Every finding on record at Medilodge of Taylor

This citation pertains to intake 3001431.Based on interview and record review the facility failed to ensure the physician was notified when medications were not administered as ordered for one resident (R902) out of three residents reviewed for medication administration, resulting in missed opportunities for physician intervention, alternative treatment considerations and the potential for further spread of the resident's infection.Findings include:Record review of electronic medical record (EMR) of R902 revealed admission into the facility on 3/14/26 and discharged from the facility on 3/15/26, with pertinent diagnoses of chronic osteomyelitis (infection of bone) of the left ankle and foot and Type 2 diabetes mellitus (metabolic disorder). Further review of EMR revealed that the resident was alert and oriented x 4 (person, place, time, and situation) upon admission to the facility.A phone interview was conducted with R902 on 5/15/26 at 10:17 AM. R902 reported that while at the facility the resident did not receive a dose of insulin or antibiotics that were prescribed. It was further reported that the resident left the facility and went back to the hospital the next morning so that antibiotics could be administered to decrease the risk of continued infection.Record review of Medication Administration Record (MAR) for March 2026 documented on 3/14/26 the following:Antibiotic- Cubicin Solution Reconstituted 500 MG (milligram) (Daptomycin) Use 500 mg intravenously every 24 hours for Osteomyelitis for 14 Days Administer 750mg in sodium chloride 0.8% -Start Date- 03/14/2026 1759. There was no documentation that the antibiotic was administered.Insulin- Glargine 100-15 unit at night shift for type 2 DM (type 2 diabetes mellitus) dated 3/14/26 9PM. 3/14/26 it was documented with number nine with nursing initials.Antibiotic- Piperacillin Sod- Tazobactam Sod Solution Reconstituted 4.0GM (grams). Use 4.5 gram intravenously every 6 hours for Infection for 14 Days. Start Date- 03/14/2026. There was no documentation that the1800 (6PM) dose was given and 0000 (12AM) dose documented the number nine with nursing initials.An interview was conducted on 5/15/26 at 11:00 AM with Director of Nursing (DON), it was reported that if there is no documentation on the MAR it was not given and if there is a nine you should refer to progress notes.Record review of progress notes documented on 3/15/26 at 3:54 AM, Did not arrive (antibiotics) from pharmacy. There was no documentation referring to why insulin dose was not given in the progress notes.An interview was conducted on 5/15/26 at 3:15 PM with Licensed Practical Nurse (LPN) A, it was reported that R902 did not receive the three prescribed antibiotics because they were not delivered from the pharmacy. It was further reported that the physician did not receive notification of the three missed doses of antibiotics or the insulin.On 5/15/26 at 3:30 PM a follow up interview was conducted with the DON. The DON reported that when prescribed medications are not available, the physician should be notified. This would give the physician an opportunity to assess the situation and provide further orders or alternative treatment recommendations. The DON reported that the insulin may not have been available in back up medications at that time.Record review of facility policy Medications Unavailable dated 1/31/24 documented the following: .4. Medications may be unavailable for a number of reasons. Staff should take immediate action when it is known that the medication is unavailable:a. Determine reasons 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 physicians of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring residents while medication is on hold.

Based on observation, interview and record review, the facility failed to fully implement a policy regarding use and storage of resident foods brought in from outside sources resulting in the potential for nutritional decline and decreased satisfaction for all residents. Findings Include:On 12/8/25 at 10:52 AM, observation of the nourishment rooms' large refrigeration unit, found minimal food storage. When asked where residents would store food brought in from outside sources that needed refrigeration, Registered Dietician D, stated the facility does not have a refrigerator for residents and only has residents keep shelf stable products in their rooms. A record review of facility policy entitled, Use and Storage of Food Brought in by Family or Visitors, revised 7/1/25, found that It is the right of the residents of this facility to have food brought in by family or other visitors. The policy goes on to state that, The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator., and that, . The facility staff will assist residents in accessing and consuming food that is brought in by resident and family or visitors if the resident is not able to do so on their own.

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.Findings Include: On 12/8/25 at 9:40AM, observation of the kitchen hand sinks found that they have an automatic faucet that is activated by movement. Once activated, the sinks were only found to have a run time of 3-5 seconds unless continually reactivated. According to the 2022 FDA Food Code section 5-202.12 Handwashing Sink, Installation. (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 29.4 C (85 F) through a mixing valve or combination faucet. Pf (B) A steam mixing valve may not be used at a HANDWASHING SINK. (C) A self-closing, slow-closing, or metering faucet shall provide a flow of water for at least 15 seconds without the need to reactivate the faucet. On 12/8/25 at 9:50 AM, an interview with Dietary Manager (DM) D and Registered Dietician (RD) D found that the facility uses a cooling process for food two to three times a week depending on the menu. On 12/8/25 at 9:54 AM, observation of the walk-in cooler found a quarter pan of puree chicken, tightly wrapped in foil, and dated 12/8-12/10. The temperature of the puree chicken was taken and found to be 70F when tested with a rapid read thermometer. When asked what time the chicken started cooling, DM E stated it was this morning, but would have to check the log to see when. A review of the cooling log found it started at 8:30 AM at 135F. According to the 2022 FDA Food Code section 3-501.15 Cooling Methods. (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; (2) Separating the FOOD into smaller or thinner portions; (3)Using rapid cooling EQUIPMENT; (4) Stirring the FOOD in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods. (B) When placed in cooling or cold holding EQUIPMENT, FOOD containers in which FOOD is being cooled shall be: (1) Arranged in the EQUIPMENT to provide maximum heat transfer through the container walls; and (2) Loosely covered, or uncovered if protected from overhead contamination as specified under Subparagraph 3-305.11(A)(2), during the cooling period to facilitate heat transfer from the surface of the FOOD. On 12/8/25 at 9:52 AM, observation of the plastic storage racks inside the walk-in cooler found an increased accumulation of spotted black debris on the shelves and legs of the racks. When asked if there was a cleaning frequency for the storage racks, DM E stated she had only been here a few weeks and hadn't established one yet. On 12/8/25 at 10:16 AM, observation of the tabletop slicer found it covered with a plastic bag. An interview with DM E found that the bag means its clean and sanitary. When asked how often the slicer gets used, DM E stated one to three times a week pending on the menu. Observation of the slicer found areas on the back side of the blade with an accumulation of debris. 12/8/25 at 10:25 AM, observation of the clean pots and pans storage rack found two quarter pans and two eighth pans stacked and stored wet trapping moisture between the pans. 12/8/25 at 10:26 AM, observation of the clean utensil bins found an accumulation of crumb debris, when asked how often these bins would get cleaned, DM E was unsure. 12/9/25 at 8:39 AM, observation of the clean utensil area found a hand press chopper used for single produce. Upon pressing the chopper down the wavy blade was observed with staining and encrusted debris from previous uses. When shown to DM E, she stated she didn't think anyone used that item and she would throw it away. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 12/8/25 at 10:43 AM, observation of the kitchen dish machine, while in operation by kitchen staff, found it required a minimum of 159F in the wash tank, 180F for the final sanitizing rinse minimum temperature before it goes into the machine, and a 160F contact temperature for pots, pans, and utensils. Observation of the next four cycles, using the surveyor and facility provided dish plate thermometers, found that the contact temperature of the three thermometers read between 147F - 158F between the four cycles performed. During these cycles it was noted that the rinse gauge would range between 165F-190F as racks of dishes were run through the conveyor. At this time, an interview with DM E found that they would reach out to their service representative to get the machine looked at. On 12/9/25 at 8:20 AM, an interview with DM E found that the service representative for the dish machine was out and had to turn up the temperature of the booster heater and will be back today to check it over more. According to the 2022 FDA Food Code section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. The temperature of hot water delivered from a ware washer sanitizing rinse manifold must be maintained according to the equipment manufacturer's specifications and temperature limits specified in this section to ensure surfaces of multi-use utensils such as kitchenware and tableware accumulate enough heat to destroy pathogens that may remain on such surfaces after cleaning.The surface temperature must reach at least 71 C (160 F) as measured by an irreversible registering temperature measuring device to affect sanitization. When the sanitizing rinse temperature exceeds 90 C (194 F) at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. The lower temperature limits of 74 C (165 F) for a stationary rack, single temperature machine, and 82 C (180 F) for other machines are based on the sanitizing rinse contact time required to achieve the 71 C (160 F) utensil surface temperature

Based on observation, interview, and record review the facility failed to ensure dignity was provided during care for one (R26) of two cognitively impaired residents and for five of eight cognitively intact residents that participated in an Anonymous Resident Council meeting reviewed for resident's rights, resulting in feelings of being ignored and discomfort.Findings include:On 12/10/2025 at 12:35 p.m., while standing in the hall across from R26's bedroom in which the door was closed, loud laughter could be heard coming from the bedroom. With moving closer to the door, two nurse aides (CNA G and CNA H) were heard laughing and talking loudly and having a personal conversation using profanity while giving R26 activity of daily living care. The aides did not verbally interact with R26, just with each other. After CNA G and H exited the room, R26 was observed resting in bed. An interview was attempted with R26, however was not completed due to the R26's impaired cognition. R26 appeared confused and had difficulty with understanding. On 12/10/25 at 12:41p.m. CNA H was interviewed and said the conversation that was overheard was not appropriate and should not have happened while giving care. On 12/10/25 at 12:45 p.m. CNA G was interviewed and said what was heard was not appropriate, That was my bad. On 12/10/25 at 12:48 p.m. the Assistant Director of Nursing (ADON) was interviewed and said the staff have been in-serviced many times about residents' dignity while giving care. The two aide's behavior will be addressed. Review of the clinical record documented R26 was admitted into the facility on 8/17/23 with diagnoses that included cerebral infarction, a-fib, vascular dementia with psychotic disturbance, and adjustment d/o with anxiety. According to the significant change Minimum Data Set (MDS) assessment dated [DATE], R26 was severely cognitively impaired (BIMS-2) and required total two-person assistance with activities of daily living. Review of the cognition and communication care plan dated 11/14/24 documented: Resident (has) impaired communication related to dementia, as evidenced by: difficulty making self-understood, as evidenced by: difficulty understanding others. Interventions: Encourage conversations in calm, quiet locations with minimal background noise. Resident Council-On 12/11/25 at 11:00 a.m. an Anonymous Resident Council meeting was held with eight cognitively intact residents. Five of eight residents verbally expressed strong dissatisfaction and discomfort with staff (primarily nurse aids) having inappropriate discussions about their personal lives while giving care. The residents said they often feel ignored while receiving care because the aides are either on the phone having personal conversations or talking to each other. The concern of loud talking, laughing, and inappropriate music in the halls on the afternoon/night shift. The residents said they must keep their doors closed just to be able to sleep and the loud noises can still be heard. The residents said they should not be subjected to hearing loud music with profanity and loud noises (laughing, talking loudly, and yelling in the halls) from staff. The residents said they have brought this concern to the attention of the facility through the regularly held monthly Resident Council meetings, but nothing has changed. Review of the Resident Council Meeting minutes for the month of November dated 11/19/25 documented a staff in-service that was to address the concern of resident's rights- dignity during care stated, Be careful of what you talk about in the hallways and in resident's rooms. Residents do not want to hear about your personal life. No phones or earbuds on the unit's period. If there is an emergency, step outside or off the unit. Failure to comply will result in you being asked to go home and disciplinary action will follow. Review of the facility's policy titled Promoting/Maintaining Resident Dignity revision date 10/26/23 documented in part the following: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Staff members do not talk to each other while performing a task for the resident as if the resident is not there. Conversation should be resident focused, and resident centered.

