT'S OUR PHILOSOPHY." ACCORDING TO THE FACILITY "SAFETY PROGRAM" DATED 02/09, "...THE INTERDISCIPLINARY TEAM WILL MONITOR, EVALUATE AND DETERMINE APPROPRIATE APPROACHES TO ENSURE RESIDENT SAFETY NEEDS ARE IDENTIFIED AND ADDRESSED." ( )

THIS CITATION PERTAINS TO INTAKE #MI 157 BASED ON INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO IMPLEMENT INTERVENTIONS TO ADDRESS FALLS FOR ONE OF SIX (#106) SAMPLED RESIDENTS, 4 OF WHICH WERE REVIEWED FOR FALLS, RESULTING IN THREE DOCUMENTED FALLS FOR RESIDENT #106 IN WHICH HE SUSTAINED MULTIPLE CONTUSIONS TO HIS LEFT HAND AND LEFT ARM, A LACERATION TO HIS LEFT ELBOW, A LARGE LACERATION TO THE BACK OF HIS HEAD, A CONTUSION TO HIS FOREHEAD AND A BRAIN BLEED WITH THE POTENTIAL FOR FUTURE ACCIDENTS WITH INJURY. FINDINGS INCLUDE: RESIDENT #106 ACCORDING TO THE FACE SHEET DATED 6/15/2011, RESIDENT #106 LIVED AT THE FACILITY SINCE 4/19/2011. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE Minimum Data Set, dated dated dated ,[DATE], RESIDENT #106 REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE ASSISTANCE WITH ALL TRANSFERS, AMBULATION AND TOILETING. RESIDENT #106 COULD NOT BALANCE WITHOUT PHYSICAL HELP FROM STAFF. ON 4/29/2011 NURSING DOCUMENTED THAT RESIDENT #106 HAD "SIGNS AND SYMPTOMS THAT ...INCREASE (D)" HIS "RISK FOR FALLS." STAFF ASSESSED RESIDENT #106 AND FOUND THAT HIS "KNEES ....BUCKLE (D)" UPON STANDING AND HE WAS "WEAK." ON 4/29/2011 A PHYSICIAN SPECIALIZING IN PHYSICAL REHABILITATION ASSESSED RESIDENT #106. THE PHYSICIAN diagnosed RESIDENT #106 WITH "DIFFICULTY WALKING" AND REQUIRED THE RESIDENT TO COMPLETE COMPREHENSIVE PHYSICAL AND OCCUPATIONAL THERAPY PROGRAMS. THE PHYSICIAN DOCUMENTED RESIDENT #106 NEEDED IMPROVEMENTS IN ALL TRANSFERS, AMBULATION, DRESSING BATHING AND HOME MANAGEMENT SKILLS. PHYSICAL THERAPY ASSESSED RESIDENT #106 ON 4/28/2011 AND IDENTIFIED HIM AS A "FALL RISK." ACCORDING TO THIS ASSESSMENT, RESIDENT #106 REQUIRED MINIMALLY ONE STAFF MEMBER TO ASSIST WITH ALL TRANSFERS, AMBULATION AND BED MOBILITY. OCCUPATIONAL THERAPY ASSESSED RESIDENT #107 ON 4/29/2011 AND REQUIRED MINIMALLY ONE STAFF MEMBER TO BE PRESENT AND PROVIDE ASSISTANCE WITH HIS HYGIENE, DRESSING AND TOILETING NEEDS. DESPITE THESE ASSESSMENTS STAFF FAILED TO IMPLEMENT A CARE PLAN TO MINIMIZE THE RESIDENTS RISK FOR ACCIDENTS AND/OR INJURY. ACCORDING TO NURSING NOTES BETWEEN 5/04/2011 AND 6/03/2011, RESIDENT #106 REQUIRED MINIMALLY ONE STAFF MEMBER TO PROVIDE PHYSICAL ASSISTANCE WITH AMBULATION, TRANSFERS AND ALL OTHER ACTIVITIES OF DAILY LIVING. ACCORDING TO NURSING NOTES DATED 5/01/2011 AT APPROPRIATELY 3:30 P.M., THE FACILITY FAILED TO PROVIDE ASSISTANCE FOR RESIDENT #106 WHEN THE RESIDENT fell NEXT TO HIS BED DURING A SELF-TRANSFER/AMBULATION ATTEMPT. NURSING DOCUMENTED RESIDENT #106 WAS CONFUSED AND DEVELOPED AN ABRASION TO HIS "LEFT/POSTERIOR" HEAD, THAT MEASURED 5 CM (CENTIMETERS) BY 3 CM AND A REDDENED AREA TO HIS RIGHT SHOULDER THAT MEASURED 9 CM BY 0.2 CM. ON 5/23/2011 AT 12:43 P.M., RESIDENT #106 WAS DESCRIBED IN NURSING NOTES AS A "PLEASANT PATIENT, FORGETFUL AT TIMES (AND REQUIRED) FREQUENT CALL LIGHT REMINDERS." ON 6/17/2011 AT 1:30 P.M., A CERTIFIED NURSING ASSISTANT IDENTIFIED AS EMPLOYEE "G" SAID, RESIDENT #106 "OFTEN TRIED TO SELF-TRANSFER ...THREE OR FOUR TIMES PER SHIFT." EMPLOYEE "G" SAID RESIDENT #106 SELF-TRANSFERRED FROM HIS BED AND HIS CHAIR, USUALLY TO THE BATHROOM