Based on observation, interview, and record review the facility failed to provide food at a palatable temperature for five of eight cognitively intact residents that participated in an Anonymous Resident Council meeting, and all residents who consume food resulting in the potential for decreased food consumption and potential nutritional decline.Findings include:Anonymous Resident Council- On 12/11/25 at 11:00 a.m. an Anonymous Resident Council meeting was held with eight cognitively intact residents. Five of eight residents verbally expressed strong dissatisfaction with food services. One of the five residents that expressed concern of food palatability eats their meal in their room, the other four eat their meals in the dining room. The residents stated, Food that is supposed to (be) hot (soup) is cold and foods that are supposed to (be) cold are hot (ice cream). The grill cheese sandwiches are so cold that the bread and cheese are as hard as the table. Eggs and sausage are cold to touch and taste. The food is overcooked and often hard and difficult to chew. The group said the food concerns have been brought to the attention of the facility multiple times and the food is getting worse. They stated, We feel like we are not being heard. This is supposed to be our home, but it doesn't feel like. We should get everything we need and sometimes what we want. Review of the Resident Council Monthly Meeting minutes for the months of September, October, and November 2025 did not document concerns with food palatability. On 12/8/25, at 11:33 AM, an interview with Registered Dietician (RD) D and Dietary Manager (DM) E found that food on the steam table should be 165F or above for service. When asked how long service takes, DM E stated they should start around 11:15 AM and take 60-90 minutes. When asked if they take temperatures of the food on the steam table at any point during the meal service to ensure temperatures of the food are maintained, DM E stated its not something they currently do. When asked if they do test trays or tray audits, RD D stated that they do perform test trays and do tray audits to ensure hot food and ensure meal tickets are correct. When asked the order in which food is delivered for lunch service, RD D stated with the main dining room down, due to Heating Ventilation and Air Conditioning (HVAC) repair, the current flow is carts to 100, 200, Lotus Dining, 300, 400, and then the rest of 100 hall. Meal carts observed were covered non-insulated stainless-steel carts that hold 20-24 trays. Meals were placed on trays with insulated covers, but no heating or pellet system was used to help maintain hot food temperatures over time once plated for service. On 12/8/25 at 11:40 AM, a regular test tray was requested for the 200 hall. On 12/8/25 at 12:01 PM, a regular test tray was plated as one of the first few meal trays on the 200 hall cart. On 12/8/25 at 12:18 PM, the test tray with 23 other trays made it to the 200 hall. On 12/8/25 at 12:34 PM, all trays on the 200 hall had been delivered and the test tray was brought into the conference room with the following temperatures found for hot food: Shepherd's Pie was found at 115F when the temperature was taken with a rapid read thermometer. On 12/9/25 at 11:40 AM, a regular test tray for the 200 hall was plated and placed as one of the first trays onto the 200 hall meal cart. On 12/9/25 at 11:56 AM, the 200 hall cart made it to the hall with trays starting to be delivered. On 12/9/25 at 12:19 PM, all trays had been delivered, and the test tray was brought to the conference room with the following temperatures found for hot food: Mashed potatoes 125F, Spinach/Mushrooms 123F, and the Chicken was 110F.

Based on observation, interview, and record review, the facility failed to offer additional food preferences, alternative or optional food choices for two (R117 and R120) residents out of 13, and three of eight cognitively intact residents that participated in an Anonymous Resident Council meeting reviewed for food, potentially resulting in weight loss and dissatisfied dining/nutrition experiences. Findings include: Anonymous Resident Council- On 12/11/25 at 11:00 a.m. an Anonymous Resident Council meeting was held with eight cognitively intact residents. Three of eight residents verbally expressed strong dissatisfaction with food services. Three residents that have concerns with food preferences being honored eat in the dining room. One resident whose family member was present during the meeting stated, My (family member) is on a special diet and cannot eat potatoes or tomatoes due to high potassium and they still give it anyway. I have written on the meal ticket not to give potatoes or tomatoes and handed them to the kitchen staff, and they still put potatoes or tomatoes on my (family member's) plate. The residents said the kitchen does not provide condiments although it is listed on the meal ticket. Juice is listed on the meal ticket but is not given. Residents request extra food items and do not receive them. The residents said they have made multiple complaints about the food, and nothing is being done. They stated, We feel like we are not being heard. This is supposed to be our home, but it doesn't feel like. We should get everything we need and sometimes what we want. Review of the Resident Council Monthly Meeting minutes documented the following: -September 17, 2025: Old Business Review- Residents receiving disliked items on their meal tray. Outcome: Not resolved- Action needed. New Business- Residents receiving disliked items on their meal tray. Outcome: No response documented. -October 15, 2025: Old Business Review: All previous concerns resolved. New Business: Residents receiving disliked items on their meal tray. Outcome: Not Resolved-Action Needed. Quality Assistance Form 10/15/25 documented the concern: Residents receiving items on Dislike Items list on their meal tickets. Plan/Action: Kitchen Manager made aware. Review of the provided documents revealed there was no evidence that the Kitchen Manager addressed this concern. -November 19, 2025: Old Business Review: There was nothing documented that concerns from the previous meeting were reviewed and accepted. On 12/8/25 at 3:38 PM, an interview with Dietary Manager (DM) E found that some items did run out today such as ice cream. When asked what the kitchen would do in the event they run out of something, DM E stated a similar alternative should be given to residents. When asked if they were out of 2% milk and bananas today, DM E stated they were not out of them. When asked if the facility should prioritize food items knowingly running low, for residents who need a higher caloric intake, DM E stated they should. R117: On12/08/2025 at 9:47 AM R117 was in a wheelchair with their breakfast tray on the overbed table at the doorway of their room looking out into the hallway. Upon interview the resident said, They never brought me 2% milk for my cereal. They put whole milk on my tray. I can't drink it. It makes my stomach upset. I've asked several times for 2% milk, and no one has brought it to me. I would have liked to have my cereal, but I can't now. Observation of R17's breakfast tray had a bowl of dry cereal on it, no milk. Observation of R117's meal ticket indicated Milk 2%. R117 said they do not bring them bananas either. My son brings me bananas. The kitchen doesn't have fresh fruit, only canned. On 12/08/2025 at 12:32 PM during the lunch meal R117 did not get hot tea. The meal ticket indicated the resident was to get 'hot tea'. R117's family member was present and said, They do not follow the preferences at all. They forget the hot tea, the bananas, and provide the wrong type of milk. I have been to conferences, resident council meetings, and spoke with the dietary people several times and it's not getting resolved. According to R117's Electronic Health Record (EHR) the residents have no cognition impairments. R117 was prescribed a regular diet with regular texture. On 8/13/2025 the resident's food preferences were updated to include no spicy foods. On 10/20/25 a dietary progress note indicated the residents enjoy banana chips and spicy food even tomato sauce upsets the resident's stomach. At this time the resident was asked if they liked banana chips and replied, I like bananas. I don't know if I'd like the chips. R120: On 12/08/2025 at 12:18 PM R120 and their family member were seated in the dining room for lunch. R120's family member was upset because the resident did not get mashed potatoes, coffee, or ice cream. R120's family member said, He (the resident) has been losing weight and is supposed to get fortified mashed potatoes and ice cream to help with that. Neither are here. He also got cranberry juice instead of apple juice. A review of R120's meal ticket indicated that the resident was to receive 'super spuds' (fortified mashed potatoes), ice cream, coffee, and apple juice. None of those items were on the resident's lunch tray. R120 had a divided plate and was independently feed their self. According to R120's EHR the resident with multiple diagnoses that included dementia and had been identified as having a significant weight loss of 10% in the last 6 months. On 10/30/2025 a nutritional note indicated the resident was to have fortified soups and mashed potatoes with a divided plate during meals. On 12/8/2025 at approximately 12:30 AM Licensed Practical Nurse (LPN) I said the kitchen had run out of mashed potatoes and did not have enough for the resident's (R120) lunch meal. LPN I could not explain why there was no substitute and no ice cream.

This citation pertains to Complaint 2681324Based on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment resulting in an increased potential for contamination and a possible decrease in the satisfaction of living for residents in the 100, 200, and 300 halls. Findings Include:On 12/8/25, at 10:59 AM, observation of the Ice room on the 200 Hall found an increased accumulation of black debris in the cabinet under the sink. On 12/8/25 at 1:20 PM, observation of the 100 Hall day space found an accumulation of Kleenex and debris stuffed into the side of chair and couch cushions. On 12/8/25 at 2:15 PM, observation of the 300 Hall Clean Utility room found an open wire rack of clean linen with an accumulation of debris, dust, and trash on the floor under the rack. On 12/8/25 at 2:46 PM, observation of the 200 hall shower room found storage racks in both shower stalls with gloves and towels open and exposed to contamination from residents showering. When asked if this is where items are normally stored, Maintenance Director (MD) F stated that everything should be in the storage closet in the shower room. Further review of shower stall two, noticed an odor to the room with numerous dried pieces of brown debris on the floor. On 12/9/25 at 9:11 AM, observation of the 100 hall storage room, off of the day room, found accumulations of dust and debris underneath the open wire rack storing clean linens. Further review found a couple blankets on the ground that had fallen behind the rack. On 12/9/25 at 9:14 AM, observation of the 100 hall shower room found a shower chair in stall one with an accumulation of dried brown smears on the seat of the chair. A review of stall two found a shower bed with an accumulation of smeared dried brown debris on the top portion of the mattress. Further review found that both stalls contained a storage rack with gloves and towels open and exposed to contamination between residents. A review of the tub area found another shower bed with an accumulation of wet black staining underneath the mattress. On 12/9/25 at 12:40 PM, observation of resident room [ROOM NUMBER] found an accumulation of dirt, crumbs, and paper trash on the floor in bed one and bed two area.

Based on observation and interview, the facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120 F. This resulted in an increased risk of injury among residents residing in the facility.Findings Include:On 12/8/25 at 1:33 PM, observation of resident room [ROOM NUMBER] found the hot water in the shower reached a temperature of 126F when tested with a rapid read thermometer. The temperature of the hand sink was 118F at this time and noted to have a point of use mixing valve installed to temper the hot water. On 12/8/25 at 1:38 PM, observation of resident rooms [ROOM NUMBERS] found hot water from the sinks and showers under the maximum 120F for resident care areas. On 12/8/25 at 2:16 PM, an interview with Maintenance Director (MD) F found that hot water temperatures are maintained between 105F-120F and a sample of rooms are checked every morning in a quantity that allows for all hot water fixtures to be checked monthly. MD F went on to state that all sinks have a point of use mixing valve and are adjusted as needed. MD F was informed of the hot water temperature recorded for the shower in resident room [ROOM NUMBER] and asked if the personal showers are part of the hot water checks, MD F stated they are not part of the routine hot water checks, but they do get checked when concerns are brought up. On 12/9/25 at 9:34 AM, observation of the 300/400 Hall boiler room found the hot water tanks set at 128F, sending domestic hot water directly to resident care areas. On 12/9/25 at 9:39 AM, observation of resident room [ROOM NUMBER], with MD F, found that he could not hold his hand under the hot water and stated, It's too hot. MD F stated he would get it fixed.

Based on observations, interview, and record review the facility failed to follow standards of practice for accurate reconciliation of Controlled Medications in three of eight medication carts resulting in the potential for drug diversion. Findings Include:Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence On 12/09/2025 at 11:04 AM inspection of 'Medication Cart - A ' on the 200-hall with Licensed Practical Nurse (LPN) A a review of the Controlled Substance Verification Log revealed it was incomplete. There were no licensed nurse's signatures to verify the Controlled Medications were reconciled for the last 24 hours; on 12/8/25 from the day shift to the night shift and on 12/9/25 from night shift to the day shift. LPN A said, Oh I counted this morning with the night shift nurse, but we forgot to sign the sheet. We should have signed it. LPN A could not say why the night shift nurse did not sign the sheet for either 12/8/25 or on 12/9/24. Further inspection of the medication cart revealed the actual number of controlled substances 'medication cards' in the medication cart did not match the number of 'cards' on the Substance Verification Log. Upon inquiry LPN A said they count the number of the prescriptions not the actual number of 'medication cards'. The Substance Verification Log specifically indicates the 'number of cards' not the 'number of prescriptions'.A complete controlled substance count was conducted with the unit manager, Registered Nurse (RN) B and there were no discrepancies.During interview with RN B she said, We have had some questions as to how we are to count the narcotics. Is it the number of medication cards or the number of prescriptions. It's something we'll have to talk to the DON (Director of Nursing) about. On 12/9/25 at approximately 11:30 AM inspection of 'Medication Cart - B ' on the 200-hall with LPN C a review of the Controlled Substance Verification Log revealed it was incomplete. There were no licensed nurse's signatures to verify the Controlled Medications were reconciled from the 12/9/25 night shift to the 12/9/25 day shift. LPN C said, Yes, I should have signed that I counted with the night shift nurse.During further investigation of this medication cart LPN C said, I need to sign out a couple medications that I gave and did not sign out yet. LPN C acknowledged that standard of practice is to sign out a controlled substance at the time of the administration. On 12/9/25 at approximately 11:50 AM inspection of 'Medication Cart - B ' on the 100-hall with LPN I a review of the Controlled Substance Verification Log revealed it was incomplete. There were no licensed nurse's signatures to verify the Controlled Medications were reconciled from the 12/9/25 night shift to the 12/9/25 day shift. LPN I said, I should have signed earlier when I counted. During an interview with the DON, RN B, and the Assistant Director of Nursing (ADON) on 12/09/2025 at 12:14 PM they confirmed that the facility's policy and standard of practice for medication reconciliation was for both the off-going shift nurse and on-coming shift nurse to sign when the narcotic count was conducted. The DON said, The nurses are supposed to sign the sheet at the time they count. They are supposed to sign out meds at the time they gave it. The DON said the way the controlled substance medication cards are counted will be reviewed to ensure consistency and accuracy. According to the Controlled Substance Administration & Accountability policy last reviewed on 10/13/2025: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure.11. Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services or His/her designee immediately. Documentation should be made on the shift verification sheet. Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence.

Based on interview and record review, the facility failed to ensure one resident (R45) out of five residents reviewed for immunizations, was provided an influenza vaccination and education resulting in the potential for the development and spread of influenza among vulnerable residents in the facility. Finding include:On 12/9/2025 at 9:28 AM the Infection Preventionist (IP) J was interviewed and reported (R45) did not have documentation of a current influenza immunization or refusal signed by the guardian. Record Review of R45's Electronic Health Record (EHR) revealed R45 was admitted on [DATE] with a diagnosis of Psychomotor deficit following Cerebral Infarction (stroke). R45 did not have documentation to indicate that the influenza vaccine was declined by the guardian or was contraindicated. On 12/11/2025 at 8:50 AM, the Director of Nursing (DON) was interviewed and said the expectation was for the guardian to be contacted and get consent or a declination regarding immunizations. Review of the facility policy titled Influenza Vaccination revised 10/26/2023 revealed in part.It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members, and volunteer workers annual immunization against influenza. The resident's medical record will include documentation that the resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal.

Based on interview and record review, the facility failed to ensure one resident (R45) out of five residents reviewed for immunizations, was provided a COVID-19 vaccination and education resulting in the potential for the development and spread of COVID-19 among vulnerable residents in the facility. Findings include: On 12/9/2025 at 9:28 AM the Infection Preventionist (IP) J was interviewed and reported (R45) did not have documentation of a current COVID-19 immunization or refusal signed by the guardian. Record Review of R45's Electronic Health Record (EHR) revealed R45 was admitted on [DATE] with a diagnosis of Psychomotor deficit following Cerebral Infarction (stroke). R45 did not have documentation to indicate that the COVID-19 vaccine was declined by the guardian or was contraindicated. On 12/11/2025 at 8:50 AM, the Director of Nursing (DON) was interviewed and said the expectation was for the guardian to be contacted and get consent or a declination regarding immunizations. Review of the facility policy titled COVID-19 Vaccination revised date 10/20/2023 revealed in part.It is the policy of this facility to minimize the risk of acquiring, transmitting, or experiencing complications from COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine. Residents or their representatives will sign the consent form prior to administration of the COVID-19 vaccine. This information will be retained in the resident's medical record. Residents or resident representatives or staff retain the right to accept, refuse or change their decision about COVID-19 immunization if administered at this facility. If refused, the residents will adhere to the protocols set forth by specific facility policy. The residents medical record will include documentation of the following: a. education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine.

This citation pertains to intake 2583399.Based on interview and record review, the facility failed to timely notify the guardian of a resident fall for one resident (R101) out of four residents reviewed for falls. Findings include:Record Review of R101's Electronic Health Record (EHR) revealed admission to the facility on 7/24/25 with diagnoses which included Unspecified Fracture of Right Femur, Chronic Lymphocytic Leukemia of B-Cell Type, Legal Blindness. Date of discharge 7/31/25 at 8:11 AM to acute care hospital.Review of 101's Brief interview for Mental Status (BIMS) assessment performed on 7/29/25 revealed a BIMS of 8/15 moderately impaired cognition. R101 is listed as having a guardian. Review of R101's functional abilities status revealed substantial/maximal assistance for bed mobility and dependent for transfers.On 8/21/25 at 9:05 AM, Certified Nursing Assistant (CNA) C was interviewed and said that on 7/29/25 at approximately 6:30 AM, she found R101 on the floor next to the bed. CNA C notified Licensed Practical Nurse (LPN) D and together they put R101 back in bed. CNA C said she did not notice anything new wrong with R101, no new injury. CNA C said that she worked with R101 on 7/30/25 and at approximately 11:00 PM while providing care she noticed something wrong with R101's left leg. CNA C said she immediately notified LPN E.On 8/21/25 at 9:30 AM, Guardian staff member (G) B was interviewed and said that the Guardian office was not notified of R101's fall on 7/29/25. G B revealed that the guardian office was notified of R101's transfer to the hospital on 7/31/25 by LPN E due to leg injury. However, the guardian office was not notified of R101's fall or how the left leg was injured.On 8/20/25 at 12:01 PM, LPN D was left a voicemail for an interview request with no return phone call.Record review of R101's progress note, created 7/31/25 at 9:43 AM, effective date 7/29/25 at 7:00 AM late entry completed by LPN D revealed in part: Nurse quickly went to get the CNA to help transfer the resident back to bed. Prior to the fall, resident was administered her pain medication. Physical assessment was conducted; no visual injury noticed. No injuries were observed at the time of the incident. Agencies/People notified Responsible Party/Family Member Guardian 7/31/25 at 9:08 AM.On 8/20/25 at 1:00 PM the Director of Nursing (DON) was interviewed and said R101's guardian, physician and herself were not notified of the fall that occurred on 7/29/25 until 7/31/25. The DON further said that the guardian, physician and herself should have been notified immediately of the fall due to probable injury.Review of the facility policy titled Incidents and Accidents Reporting date reviewed/revised 8/11/22 revealed in part: It is the policy of this facility for staff to utilize electronic and/or approved forms to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. The following incidents/accidents require an incident/accident report but are not limited to falls. The supervisor or other designee will be notified of the incident/accident. The nurse will notify the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies). The resident's family or representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital. The nurse/designee will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. If an incident/accident was witnessed by other people, the supervisor or designee will obtain the witness' account.

This citation pertains to intake 2583399.Based on interview and record review, the facility failed to report an injury of unknown origin to the State Agency (SA) for one resident (R101) out of four residents reviewed for injuries of unknown origin. Findings include:On 7/31/25 the State Agency (SA) received a complaint from Adult Protective Services regarding R101 sustaining a fractured leg.Record Review of R101's Electronic Health Record (EHR) revealed admission to the facility on 7/24/25 with diagnoses which included Unspecified Fracture of Right Femur, Chronic Lymphocytic Leukemia of B-Cell Type, Legal Blindness. Date of discharge 7/31/25 at 8:11 AM to acute care hospital.Review of 101's Brief interview for Mental Status (BIMS) assessment performed on 7/29/25 revealed a BIMS of 8/15 moderately impaired cognition. R101 is listed as having a guardian. Review of R101's functional abilities status revealed substantial/maximal assistance for bed mobility and dependent for transfers.On 8/21/25 at 9:05 AM, Certified Nursing Assistant (CNA) C was interviewed and said that on 7/29/25 approximately at 6:30 AM, she found R101 on the floor next to the bed. CNA C said she notified Licensed Practical Nurse (LPN) D and together they put R101 back in bed. CNA C said she did not notice anything wrong with R101, or a new injury. CNA C further said that she worked with R101 on 7/30/25 and at approximately 11:00 PM while providing care she noticed something wrong with R101's left leg. CNA C said she immediately notified LPN E.On 8/20/25 at 1:16 PM, LPN E was interviewed and said she worked on 7/30/25 and became aware of R101's left leg injury around 11:30 PM. LPN E said she immediately notified the doctor. LPN E further said she notified the Director of Nursing (DON) and Nursing Home Administrator (NHA).On 8/20/25 at 11:25 AM Certified Occupational Therapist Assistant (COTA) G and Physical Therapist Assistant (PTA) H were interviewed and said they worked with R101 on 7/29/25 through 7/30/25 and did not notice anything changes in condition during the therapy sessions.On 8/21/25 at 9:30 AM, Guardian staff member (G) B was interviewed and said that the Guardian office was not notified of R101's fall on 7/29/25. G B revealed that the guardian office was notified of R101's transfer to the hospital on 7/31/25 by LPN E due to a leg injury however the guardian office was not notified of R101's fall or how the leg injury occurred.On 8/20/25 at 12:01 PM, LPN D was left a voicemail for an interview request with no return phone call.Record review of R101's progress note date created 7/31/25 at 9:43 AM, effective date 7/29/25 at 7:00 AM late entry completed by LPN D revealed in part: Nurse quickly went to get the CNA to help transfer the resident back to bed. Prior to the fall, resident was administered her pain medication. Physical assessment was conducted; no visual injury noticed. No injuries were observed at the time of the incident. Agencies/People notified Responsible Party/Family Member Guardian 7/31/25 at 9:08 AM. Review of the progress note dated 7/30/25 at 11:47 PM, revealed Resident resting in bed, writer noted left leg twisted and a bulge in left hip. Dr. phoned.On 8/20/25 at 1:15 PM, the NHA was interviewed and said LPN E notified her of R101's inured left leg. The NHA further said she did not notify the SA of R101's injured left leg or conduct an investigation and should have.Review of the facility policy titled Incidents and Accidents Reporting date reviewed/revised 8/11/22 revealed in part: It is the policy of this facility for staff to utilize electronic and/or approved forms to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. The following incidents/accidents require an incident/accident report but are not limited to falls. The supervisor or other designee will be notified of the incident/accident. The nurse will notify the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies). The resident's family or representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital. The nurse/designee will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. If an incident/accident was witnessed by other people, the supervisor or designee will obtain the witness' account.Review of the facility policy titled reporting Alleged Violations date reviewed/revised 1/10/24 revealed in part: The purpose of this policy is to assure that alleged violations are reported immediately to the facility administrator and other officials as required by State and Federal Guidelines. The facility must ensure:1. Alleged violations involving abuse, neglect, exploitation, or mistreatment are reported in accordance with State and Federal Guidelines. This includes injury of unknown source and misappropriation of resident property.2. If the alleged violation involves abuse or results in serious bodily injury it must be reported immediately but no later than 2 hours after the allegation in made.3. If the alleged violation does not involve abuse or does not involve serious bodily injury it must be reported no later than 24 hours after the allegation is made.4. The alleged violations must be reported to the administrator of the facility and to other officials (including to the state survey agency and adult protective services where state law provides jurisdiction in long term care facilities) in accordance with state law through established procedures.Injuries of unknown source: Includes circumstances when both of the following conditions are met:1. The source of the injury: a. was not observed by any person orb. could not be explained by the resident; andPolicy Reporting Alleged Violations 2. The injury is suspicious because of: a. the extent of the injury orb. the location of the injury (e.g., an area not generally vulnerable to trauma) orc. the number of injuries observed at one particular point in time ord. the incidence of injuries over time.Response and Reporting of Alleged Violations:Anyone in the facility can report an alleged violation. When an alleged violation is suspected, the Licensed Nurse should:1. Respond to the needs of the resident and protect them from further incident.2. Notify the Director of Nursing Services and Administrator.3. Complete an incident report and initiate an investigation immediately.4. Notify the attending physician, resident's family/legal representative and Medical Director.5. Obtain statements from direct care staff.6. Monitor and document the resident's condition, including the response to medical treatment or nursing interventions.7. Document actions taken in the medical record.The Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies.