TO USE HIS TOILET. EMPLOYEE "G" SAID RESIDENT #106 WAS CONFUSED BUT THE ONLY INTERVENTION STAFF IMPLEMENTED WAS CONTINUAL RE-EDUCATION ON THE USE OF HIS CALL LIGHT AND TO WAIT FOR ASSISTANCE. EMPLOYEE "G" SAID RESIDENT #106 FAILED TO RETAIN OR USE THIS INFORMATION AND OFTEN SELF-TRANSFERRED AND SELF-AMBULATED MINUTES LATER. ON 6/17/2011 AT 1:45 P.M., A CERTIFIED NURSING ASSISTANT IDENTIFIED AS EMPLOYEE "H" SAID, RESIDENT #106 OFTEN WAS NOT ABLE TO STAY ON TASK, EVEN WITH REPEATED INSTRUCTIONS. SHE SAID HE DID NOT SIT STILL AND FREQUENTLY SELF-TRANSFERRED TO THE RESTROOM WITHOUT ASSISTANCE. EMPLOYEE "H" SAID RESIDENT #106 WAS CONTINENT OF URINE AND WOULD USE THE RESTROOM INDEPENDENTLY. ON 6/17/2011 AT 2:10 P.M., THE DIRECTOR OF NURSING SAID RESIDENT #106 REQUIRED ASSISTANCE WITH EITHER STAND BY ASSISTANCE OR ONE PERSON TO PHYSICALLY PROVIDE SOME SUPPORT DURING TRANSFERS AND AMBULATION BECAUSE OF HIS UNSTEADY GAIT. SHE SAID, DESPITE THE ASSESSMENTS MADE BY THERAPY AND NURSING STAFF RESIDENT #106 DID NOT REQUIRE A SAFETY CARE PLAN TO PREVENT ACCIDENTS WITH INJURY BEFORE HE fell on [DATE]. THE DIRECTOR OF NURSING SAID THE SAFETY CARE PLAN IMPLEMENTED ON 5/01/2011 INITIATED A "LOW BED AT NIGHT." SHE COULD NOT EXPLAIN HOW THE IMPLEMENTED CARE PLAN IMPROVED THE RESIDENTS SAFETY OR SUPERVISION FOR THE DEMONSTRATED SELF-TRANSFER HE COMPLETED DURING THE DAY. SHE SAID "I KNOW THEY (THE STAFF) DID MORE" BUT SHE DID NOT PROVIDE ANY DOCUMENTED PROOF OR STAFF INTERVIEWS TO SUPPORT HER COMMENT. ACCORDING TO NURSING NOTES DATED 6/03/2011 AT 11:51 P.M., STAFF WERE PRESENT IN THE BATHROOM WHEN RESIDENT #106 fell STRIKING HIS HEAD ON THE FLOOR. RESIDENT #106 WAS SENT TO THE LOCAL HOSPITAL AND FOR A LEFT HAND INJURY, A LACERATED ELBOW AND A LARGE SCALP LACERATION. RESIDENT #106 THEN RETURNED TO THE FACILITY AT 3:06 A.M. BUT NO EVIDENCE COULD BE FOUND IN HIS MEDICAL RECORD TO INDICATE THAT THERE WERE ANY CHANGES IN SUPERVISION OR ASSISTIVE DEVICES TO PREVENT FUTURE ACCIDENTS WITH INJURY. ON 6/17/2011 AT 2:10 P.M., THE DIRECTOR OF NURSING REVIEWED THE MEDICAL RECORD AND SAID RESIDENT #106 CAME BACK FROM THE HOSPITAL AT 3:10 A.M., AND STAFF IMPLEMENTED "NO" CHANGES IN SUPERVISION OR ASSISTIVE DEVICES TO PREVENT FUTURE ACCIDENTS WITH INJURY. THE DIRECTOR OF NURSING THEN SUGGESTED HER STAFF HAD INCREASED THE RESIDENTS SUPERVISION. THERE WAS NO INDICATION IN THE MEDICAL RECORD THAT RESIDENT #106 EVER RECEIVED ADDITIONAL SUPERVISION. THERE WAS NO EVIDENCE RESIDENT #106 RECEIVED ANY SUPERVISION ON 6/04/2011, BETWEEN 6:00 A.M. AND 8:30 A.M. WHEN EMPLOYEE "J" (A REGISTERED NURSE) FOUND RESIDENT #106 "UNCONSCIOUS, LYING ON THE FLOOR" IN HIS BATHROOM. ON 6/14/2011 AT 1:30 P.M., EMPLOYEE "E" A CERTIFIED NURSING ASSISTANT SAID SHE KNEW RESIDENT #106 PUSHED HIS CALL LIGHT TWENTY MINUTES BEFORE HE WAS FOUND ON THE BATHROOM FLOOR. SHE SAID THE CALL LIGHT REMAINED ON, RINGING FROM HER PAGER FOR THE ENTIRE TWENTY MINUTES BEFORE HIS FALL. EMPLOYEE "E" SAID, "WE WERE TOO BUSY" TO ASSIST HIM. ON 6/04/2010 AT 11:15 A.M., RESIDENT #106 HAD COMPLETED A HEAD SCAN AND HIS PHYSICIAN diagnosed HIM WITH A LEFT FRONTAL AND RIGHT POSTERIOR TEMPORAL LOBE CEREBRAL CONTUSION (BRUISING IN THE BRAIN) WITH CORTICAL PETECHIAL HEMORRHAGES AND A SMALL AMOUNT OF SUBARACHNOID BLOOD (BRAIN BLEED). RESIDENT #106 WAS THEN admitted TO THE INTENSIVE CARE UNIT FOR FURTHER TREATMENT AND OBSERVATION.