This citation pertains to intake 2583399.Based on interview and record review, the facility failed to investigate an injury of unknown origin for one resident (R101) out of four residents reviewed for injuries of unknown origin. Findings include:On 7/31/25 the State Agency (SA) received a complaint from Adult Protective Services regarding R101sustaining a fractured leg.Record Review of R101's Electronic Health Record (EHR) revealed admission to the facility on 7/24/25 with diagnoses which included Unspecified Fracture of Right Femur, Chronic Lymphocytic Leukemia of B-Cell Type, Legal Blindness. Date of discharge 7/31/25 at 8:11 AM to acute care hospital.Review of 101's Brief interview for Mental Status (BIMS) assessment performed on 7/29/25 revealed a BIMS of 8/15 moderately impaired cognition. R101 is listed as having a guardian. Review of R101's functional abilities status revealed substantial/maximal assistance for bed mobility and dependent for transfers.On 8/21/25 at 9:05 AM, Certified Nursing Assistant (CNA) C was interviewed and said that on 7/29/25 approximately at 6:30 AM, she found R101 on the floor next to the bed. CNA C notified Licensed Practical Nurse (LPN) D and together they put R101 back in bed. CNA C said she did not notice anything wrong with R101 or new injury. CNA C further said that she worked with R101 on 7/30/25 and at approximately 11:00 PM while providing care she noticed something wrong with R101's left leg. CNA C said she immediately notified LPN E.On 8/20/25 at 1:16 PM, LPN E was interviewed and said she worked on 7/30/25 and became aware of R101's left leg injury around 11:30 PM. LPN E said she immediately notified the doctor. LPN E further said she notified the Director of Nursing (DON) and Nursing Home Administrator (NHA).On 8/20/25 at 11:25 AM Certified Occupational Therapist Assistant (COTA) G and Physical Therapist Assistant (PTA) H were interviewed and said they worked with R101 on 7/29/25 through 7/30/25 and did not notice anything changes in condition during the therapy sessions.On 8/21/25 at 9:30 AM, Guardian staff member (G) B was interviewed and said that the Guardian office was not notified of R101's fall on 7/29/25. G B revealed that the guardian office was notified of R101's transfer to the hospital on 7/31/25 by LPN E due to a leg injury however the guardian office was not notified of R101's fall or how the left leg injury occurred.On 8/20/25 at 12:01 PM, LPN D was left a voicemail for an interview request with no return phone call.Record review of R101's progress note date created 7/31/25 at 9:43 AM, effective date 7/29/25 at 7:00 AM late entry completed by LPN D revealed in part: Nurse quickly went to get the CNA to help transfer the resident back to bed. Prior to the fall, resident was administered her pain medication. Physical assessment was conducted; no visual injury noticed. No injuries were observed at the time of the incident. Agencies/People notified Responsible Party/Family Member Guardian 7/31/25 at 9:08 AM. Review of the progress note dated 7/30/25 at 11:47 PM, revealed Resident resting in bed, writer noted left leg twisted and a bulge in left hip. Dr. phoned.On 8/20/25 at 1:15 PM, the NHA was interviewed and said LPN E notified her of R101's inured left leg. The NHA further said she did not notify the SA of R101's injured left leg or conduct an investigation and should have.Review of the facility policy titled Incidents and Accidents Reporting date reviewed/revised 8/11/22 revealed in part: It is the policy of this facility for staff to utilize electronic and/or approved forms to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. The following incidents/accidents require an incident/accident report but are not limited to falls. The supervisor or other designee will be notified of the incident/accident. The nurse will notify the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies). The resident's family or representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital. The nurse/designee will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. If an incident/accident was witnessed by other people, the supervisor or designee will obtain the witness' account. Review of the facility policy titled reporting Alleged Violations date reviewed/revised 1/10/24 revealed in part: The purpose of this policy is to assure that alleged violations are reported immediately to the facility administrator and other officials as required by State and Federal Guidelines.The facility must ensure:1. Alleged violations involving abuse, neglect, exploitation, or mistreatment are reported in accordance with State and Federal Guidelines. This includes injury of unknown source and misappropriation of resident property.2. If the alleged violation involves abuse or results in serious bodily injury it must be reported immediately but no later than 2 hours after the allegation in made.3. If the alleged violation does not involve abuse or does not involve serious bodily injury it must be reported no later than 24 hours after the allegation is made.4. The alleged violations must be reported to the administrator of the facility and to other officials (including to the state survey agency and adult protective services where state law provides jurisdiction in long term care facilities) in accordance with state law through established procedures.Injuries of unknown source: Includes circumstances when both of the following conditions are met:1. The source of the injury: a. was not observed by any person orb. could not be explained by the resident; andPolicy Reporting Alleged Violations 2. The injury is suspicious because of: a. the extent of the injury orb. the location of the injury (e.g., an area not generally vulnerable to trauma) orc. the number of injuries observed at one particular point in time ord. the incidence of injuries over time.Response and Reporting of Alleged Violations:Anyone in the facility can report an alleged violation. When an alleged violation is suspected, the Licensed Nurse should:1. Respond to the needs of the resident and protect them from further incident.2. Notify the Director of Nursing Services and Administrator.3. Complete an incident report and initiate an investigation immediately.4. Notify the attending physician, resident's family/legal representative and Medical Director.5. Obtain statements from direct care staff.6. Monitor and document the resident's condition, including the response to medical treatment or nursing interventions.7. Document actions taken in the medical record.The Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies.

This citation pertains to Intake 1351543Based on observation, Interview, and record review, the facility failed to ensure a call light was answered within a timely manner for one resident (R906) out of six residents reviewed for call lights, resulting in the R906 being left of the toilet for an extended period, discomfort, disrespect, and feelings of anxiety.Findings include:On 7/22/25 at 12:35 pm, R906 was observed in their room sitting in a wheelchair. R906 was interviewed about the care received at the facility. R906 said they were not receiving good care. R906 stated they went to the bathroom on 6/21/25 around 1:30 pm. R906 said, I was able to put myself on the toilet.I put the call light on and waited almost two hours for staff to answer the bathroom call light. R906 stated their family was visiting and went looking for staff but could not find anyone to help. R906 was asked if family was able to assist and the resident said, No they can't help me. At this time, R906 said, I was begging for help.I was yelling please help me. It made me feel like I was not important. During the interview, R906 was crying uncontrollably while explaining what occurred.A review of R906 electronic medical records revealed an admission to the facility on 6/22/2022 with the diagnoses of Type 2 Diabetes Mellitus, Peripheral Vascular Disease, Atherosclerotic Heart Disease, Chronic Fatigue, Age-Related Macular Degeneration, and Adjustment Disorder with Mixed Anxiety and Depressed Mood. A review of R906's Brief Interview for Mental Status (BIMS) dated 5/10/2025 disclosed a score of 15/15 (cognitively intact). A review of R906's Minimum Data Set (MDS) dated [DATE] revealed R906 required partial to moderate assistance with toileting hygiene, substantial to maximal assistance with lower body dressing, supervision or touching assistance with toilet transfer. A review of R906 care plan revealed the following: Interventions-Toileting: 1 person assist, will request to be changed when needed.dated 8/15/2023 and revised on 6/23/2025.Intervention-Encourage resident to use call light when assistance is needed.dated 8/15/2023. A review of R906's progress notes revealed documentation by Unit Manager F dated 6/23/2025 at 2:05pm: On 7/23/25 at 9:28am, Unit Manager F was interview about R906 allegation of being left on the toilet from 1:30pm-3:15pm. Unit Manager F stated, I was told that lunch trays were delivered late that day. The two certified nurse assistants (CNA) were passing trays at this time. Unit Manager F said the call system will go to the CNA pager and after 10 minutes it will alert the nurse that the call light was on. Unit Manager F said, The CNAs and nurse were feeding residents and it would not be fair to stop feeding a resident to answer a call light. Unit Manager F said that R906 usually goes to the bathroom on their own and will need assistance with bowel movements. Unit Manager F said she educated the CNAs and the Nurse about answering call lights. On 7/23/25 at 10:15am, the NHA was interviewed about R906 being left on the toilet for an extended period. The NHA said, I spoke to (R906) and was made aware of being on the toilet for an extended time.This is not acceptable, and the staff was educated. A review of the facility's policy Call Lights: Accessibility and Timely Response dated 12/28/2023 revealed the following: Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.Policy Explanation and Compliance Guidelines: 1.Staff are educated in the proper use of the resident call system, including how the system works and ensuring resident access to the call light.7. Any staff member who sees or hears an activated call light is responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

Based on observation, interview and record review the facility failed to ensure enhanced barrier precautions (EBP) were applied during wound care for one resident (R912) out of one resident reviewed for infection control.Findings include:Record review of R912's electronic medical records (EMR) revealed admission into the facility on 5/28/23 with a pertinent diagnosis of pressure ulcer of sacral area (upper buttocks) region Stage 4 (deep wound were bone and muscle can be observed). An observation conducted on 7/23/25 at 9:56 a.m. revealed a sign posted on the outside of R912's door instructing staff to wear personal protective equipment (PPE) during care. Additionally, a storage unit containing PPE was observed outside the resident's room.An observation on 7/23/25 at 10:00 am, was made of Licensed Practical Nurse (LPN) C entering R912's room without donning the required PPE. During the wound care procedure, after R912's soiled bandages were removed, the wound was observed with red-colored drainage.Record review of R912 's physician's orders, dated 5/30/25 at 3:00 p.m., documented, use enhanced barriers while performing high-contact activity with the resident during every shift.Record review of R912's Enhanced Barrier Precaution care plan indicated that enhanced barrier precautions were to be implemented when providing high-contact resident care activities. These included dressing, bathing, transferring, personal hygiene, changing linens, changing briefs/assisting with toileting, device care: central lines, urinary catheters, feeding tubes, tracheostomy/ventilators, wound care, dialysis. This care plan was initiated on 04/01/2024.An interview conducted on 7/23/25 at 10:50 a.m. with LPN C, revealed that PPE should be worn during wound care procedures.During an interview on 7/23/25 at 11:15 a.m., the Assistant Director of Nursing (ADON) A, reported that PPE was required to be worn when performing wound care for R912.An interview on 7/23/25 at 11:45 a.m. with Infection control Preventionist (IFC) D confirmed that staff are expected to consistently wear appropriate PPE during wound care and that staff had been in-serviced on these protocols on multiple occasions.Record review of facility's Policy, Enhanced Barrier Precautions documented, . It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.

Based on observation, interview, and record review, the facility failed to properly date-label food in the kitchen and ensure the drain from the coffee machine was properly air gapped. Findings include: On 10/15/24 at 8:50 AM, during the initial tour of the kitchen with Dietary Manager (DM) D and Registered Dietitian (RD) C the following was observed: Three loaves of white bread, two loaves of wheat bread, and one bag of white hotdog buns were opened and undated on the bread rack. RD C stated food items should specify delivery, opened, and discard dates. Inside the reach in cooler, an opened five-pound bag of shredded cheese was dated 10/8/24. DM D and RD C were unable to identify if the date signified the delivery, opened, or discard date. Additionally, an opened five-pound tub of sour cream did not specify an expiration date. The drain line from the coffee machine did not have the required minimum one-inch air gap (an unobstructed vertical space between the end of the drain line and the flood rim of the floor drain). On 10/17/24 at 12:40 PM, the Nursing Home Administrator (NHA) said the items in the kitchen should be labeled when received, opened, and use-by. Kitchen staff should have notified maintenance to adjust the coffee machine drainpipe. On 10/18/24 at 4:40 PM during the exit conference, the NHA and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and they reported there was not. According to the following sections of the 2013 FDA Food Code: 3-101.11, entitled, Safe, Unadulterated, and Honestly Presented, was reviewed and revealed, Food shall be safe, unadulterated, and, as specified under S 3-601.12, honestly presented. 5-202.13: An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch.

Based on observation, interview, and record review the facility failed to ensure one resident (R76) was updated in a timely manner regarding preference to move to another home, resulting in resident experiencing frustration. Findings include: On 10/15/24 at 12:12 PM, R76 was observed awake and lying in his bed. When queried about his stay in the facility, R76 said he wanted to speak to the social worker. R76 stated, I want to move to (Facility XX). I haven't spoken with anyone about this in two months. A review of the clinical record for R76 revealed an admission into the facility on [DATE] with diagnoses of metabolic encephalopathy, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. R76 was his own responsible party. A Minimum Data Set assessment dated [DATE] documented intact cognition. A Social Service progress note dated 8/22/24 documented the following: MSW (Masters of Social Work) notified by SS asst. (Social Service Assistant) that patient is wanting referral sent to (Facility XX). Referral was sent, as requested, to admissions dept and writer additionally notified RDO (Regional Director of Operations). Writer requested for team to be updated when/if they are able to accept to confirm again with patient at that time on wishes to transfer. On 10/16/24 at 2:14 PM, MSW B said when a resident expresses a desire to move to another facility, we first determine if they are their own responsible party and then ask where they want to move to. Once the appropriate documents have been sent to the admission department of the desired location, we give them time to review it clinically. We then reach out to obtain an update regarding the resident's move request. MSW B stated, I usually wait two days to reach out and will go back to the resident regarding what happened when we reached out. MSW B added that they try for week to get information and will let the resident know if they are not getting a response. When queried about R76's request to move, MSW B acknowledged that R76 wanted to move to (Facility XX). MSW B said because the admission person for (Facility XX) was on vacation during the time the request was made, that the Admission Director and RDO were also notified. MSW B said she waited for them to respond. MSW B could not recall if she got back with the resident and was unable to provide documentation that R76 had been updated. MSW B stated, I should have followed up with them (Facility XX) and got back with the resident. I needed to see the referral through, provide and update to the resident, and (determined) if there was another facility choice. On 10/17/24 at 12:29 PM, Assistant Director of Nursing (ADON) A said when the social worker did not hear back from the facility, she should have called to see if they received the referral and notified the resident of that status. On 10/18/24 at 4:40 PM during the exit conference, the Nursing Home Administrator and Director of Nursing were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

Based on observation, interview, and record review the facility failed to provide adequate nail care, facial hair grooming, and hair washing for two (R18 and R118) of seven residents reviewed for activities of daily living for dependent residents resulting in unmet hygiene needs, loss of dignity, and emotional distress. Findings include: R18: On 10/15/24 at 11:25 a.m. R18 was observed in bed watching television. R18 was also observed with matted braided hair that was greasy and full of dandruff. R18 facial hair was overgrown and unkept. R18 had impaired speech, however when asked the last time his facial hair was trimmed and hair was washed, the resident replied, good question (indicating it has not been done). R18 became tearful when asked if the staff offered to wash hair and trim facial hair. R18 responded, No! No! No! R18 was asked do you want your hair washed and facial hair trimmed. Tearfully R18 said, Yes! Yes! Yes! Please, please, please. On 10/15/24 at 11:59 a.m. CNA O was interviewed and confirmed regularly being the resident's nurse aid. CNA O said R18 often refuses care, and it has been documented. On 10/15/24 at 12:01 p.m. LPN I was interviewed and said R18 will cooperate with care with regularly scheduled staff. The resident will refuse care with newer staff. When the resident (all residents) refuse care, the aides are to report the refusal to the nurse or unit manager. On 10/15/24 at 12:25 p.m. Director of Nursing (DON) A and Unit Manager (UM) N were in R18's room and said the resident received a shower yesterday. They were asked is shaving and hair washing included if needed on shower days. DON A said shaving and hair washing should be done on shower days. DON A did not know why the care have not been rendered. UM N said R18 refuses but was uncertain if he refused getting shaved or hair washed. DON A and UM N agreed the resident's hair needed to washed and facial hair trimmed. On 10/16/24 at 1:11 p.m. review of the clinical record documented R18 was admitted into the facility on [DATE] with diagnoses that included diabetes mellitus with neuropathy, dementia, encephalopathy, and traumatic brain injury. According to the quarterly minimum data set assessment (MDS) dated [DATE], R18 had moderate impaired cognition and dependent on staff for grooming and bathing. Review of the Activities of Daily Living care plan dated 9/22/23 documented: Resident has an ADL self-care performance deficit related to dementia and traumatic brain injury. Interventions: Bathing: 2-person assistance, prefers a shower over a bed bath; Personal Hygiene: 2-person assistance. Honor resident's choices and preferences whenever possible. Review of the task list revealed no refusals were documented for R18. Review of the facility's policy titled Activities of Daily Living (ADLs) dated 12/28/23 documented: The facility takes measures to minimize the loss of resident's functional abilities, including activities of daily living (ADLs). Activities of Daily Living include the ability to: 1. Bathe, dress, and groom . A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . 41423 R81 On 10/15/24 at 09:46 AM, Resident 81 was observed open in bed with their eyes opened. R81 had an unkept appearance and their hair was disheveled with a greasy appearance. R81's hair had thick dandruff and was matted at the top of their head. On 10/15/24 at 01:18 PM and on 10/16/24 at 09:17 AM, R81 was observed in bed on their back. R81 had an unkept appearance and their hair was disheveled with a greasy appearance. R81's hair had thick dandruff and was matted at the top of their head. The Resident's hands and legs were visible. The Resident's fingers on their left hand were curled towards palm. Their right leg was tucked underneath their left leg. R81's left leg appeared contracted. On 10/16/24 at 01:05 PM, R81 was observed in bed, positioned on their back with their eyes closed. R81 continued to have an unkept appearance and their hair was disheveled with an oily appearance. R81's hair had thick dandruff and was matted at the top of their head. On 10/17/24 at 09:01 AM, Certified Nurse Aide (CNA) M was interviewed and asked if they provided care to R81. CNA M said that they were not familiar with R81. CNA M was asked about the facility's policy if a resident refused care. CNA M said, If a resident refused a bath or shower I tell a nurse. A review of R81's electronic medical records indicated an initial admission was on 09/01/2020 and most resent admission on 05/30/2024 with diagnoses of Cerebral Infarct (lack of adequate blood supply to brain), Toxic Encephalopathy, Dysphagia, Type II Diabetes, Hypertension, and Seizures. A review of the R81's Minimum Data Set (MDS) dated [DATE] indicated a score of 15 (resident's cognition was intact). R81 was dependent with all Activities of Daily Living (ADLs). A review of R81's care plan noted the following, Resident has an ADL self care performance deficit related to [Stroke], Muscle Weakness . Date initiated 08/22/2023, Revision on 10/16/2024 .Encourage participant in daily care and provide positive reinforcement for activities attempted and/or partially achieved .Dated 8/23/2023 .Observed for pain during ADL tasks and report to Nurse if observed. Dated 8/23/2024 .Oral mouth swab [R81] q 4 hours [every four hours] .Dated 06/06/2024 .Actively involve the resident/family in the resident's plan of care .Dated 09/01/2023. A review of R81's electronic medical records progress notes resident's refusal to bathe on 7/31/2024. No other resident refusal and/or notification of legal guardian from 06/01/2024-10/11/2024. On 10/17/24 at 10:25 AM, the Director of Nursing (DON) was asked about her expectations for bathing and the DON stated that R81 always refused bathing.

Based on observation, interview and record review, the facility failed to ensure continuous tracheostomy humidification for one (R125) of three residents reviewed for respiratory therapy, resulting in the potential for thickened secretions, dehydration of airway secretions, and the potential for lung infection. Findings include: On 10/16/24 at 08:39 AM, R125 was observed in bed on their back, with eyes opened. R125 was lying on their back with their left arm pulled up to their chest and right hand culled tight towards their palm. The humidifier canister that holds water for humidification was completely empty (without water to generate humidification). On 10/17/24 at 08:40 AM, R125 was observed in bed on their back, with eyes closed. R125 was lying on their back with their left arm pulled up to their chest and right hand culled tight towards their palm. The humidifier canister that holds water for humidification was completely empty (without water to generate humidification). On 10/17/24 at 10:15 AM, R125 was observed in bed on their back, with eyes closed. R125 was lying on their back with their left arm pulled up to their chest and right hand culled tight towards their palm. The humidifier canister that holds water for humidification was completely empty (without water to generate humidification). A review of R125's electronic medical record revealed an admission to the facility on [DATE] with diagnoses which included a Traumatic Subdural Hemorrhage (07/03/2024 secondary to a motor vehicle accident), Traumatic Brain Injury, Lung Injury, Fracture of Lumbar Vertebra, and Fracture of Right Eye. Review of the Minimum Data Set (MDS) assessment revealed R125 was severely cognitively impaired and dependent with all Activities of Daily Living (ADLs). A review of R125's care plan noted: Resident has an impaired pulmonary/respiratory status related to tracheostomy date Initiated 09/17/2024. On 10/17/24 at 10:39 Director of Nursing (DON) was interviewed and asked if water was needed for tracheostomy treatment of R125. The DON stated, It should not be empty .it should always have water. A review of the facility's policy Tracheostomy Care reviewed/revised 10/26/23, noted the following: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person care plan and resident goals and preferences.

This citation has two deficient practice statements. Deficient Practice Statement #1 Based on observation, interview, and record review, the facility failed to obtain and verify documented evidence (such as a medical power of attorney, patient advocate, legal guardianship, or living will) that a family member was authorized to designate a Do Not Resuscitate (DNR) directive for one resident (R#24) of a total of four sampled residents reviewed for advance directives, resulting in R#24 dying in the facility with unknown legal representation authorized to make life withholding treatment decisions, and the likelihood of other residents not receiving authorized life sustaining or life withholding treatment. On [DATE] at 10:15 a.m., the initial Immediate Jeopardy (IJ) concern was identified on [DATE] at 10:15 a.m. and began on [DATE]. The facility Administrator was notified of the IJ and a request for a written plan for removal occurred on [DATE] at 12:27 p.m. Findings included: On [DATE] at 7:48 a.m. during the initial pool process R#24 was observed in bed. R#24 presented with unclear speech however was able to answer with simple phrases (yeah, ok, no). The resident denied having pain, however presented with restlessness as evidenced by moving upper body, grabbing at the top of the bed, and at times grabbing at the air but would not say what he was grabbing at. R#24 was unable to participate in the interview. On [DATE] at 9:56 a.m. review of the electronic clinical record documented R#24 was initially admitted into the facility [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the quarterly Minimum Data Set assessment dated [DATE], R#24 had a BIMS (Brief Interview for Mental Status) of 2 (severe cognitive impairment) and required extensive - total care with activities of daily living. Review of the medical record revealed R#24 received hospice services from [DATE]- [DATE] but was discharged due to Patient no longer showing decline, patient discharged due to extended prognosis. On [DATE] an Advance Directive care plan was initiated and documented the following: Resident does not have an Advance Directive. POA/Guardian signed DNR [DATE]. DNR status. Further record review revealed a DO-NOT-RESUSCITATE ORDER PATIENT ADVOCATE CONSENT which documented the following: I authorize that in the event the declarant's (resident) heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law. The order had a signature on the Patient Advocate line and was dated for [DATE]. The individual that signed the order was identified in the medical record as R24's daughter. Review of a document titled Advance Directives/ Medical Treatment Decisions Acknowledge of Receipt dated [DATE] documented the following: The box was not checked for Medical Durable Power of Attorney (Patient Advocate) or Guardian. A handwritten note documented, Confused . Full Code . Unable to make decisions. The section designated for the Legal Representative to sign documented, NONE. The document was signed by facility staff. The Patient Advocate documents were not in the electronic medical record to verify the patient advocate had authority to make the Do-Not-Resuscitate decision for R#24. Documented evidence in which R#24 was declared incapacitated to make decisions independently was also not in the electronic medical record. The declaration would be needed in order for the Patient Advocate to be activated. On [DATE] at 1:05 p.m., the Administrator was asked to provide the Patient Advocate document for R#24. On [DATE] at 1:27 p.m., the Administrator returned and stated she was still looking for the Patient Advocate document and placed a call to the daughter to get it. The Administrator also stated medical records was searching in old files that did not transfer over from the old computer system. On [DATE] at 4:37 p.m. the Administrator stated she spoke with the daughter that was out of the country and would not be able to provide the document to the facility at this time, but assured she was the Patient Advocate and had provided the document to the facility some time ago. On [DATE] at 9:42 a.m., the Administrator was again asked to provide the Patient Advocate document. The Administrator stated the document could not be located within the facility. On [DATE] at 10:15 a.m. an additional visit was made to R#24's room. There were boxes packed with the resident's belongings and housekeeping was cleaning the room. The housekeeper stated R#24 passed away (died ) last night ([DATE]). Review of the following nurse's progress notes documented: -Nurse's Progress Note [DATE] at 06:53- Daughter made aware of change in condition. Did not want him sent out. Wants to be notified of chest x-ray. Call next family member if she is unavailable. -Nurse Progress Note [DATE] 22:47- Nurse entered patients' room at 22:05 pm. Resident noted to be in respiratory distress and declining rapidly. Code status indicates DNR, family was contacted and informed of change in condition. Nurse reentered the resident's room after speaking with family with other staff nurse shortly after resident showed respiration stopped and no heartbeat noted. 2 staff nurses evaluated resident and no signs of life noted at 22:15 pm. On [DATE] at 11:56 a.m. the Administrator was still unable to provide the Patient Advocate document with no evidence of the daughter legally authorized to make life withholding decisions. The Administrator was asked if the other family members noted in the nurse's progress notes dated [DATE] had access to the Patient Advocate document that named someone to make decisions if the daughter was unavailable. The Administrator stated she was not sure and from her understanding, the daughter has the Patient Advocate forms, locked in a cabinet in her home. Review of the facility's policy titled Residents' Rights Regarding Treatment and Advance Directives dated [DATE] documented: 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 . The facility will periodically assess the resident for decision-making abilities and approach the healthcare proxy or legal representative if the resident is determined not to have decision making capacities . 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 . The facility will use the process as provided by State law for handling situations in which the facility and/or physician do not believe that they can provide care in accordance with the resident's advance directives or other wishes. According to MCL 700.5507 Patient advocate designation; statement; acceptance effective [DATE], amended [DATE], documented: (1.) This patient advocate designation is not effective unless the patient is unable to participate in decisions regarding the patient's medical or mental health, as applicable. (4). A patient advocate may make a decision to withhold or withdraw treatment that would allow a patient to die only if the patient has expressed in a clear and convincing manner that the patient advocate is authorized to make such a decision, and that the patient acknowledges that such a decision could or would allow the patient's death. The facility presented an acceptable removal plan for the immediate jeopardy on [DATE] at 2:04 p.m.: Resident #24 no longer resides in the facility Regional Social Worker has completed an audit of all residents Code status to ensure that any Do Not Resuscitate orders that have been executed by a family member, the facility has documentation of Legal authority to do so on [DATE] at 1:15 pm. Regional social worker will re-educate social services personnel at the facility on the Resident Rights regarding treatment and Advance Directive Policy on [DATE] at 1:30 pm. The Administrator has notified the Medical Director on [DATE] at 1:28 pm. The Administrator will audit new DNR orders to ensure they are executed with legal authority. Additionally, the facility identified another resident (R#15) that did not have the appropriate documents that authorized the individual that signed the DNR order to make life withholding decisions, and was corrected immediately. Deficient Practice Statement #2 Based on interview and record review, the facility failed to ensure competent residents and/or legal representatives were involved in the formulation of an advance directive to grant and/or withhold life sustaining treatment (Cardiopulmonary Resuscitation/CPR, Artificial Nutrition/Peg Tube, Artificial Hydration/ IV, and Diagnostic Testing) according to their wishes for two residents (#18, #32) of four sampled residents reviewed for advance directives, potentially resulting in the denial of the resident's right to formulate an advance directive, and the potential for unmet resident health care decisions. Findings include: Resident #18 Review of the the Electronic Medical Record (EMR) revealed R18 had resided in the facility since [DATE] and had code status of 'Full Code', 'Fully Resuscitate'. R18 did not have an Advance Directive/Medical Treatment Decision form in the EMR. R18 had a family member that was the resident's court appointed Legal Guardian (LG). According to the Minimum Data Set (MDS) dated [DATE] R18 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R18 was assessed to have a Brief Interview for Mental Status (BIMS) or ,d+[DATE] which indicated moderately impaired cognition status. A review of the R18's care conferences on [DATE], [DATE], and [DATE] revealed the resident's LG attended the care conferences 'in-person', and on [DATE] the LG attended via telephone. None of the care conferences documented that 'Advance Directives/Medical Treatment Decisions' for R18 were discussed. On [DATE] at 1:11 PM, Administrator A was asked if there was an Advance Directive (AD) form for R18. At 4:28 PM the AD form had not been provided for R18. The Administrator said the AD form may be in the Social Worker's office. On [DATE] at 9:15 AM, Administrator A brought in an AD form for R18 dated [DATE] that indicated a telephone consent was obtained by the Director of Nursing from R18's LG. The AD form indicated the following; I do not choose to formulate or issue any Advance Directive at this time. It's signed by the Director of Nursing (DON) B. On [DATE] at 10:01 AM DON B said she called R18's LG over the phone to ask about Advance Directives for R18. DON B could not explain why the AD form was not completed during the care conferences. Resident #32 Review of an Electronic Health Record (EHR) revealed, Resident #32 (R32) had a code status of Full Resuscitate. R32 did not have a signed Advance Directive (AD). Review of an Admission Record revealed, R32 admitted to the facility on [DATE] with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, with a reference date of [DATE] revealed R32 had mild cognitive impairment with a Brief interview for Mental Status (BIMS) score of 12, out of a total possible score of 15. In an interview on [DATE] at 1:06 p.m., Administrator A reported could not locate an AD for R32 in the EHR. Administrator A reported she would call the hospice company to ask for R32's. In an interview on [DATE] at 8:34 a.m., Administrator A presented an AD for R32. R32's AD signed and dated [DATE] revealed, R32 did not wish to formulate an AD.

This citation pertains to intakes: MI 843, and MI 577. Based on interviews and record review, the facility failed to promptly assess resident's skin to identify changes in skin conditions and ensure interventions were implemented in a timely manner to prevent the development and worsening of pressure ulcers for two (R501, R502) of five residents reviewed for pressure ulcers, resulting in the development, and worsening of coccyx facility-acquired unstageable (obscured full-thickness skin and tissue loss) pressure ulcers that required hospitalization and surgical intervention. Findings include: Resident 501: According to the complaint intake, R501 admitted to the hospital's emergency room (ER) on 3/13/21 with an unstageable, infected pressure ulcer in the coccyx area that required intravenous antibiotics and immediate surgical intervention to debride the wound (surgically remove dead, infected tissue). According to the hospital's ER notes dated 3/13/21, R501 presented to ER with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . No measurements are provided. The 'ER plan' includes the following: 'General surgery was consulted for evaluation of sacral pressure ulcer to rule out necrotizing infection, which is likely the contributing source to his infection'. A closed record review for R501 revealed that he admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R501's initial skin assessment dated [DATE] revealed the resident had a 10 cm ( centimeter) surgical incision with no location specified, and a left elbow bruise. There are no other skin conditions identified. The Minimum Data Set (MDS) dated [DATE] indicated that R501 had moderately impaired cognition and required extensive assistance for 'bed mobility' and 'transfers between surfaces' from two staff members. R501 was identified to be frequently incontinent of bowel and occasionally incontinent of bladder. Section M 'Skin condition' indicated that R501 was 'at risk' for developing pressure ulcers and had 'none' at the time of the assessment. The MDS indicates that R501 is not provided a pressure relieving device for his bed, or his chair. The resident is not placed on a turning or repositioning program. A care plan for 'pressure ulcer' was initiated on 2/6/21 with the following intervention: skin inspections by CENA (Certified Nursing Assistant) during care and showers/baths. Report changes to licensed nurse immediately. There is no intervention for pressure relieving devices, or a turning and reposition schedule. On 2/19/21 (two weeks after admission) there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no corresponding skin assessment, or progress note regarding a change in R501's skin condition. The care plan for 'pressure ulcers' was not revised at this time. A review of R501's progress notes revealed one 'wound care note' from the Wound Care Nurse Practitioner (NP) C dated 2/24/21. On 2/24/21, the one progress note from NP C indicated that R501 had a stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss) pressure ulcer in the coccyx area that was a scattered area measuring 5.0 cm x 5.0 cm. Wound care treatments were ordered daily and as needed, along with a Low Air-Loss Mattress (LAL), and a ROHO cushion (inflatable gel cushion placed in the seat of a wheelchair that redistributes weight, prevents pressure ulcer/injury, and improves comfort while seated for long periods of time). The care plan for 'pressure ulcer' was revised on 3/2/21 to include the prescribed skin treatments. On 3/23/21 at 12:15 PM, NP C said that she only saw R501 one time because he went to [CONDITION(S)] three times a week and was not in the facility during the times she was there. NP said that she had ordered a LAL mattress and ROHO cushion for R501's wheelchair but could not confirm that he ever received the ROHO cushion. NP C went on to say that the facility has not had a 'wound care nurse' in the building for over a year. Skin assessments are not being done accurately, nor is she being notified in a timely manner when a resident is identified with skin breakdown. NP C said that R501 had skin breakdown prior to her initial assessment because an order was written on 2/19/21 for 'wound cleanser', but there was no skin assessment to correspond with that order. A review of R501's 'Braden' skin assessments conducted on 2/5/21, 2/16/21, and 2/23/21 all indicate R501 was 'at risk' to develop pressure ulcers. On 3/2/21 a 'Braden' skin assessment indicated R501 was 'at high risk' to develop pressure ulcers. A 'nurse progress note' dated 3/12/21 included the following: resident sacral/coccyx wound has necrotic tissue. Skin around wound is red. On 3/13/21, a 'nurse progress note' reads as follows: wound odorous and necrotic (darkened tissue that is dead), Physician wants the patient sent to the hospital for wound debridement. There are no measurements documented in the progress notes. R501 was transferred out to the ER according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/23/21 at 2:00 PM during an interview with staff member J the work order for a LAL mattress for R501 revealed that the resident received his LAL mattress on 2/25/21 (six days after the first observation of an open pressure ulcer). There was no documentation to support that R501 ever received a ROHO cushion for his wheelchair. On 3/23/21 at 2:30 PM, the Director or Nursing (DON) confirmed that R501 did develop the pressure ulcer while at the facility, and there was no documentation to support that a ROHO cushion had been placed on his wheelchair during his [CONDITION(S)] chair time. The DON reported that R501 would be at the hemodialysis for approximately five to six hours, for three days a week. Resident 502: According to the complaint intake, R502 admitted to the hospital's emergency room (ER) on 1/13/20 with an infected large pressure ulcer to her coccyx and sacral area that required immediate surgery to remove the dead tissue. According to the hospital's ER notes dated 1/13/21, R502 presented to the ER with a 'stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) in the sacral/coccyx area that had purulent discharge (thick, milky drainage), foul odor and [CONDITION(S)]. The wound measured 5.9 cm x 6.5 cm x 2.6 cm with undermining and tunneling. Wound cultures, intravenous antibiotics, and surgical intervention to debride the wound was ordered. The hospital records revealed the resident's sacral wound cultures were positive for several different types of bacteria. A closed record review for R502 revealed that she admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R502's initial skin assessment dated [DATE] documented the resident had 'suspected deep tissue injury' (DTI, deep tissue injury is an injury to the soft tissue under the skin due to pressure and is usually over boney prominences) of the coccyx area. There are no measurements. A 'norton' skin assessment (a tool used to determine risk for developing pressure ulcers) dated 12/18/19 identified R502 to be 'high risk' for developing pressure ulcers. The initial MDS dated [DATE] indicated that R502 had moderately impaired cognition and required limited assistance from one staff member for 'bed mobility' and 'transfers between surfaces'. Section M 'Skin condition' indicated that R502 was 'at risk' for developing pressure ulcers and had 'none' at the time of the assessment. The MDS indicates that she is on a pressure relieving device for her bed, but not her chair. R502 is not placed on a 'turning and repositioning' program. A care plan was initiated on 12/18/19 that had the following intervention: skin inspections by CENA (Certified Nursing Assistant) during care and showers/baths. Report changes to licensed nurse immediately. There are no interventions for a turning or repositioning prgram. On 12/21/19 at 10:51 AM a progress note documented R502 had a 'stage 3' pressure ulcer on her coccyx area that measured 3.0 cm x 3.0 cm. Wound care treatments were prescribed and the wound care nurse practitioner was consulted. Wound care orders were as follows: cleanse sacral area with wound cleanser and cover with hydrogel foam every day and as needed. On 1/3/20, the wound care nurse practitioner, (NP C) documented the following: initial would care visit. Stage 3 decubitus ulcer sacrum. 3.0 cm x 3.0 cm. Wound care orders were changed to include collagen directly to the wound and then cover with foam dressing. On 1/10/20, NP C's documented: sacral ulcer has declined since last seen the patient one week ago, wound base is now necrotic and malodor with discolored drainage. Measures 4.0 cm by 3.0 cm with an unknown depth. The wound is now unstageable and infected. Patient has a LAL mattress. Roho wheelchair cushion was ordered upon admission, this is needed as soon as possible. On 3/23/21 at 12:15 PM, NP C said that upon reading her note from 1/10/20 (over one year ago), it does indicate that R502 did not have a ROHO cushion on her wheelchair at the time of this assessment. During an interview with the DON on 3/23/21 at 2:30 PM, she had only been working in the facility for a few months, and therefore did not have any knowledge of R502's facility acquired pressure ulcer. The DON could not produce any documentation to support that R502 had received a ROHO cushion for her wheelchair, while R502 resided at the facility. According to the facility's 'Pressure Injury Prevention and Management' policy implemented on 1/1/21: This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. Definitions: Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. Avoidable means that the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Policy Explanation and Compliance Guidelines: 1. There are multiple terms used to describe this type of skin damage, including pressure ulcer, pressure injury, pressure sore, decubitus ulcer, and bed sore. For purposes of this policy, pressure injury, as the current standard terminology, will be used. 2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Assessment of Pressure Injury Risk: a. Licensed nurses will conduct a pressure injury risk assessment, using the Norton or Braden tool on all residents upon admission/re-admission, weekly x four weeks, then quarterly or whenever the resident's condition changes significantly. b. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. c. Assessments of pressure injuries will be performed by a licensed nurse, and documented in the medical record. d. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task. 4. 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.); ii. 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. d. Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. i. Pressure injuries will be differentiated from non-pressure injuries, such as arterial, venous, diabetic, moisture or incontinence related skin damage. ii. Treatment decisions will be based on the characteristics of the wound, including the stage, size, amount of exudate, and presence of pain, infection, or non-viable tissue. e. The goals and preferences of the resident and/or authorized representative will be included in the plan of care. f. Interventions will be documented in the care plan and communicated to all relevant staff. 5. Monitoring a. The attending physician will be notified of: i. The presence of a new pressure injury upon identification. ii. The progression towards healing, or lack of healing, of any pressure injuries weekly. iii. Any complications (such as infection, development of a [MEDICATION(S)] tract, etc.) as needed. b. The effectiveness of current preventative and treatment modalities and processes will be discussed in accordance with the QAA Committee Schedule, and as needed when actual or potential problems are identified. 6. Modifications of Interventions a. Any changes to the facility's pressure injury prevention and management processes will be communicated to relevant staff in a timely manner. b. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include: i. Changes in resident's degree of risk for developing a pressure injury. ii. New onset or recurrent pressure injury development. iii. Lack of progression towards healing. iv. Resident non-compliance. v. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights.

This citation pertains to MI 854 Based on interview, and record review, the facility failed to consistently assess and provide interventions to prevent the worsening of a resident's skin integrity (#602) in a timely manner; this deficient practice resulted in the development of a large unstageable pressure ulcers ( pressure ulcers that are covered with dead tissue that prevents accurate assessment of depth and width) and a right foot deep tissue injury (injury of the skin due to pressure). Findings include: A review of the Admission Record and Minimum Data Set ((MDS) dated [DATE] revealed resident 602 was admitted to the facility on [DATE] and discharged on [DATE]. Resident 602 admission [DIAGNOSES REDACTED]. The MDS indicated the resident's Brief Interview for Mental Status (BIMS) score as 15/15; a high level of cognition (thought processes). Resident (#602) was non-ambulatory and required extensive one-person assistance with transfers. An interview was conducted with the Administrator on 6/25/20 regarding the care of resident's pressure ulcers in the facility. The Administrator stated, the care of pressure ulcers is provided by nurses on the floor. Our former wound care nurse is no longer working here, our new wound care nurse is still in orientation, and the DON is new to our facility. The Administrator was asked if documentation related to pressure ulcers would be in the electronic medical records, the Administrator stated, yes. A record review of resident 602's admission nursing assessment conducted on 4/7/20 revealed the resident was admitted from the hospital with [DIAGNOSES REDACTED]. The admission nursing skin assessment stated, patient buttocks red. A record review of resident 602's skin admission care plan revised on 4/9/20 revealed, The potential for impairment to skin integrity related to impaired mobility. The goal indicated the resident was at significant risk for skin injury. Interventions consisted of: Assisting the resident with turning and repositioning to prevent skin breakdown, monitoring/documenting location, size, and treatment of [REDACTED]. to physician/provider. A record review of the corresponding Certified Nursing Assistant (CNA) tasks specific to skin care for Resident 602 included: application of skin protectant to the buttocks every shift. Charting of the application of the skin protectant began on the night shift of 4/7/20 and was present on all three shifts from 4/8/20 to 4/17/20. A review of the physician's history and physical dated 4/8/20 under the Review of Systems section revealed, the skin was determined to be within normal limits. The Physical Exam section was determined to be negative for the skin condition and wounds. A record review of the Dietitian's initial assessment of resident 602 dated 4/12/20, stated the resident's skin is intact. Review of a late entry nursing note dated 4/21/20, Writer called resident's husband Anthony to discuss husbands' concerns related to residents' wounds. No answer. Writer will attempt to recontact. An additional review of a late entry nursing note dated 4/30/20, Writer called resident's husband Anthony to discuss husband's concerns related to wounds. Husband stated that resident is still in the hospital and wound to butt is 9.0 x 11.0cm. Writer explained to husband that resident was seen by wound care nurse on 4/12 and the wound was noted, and treatment plan started. Writer explained that resident was seen by MD on 4/13 and 4/14 and decline was noted on 4/14 in resident's condition. Labs and x-ray ordered by MD on 4/14. Writer further explained that resident was seen by wound care Nurse Practitioner on 4/15 and wound had increased in size and that resident had a decline. Writer explained that resident had a low air loss mattress, RoHo cushion and heel float boots in place and was in yellow dot turning program. Review of Wound Care Nurse Consultant dated 4/15/20 identified the chief complaint as, large unstageable pressure ulcer to sacrum that extends to proximal buttocks, deep tissue injury right heel. Under the section entitled, History of Present illness, the consult stated, Today's initial wound consult requested by medical physician for evaluation and treatment of [REDACTED]. Currently it is unclear when these wounds were acquired. This wound is concerning and measures 7 cm in length by 8cm in width with undetermined depth. Right heel deep tissue injury measure 2cm width with no depth. Low-air-loss mattress recommended as well as soft boots to protect her feet and heels. An interview was conducted with the Administrator regarding the lack of assessment and documentation regarding the resident's wound in the electronic record. The surveyor informed the Administrator resident 602 was admitted to the facility with redness on both buttocks. The resident's buttocks wounds and right foot deep tissue injury did not appear to be present on admission. the Administrator stated, I don't know that. When asked about the lack of skin assessment, during the days of the resident's admission, the Administrator stated the resident was on a Covid-19 observation unit and the residents on that unit were not receiving showers. The Administrator, stated, I believe the former wound care nurse was off a few days during the period the resident was here; but usually when she comes back, she checks with the resident. The Administrator called the former wound care nurse to the facility to meet with the surveyors. When asked about the resident, the former wound care nurse stated, I saw the resident. When asked for her notes, the former wound care nurse provided the surveyor with the 4/15/20 wound care assessment developed via the Wound Care Nurse Consultant. When a facility pressure ulcer policy was requested, the Administrator provided the resident with a document entitled, Pressure Ulcers/Pressure Injury Prevention and Treatment Clinical Protocol with a revision dated of November 28, 2017. The purpose statement indicated, 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. Under number 1 of the policy entitled Prevention, an admission evaluation helps identify residents at risk of developing pressure ulcer/pressure injury, and residents with existing Pressure Ulcer/ Pressure Injury. Because a resident at risk can develop a pressure ulcer/pressure injury within hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt prevention. Under number 5 entitled Continued assessment and management, Weekly skin evaluation/assessment by the licensed nurse on residents who have no Pressure Ulcers/Pressure Injuries. The CNA completes a skin worksheet/point of care (POC) documentation with bath/shower.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to a resident (98) with a known history of behaviors, resulting in the resident falling and sustaining an injury to her wrist; requiring transfer to the hospital with a [DIAGNOSES REDACTED]. Findings include: During the initial tour conducted on 2/23/20 at 6 PM, resident (98) was observed lying in bed, a certified nursing assistant (CNA) was observed siting at the resident's bedside. The CNA was asked if she worked for the facility, or if she was contracted from an outside company to sit with the resident. The CNA, stated, I work at this facility and I am providing the resident with a one-to- one (CNA assigned to remain with a resident throughout a shift or shifts). On 2/24/20 at 1:30 PM CNA sitter was observed walking the resident in the hall via a wheelchair. According to a record review conducted on 2/24/2, resident (98) was initially admitted to the facility on [DATE], discharged on [DATE] due to a fall, and readmitted on [DATE]. A readmission Significant Change Resident Assessment was conducted with a reference date of 2-6-20. The resident's [DIAGNOSES REDACTED]. The BI[CONDITION] (Brief Interview for Mental Status) scored the resident 3/15, indicating severe cognitive (thought process) impairment. The resident's assessment was updated with a psychiatric disorder of anxiety. In addition, the assessment revealed the need for extensive two-person assistance with activities of daily living such as transfer, bed mobility, dressing, and extensive one- person assistance with personal hygiene, total dependence on one person with eating. Resident (98) required the use of a wheelchair for ambulation and one-person assistance (to steady the resident) when moving from seated to standing positions, and for surface-to-surface (transfer between bed and chair or wheelchair). The resident is always incontinent (unable to hold) of bowel and bladder. The resident's care plan was updated in accordance with the 1/13/20 significant change resident assessment, to include goals specific to Fall Risk to reduce the risk of serious injury in the event of a fall. Interventions included the provision of a 1:1 sitter (the assignment of one CNA to remain with the resident throughout the shift or shifts) during periods of restlessness. A Behavior Care Plan was developed to address the resident's resistance to care and combativeness. Interventions included: assessing the resident for pain, incontinence, praise when behavior is appropriate, and Psychiatric evaluation as needed. A record review conducted on 2/25/20 at 8 AM revealed the residents sustained falls on the following dates: 9/3/19, 12/10, /19, 1/9/20, and 1/12/20. On 9/3/19 the resident was observed lying on the floor in her room. The fall was un-witnessed, and the resident sustained [REDACTED]. The root cause was of the fall was identified as impulsiveness. Care plan updated to include the use of a one-to-one nursing assistant upon resident's release from the hospital. On [DATE] the resident sustained [REDACTED]. The resident did not sustain an injury during this fall however the results of the investigation indicated the resident has no safety awareness and is impulsive. The care plan was updated to include toileting prior to assisting the resident to bed. The resident was also placed on every 15 minutes safety checks. On 1/9/20 the resident was observed on the floor in her room. The fall was un-witnessed, and the resident was assessed as confused and disoriented. Interventions included changing resident's 6 AM medication to 8 AM so as not to disturb her sleep. The root cause of the resident's falls was identified as impulsive behaviors. On 1/12/20 the resident was observed on the floor sitting in the hallway in the front of her room with the left side of her forehead bruised. According to the investigation documentation, the resident sustained [REDACTED]. The fall occurred at 6 AM. The resident was transferred to the hospital. According to the hospital records the resident sustained [REDACTED]. An interview was conducted with the Administrator regarding the resident's fall on 1/12/20 that resulted in a fractured wrist. The Administrator stated, we did not know her wrist was fractured. The resident had a one-to-one sitter prior to this fall on all three shifts because of behaviors, however we decided to take the resident off the one-to-one sitter on the Midnight shift because resident (98) was sleeping during that time. The Administrator was asked the time of the fall on 1/12/20. The Administrator stated, the fall occurred at about 6 AM. We are unable to keep the resident on one-to-one sitters at this facility. We have tried to contact her daughter via phone to discuss this with her; however, she has not responded. At this point we are looking at processing an involuntary discharge for this resident.

Based on observation, interview and record review, the facility failed to document, care plan and implement appropriate interventions timely for one (#603) of three sampled residents reviewed for skin integrity, resulting in the development of a pressure sore, and the potential for worsening or delayed healing of the sore and development of further sores. Findings include: On 1/14/20 at 11:10 AM, resident #603 was observed dressed and sitting in a wheelchair in the hallway with a Hoyer (total body mechanical) lift sling underneath. He was placed in bed for a skin observation in the presence of nurse Unit Manager B and nurse C. The resident was alert, confused and slow to respond to questions. When his incontinence brief was opened, there was a pressure sore on the coccyx that the resident had been sitting on, covered by a piece of soiled gauze that was wedged between the buttocks. The sore was at stage 3 (full thickness skin loss) and had necrotic (black, dead) skin around the edges, yellow drainage, appeared approximately 3 centimeters (cm) in diameter and surrounded by deep rose-colored skin. Nurse B was asked to press the discolored area to see if it was blanchable (had return of blood flow once the finger was lifted), but the color remained unchanged. When asked if she knew the sore was there, nurse B said no. The resident had a wheelchair in the room with no pressure relief-type cushion in the seat. Nurse B said, He used to have a Broda chair, but it was switched out. He was doing well in it. (Broda chairs tilt back and are used for difficult positioning for comfort, such as with spinal conditions and for air circulation to prevent moisture and skin breakdown.) Nurse B said she did not know when the Broda chair was removed or why. She said that the resident was receiving Hospice services and they were responsible for providing the resident's equipment. At 11:30 AM, the resident's clinical record was reviewed and noted: an admission into the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum data sets completed 10/7/19 and 1/6/20 noted the resident had severe cognitive impairment, difficulty communicating, was non-ambulatory, required extensive assistance for care including bed mobility, was incontinent of bowel/bladder and receiving Hospice services for a [DIAGNOSES REDACTED]. The resident's care plans were as follows: A Skin care plan written by Hospice staff, dated 11/14/19 noted: Patient is at risk for skin breakdown due to immobility. Teaching done on importance of 'removing the Hoyer sling from under patient' so as to not cause breakdown. (Per a facility nursing note dated 11/17/19: writer did the skin assessment on resident, resident is having dry and scaly skin over his sacrum (coccyx area) ) A Skin care plan written by the facility, last revised 10/7/19 noted: (Resident) is at risk for pressure ulcer development related to incontinence and impaired mobility (Resident's) risk of significant skin injury will be reduced/minimized Therapy/Hospice to provide cushion to residents wheelchair. There were no documented revisions to either care plan to reflect that an actual pressure sore had developed and interventions for care. On 1/14/20 at 2:35 PM, when queried interim wound care nurse [NAME] said that she was not aware of the pressure sore, was just told about it by staff and that documentation and interventions were just put in place. On 1/15/20 at 8:30 AM, the resident's clinical record was again reviewed. Per notes dated 1/14/20 at 2:01 PM- Writer made aware of new area on residents coccyx. Resident has new open area stage III of 2.5 cm by 2 cm. New order for [MEDICATION NAME] (a gel forming dressing that provides moisture and promotes healing) started, area cleansed and new [MEDICATION NAME] applied; At 4:48 PM- small open area over coccyx, partially scabbed over. About 3 cm by 3 cm. Interventions: Hospice ordering 'gel' (pressure relief) cushion to replace current one Referrals: Wound care consult (an evaluation by the contracted wound specialist). On 1/15/20 at 8:50 AM, the resident was observed frowning, grimacing and sitting upright in the wheelchair on a cushion. When asked how he was doing, the resident repeated several times, Not too good, but had difficulty expressing what was wrong. When asked if he was in pain and where, the resident said, Yes, my bottom side. Nurse G was called to the room and she asked the resident to say what his pain level was on a scale of 1 to 10. After some difficulty, the resident said, 10. She said, I never heard him say he had that much pain before. Nurse G was observed giving the resident [MEDICATION NAME] for pain. Therapy manager H was called to the room and asked about the resident's cushion. She said, It's a pommel cushion, which had an elevated wedge in the middle between the legs, used to prevent falls from sliding forward, not pressure relief. Staff H was asked if a gel cushion was appropriate. She explained that gel cushions conformed to the body and were standard in wheelchairs for all the residents without pressure sores. She said a Roho cushion was usually recommended when pressure sores were present because it was inflated with air and adjusted to position changes. While talking with staff H, the resident was grimacing in pain and yelled, Can you help me with this chair! Nurse B came to the room, asked the resident if he wanted to get in bed and he said, yes. Nurse B said, I'll call (Hospice) and get a different chair, like a geri-chair (a lounge-type chair for comfort that is wider, roomier and easier to reposition in. The chair can be reclined with leg/foot elevation to prevent sliding forward for safety, making the Pommel cushion unnecessary) and a cushion. The resident was placed in bed. Gel cushions were observed in the wheelchairs of four residents sitting in the hallway and in the surrounding rooms. At 11:50 AM, when asked why the Broda chair was removed, the Director of Nursing (DON)said, Hospice doesn't use Broda chairs anymore. We're looking into a geri-chair and the right kind of cushion. She did not explain why a geri-chair was not provided after the Broda chair was removed or a gel cushion was being requested rather than a Roho-type cushion. The DON did not respond when asked how the pressure sore could have advanced to stage 3 with nonblanchable and necrotic skin without any prior documented observation by staff until 1/14/20, during the survey and no care planning and proper wound care implemented On 1/15/20 at 5 PM, per review of the facility's Pressure Ulcers/Pressure Injury Prevention and treatment-Clinical Protocol dated 11/28/17: 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 New skin alteration: .Update plan of care to reflect any new risks, goals, and interventions.

This citation pertains to Intakes M 8045 and M 7777 This citation has two deficient practices: Based on observation, interview, and record review the facility failed to follow the care plan for the use of a mechanical Lift (a device most commonly used to move those who are unable to stand on their own; making it unsafe to move or lift manually) for transferring one (R#801) of three residents reviewed for falls, resulting in the resident being injured and transferred to the hospital for further treatment and evaluation. Findings include: Review of the Facility's Investigational Summary dated 11/1/19, on 10/31/19 at 9:45 P.M. R#801 was being transferred by Nurse Aid K , while transferring R#801 legs kicked off the wall and the resident fell out of the sling to the floor, hitting his head. R#801 was transferred to a local hospital for further evaluation and treatment for [REDACTED]. On 12/6/19 at 9: 00 [NAME]M., Review of the care plan initiated 12/27/2018, Titled: Activity of Daily Living (ADL) R#801 has an ADL self-care performance deficit R/T muscle weakness. Goal: R#801 will participate in all ADL's to maximum ability through next review. Interventions: documented (included but not limited to) included: *two persons on mechanical Lift for transfers and two-person extensive assist with bed mobility/ toileting/activities of Daily Living (ADL's). *Apply leg brace to left leg in the [NAME]M. and he is to wear it as long as tolerated. * Encourage R#801 to get up and out of bed every day by 10:00 [NAME]M. etc . On 12/6/19 at 8:50 [NAME]M, during interview with the Administrator, Director of Nursing (D.O.N.) and Assistant Administrator whether N.[NAME] K followed the Care Plan for R#801during the transfer the D.O.N. responded NO. When asked, should R#801 have been transferred with two (2) persons, the response was yes' The D.O.N. stated: We recognized this as a problem. N.[NAME] K knew she should have followed the Care Plan, why she did not, I do not know. The Care Plan was reviewed and was appropriate for the resident. Review of the Clinical Records from the Hospital documented R#801 was transferred back to the facility on [DATE]. On 12/6/19 at 11:30 [NAME]M. review of the Facility's Policy revised 8/2016, Titled: Mechanical Lift stated: 1. Review the resident's Care to assess for any special needs of the resident. 2. Two (2) Nurse Assistants (N.[NAME]) will be required to perform any mechanical lift procedure. A request was made to interview N.[NAME]K but the employee had been suspended and the telephone number provided by the facility indicated the number was no longer active. Review of the Clinical Record documented R#801 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], R#801 was moderately impaired in cognitive skills for daily decision making, had long and short-term memory problems and was totally dependent on staff forall Activities of Daily Living with two + persons physical assist with transfers. Deficient practice #2 Based on observation, interview and record review the facility failed to supervise and ensure physician's orders [REDACTED].#801) of three residents reviewed with [MEDICAL CONDITION] and orders for Nothing by mouth (NPO) , resulting in the potential for aspiration and or choking. Findings include: On 12/4/19 at 10:32 [NAME]M., during a telephone interview, the wife of R#801 reported her husband had received a tray and consumed some of the food that should have been served to his roommate. According to the resident's wife her husband had a [MEDICAL CONDITION] and should have been NPO, since he received all his nutrition by a (percutaneous endoscopic gastrostomy) peg tube. The wife stated this incident occurred earlier on the same day when the resident fell from the mechanical lift. On 12/5 at 9:30 [NAME]M. and on 12/6/19 at 10:00 [NAME]M. R#801 was observed with a closed enteral Container hanging at his bedside. Review of the care plan initiated 12/27/2018, titled: R#801 requires tube feeding related to severe dysphagia. Goal: R#801 will be free of aspiration through the review date. Interventions (initiated 12/27/18) included: Nothing by mouth (NPO) observe all aspiration precautions. Elevate head of bed. On 12/6/19 at 8:50 [NAME]M, during interview with the Administrator, Director of Nursing (D.O.N) and Assistant Administrator the D.O.N. reported the resident should not have received the tray and Nurse Assistant ---- had served him the tray that should have been served to his room mate in (bed2). R#801 reportedly ate 15% to 30% of the pureed tray served with Thickened liquids. The D.O.N. reported R#801 did not choke but was coughing requiring the nurse to suction his airway. While at the hospital for the fall R#801 was checked (X-Ray) to ensure the resident did not aspirate. On 12/6/19 at 12:30 P.M. interview with the Speech Language Pathologist (SLP) , revealed the wife had requested a swallowing assessment on 10/17/19. The conclusion and recommendations approved by the Physician stated: NPO for liquids and solids secondary to dysphagia and oropharyngeal phase. The SLP reported during the testing phase R#801 had an excess oral secretions and ice cubes were not recommended or used .

This pertains to intake #s MI 614 and MI 964. Based on interview and record review, the facility failed to assess, care plan, consistently bathe and turn and reposition as scheduled, one (#224) totally dependent sampled resident of four sampled residents reviewed for skin integrity, resulting in the development of multiple facility acquired pressure sores, infection in a pressure sore and emergency hospitalization . Findings include: The complainant reported to the State Agency that resident #224 was not assessed, bathed or turned and repositioned causing development of multiple pressure sores at the facility and infection to a wound. On 6/27/18 at 11 AM, the clinical record for resident #224 was reviewed. The resident was transferred to the facility on [DATE] after an admission on 10/18/17 into a facility that specialized in ventilator dependent residents. The resident's [DIAGNOSES REDACTED].difficile (a bacteria causing diarrhea) and history of [MEDICAL CONDITION] ([MEDICAL CONDITION]-blood clots in one or more veins commonly in the legs typically from poor circulation). The minimum data set ((MDS) dated [DATE] noted that the resident had severe cognitive impairment, a gastric feeding tube, was incontinent of bowel/bladder, had one stage 2 (partial skin thickness loss) pressure sore with granulation (new, healing) tissue that was present on admission, was at risk for development of pressure sores and required total assistance for all care. The resident's admission Nursing Evaluation dated 12/19/17 noted that the resident did 'not' have any identified skin conditions or wounds, contrary to the MDS data. A Norton Plus Pressure Ulcer (risk) Scale dated 12/19/17 noted that the resident was at high risk for development of pressure sores. The resident's At risk for impaired skin integrity care plan, related to impaired mobility initiated 12/20/17, did not note that there was actual impairment to the skin. The care plan goal-Will not have any complications in skin integrity related to impaired mobility through next review (on 3/19/18). The care plan interventions, both initiated on 12/20/17, included: Assist with turning and repositioning to help prevent skin breakdown, Monitor for signs/symptoms of skin breakdown and notify wound care if present. An Impaired skin integrity care plan dated 12/22/17 noted that the resident had the stage 2 pressure sore on the left buttock. Interventions, all initiated on 12/22/17, included: Monitor skin during care/bathing for breakdown. Report changes to nurse/wound care, Resident will be followed by wound care weekly until wound resolves, Treatment as ordered by MD, Turn and reposition resident frequently and PRN (as needed). There were no care plan interventions specific for the feet, such as pressure relief boots, heel protectors or floating of heels. Resident #224's History and Physical dated 12/20/17 noted: Stage 2 decubitus ulcer (pressure sore) to the sacral area, prognosis poor and contractures to unidentified areas. Plans included: repositioning for the decubitus ulcer. The resident was prescribed on 12/22/17: Cleanse left buttock wound with wound cleanser and cover with [MEDICATION NAME] (absorbent, non-breathable) dressing every Monday-Wednesday-Friday. The order had a start date of Monday, 12/25/17. Per a New admit wound care skin assessment dated (Friday) 12/22/17, the left buttock pressure sore measured 0.7 centimeters (cm) by 0.8 cm. The wound was cleaned and the dressing was applied. There were no other identified, documented wounds in the assessment. On 6/27/18 at 12:50 PM, resident #224's clinical record was further reviewed with wound care nurse 'N'. According to the resident's treatment administration record (TAR) for 12/2017, there was no indication that wound care was provided as prescribed on 12/25/17 or on Wednesday, 12/27/17. When asked why, nurse 'N' said she did not know why staff did not do the treatments and that she was off due to the holiday. The TAR indicated that wound care was next provided on Friday, 12/29/17 by nurse 'N'. Nurse 'N' said the resident was being seen by the facility's contracted wound care specialist, Nurse Practitioner (NP) 'CC', who came to the facility on ce a week. On 12/25/2017 at 9:35 PM-Progress Note by NP 'CC': Resident presented with a small stage 2 pressure wound to the left buttock on admission. This open wound measures 0.7 cm in length x 0.8 cm in width with a depth of 0.1 cm. [MEDICATION NAME] pink tissue is noted with scant serous (yellow) drainage. Periwound area is intact. His chronic diarrhea is being managed and he is on contact isolation for [DIAGNOSES REDACTED]. infection Due to his limited mobility with other problems, he is at risk for other skin and wound problems and bears watching. Follow Up: I will see him in one week. A weekly Skin assessment dated [DATE] noted resident #224 had a small opening to the sacral area. There were no documented nursing progress notes between 1/1/18 thru 1/19/18. Per the resident's Impaired skin integrity care plan, an intervention was initiated on 1/4/18: Resident is in yellow dot program (a turning and repositioning schedule). Resident #224's TAR for 1/2018 noted that the left buttock was last treated on Friday, 1/5/18 by nurse 'N'. There was no documented treatment for [REDACTED]. she last saw the resident on 1/11/18 at which time the left buttock wound had resolved (healed) and did not see the resident again until 1/19/18. Per a skin note dated 1/11/2018: Left buttocks: resolved Resident is in yellow dot program. There was no mention in the note regarding presence of any other wounds. Per a 1/15/2018 physician progress notes [REDACTED]. When asked if the physician had personally assessed the resident's skin, nurse 'N' said that the physician probably noted what he was told by staff about it being better because by that time it was resolved. The following occurred on 1/19/18 regarding resident #224: 9:22 AM Progress Note by NP 'CC': Asked to see patient this morning for multiple wound sites hot to touch with fever Unfortunately he has developed eight wound sites Appears septic. His medical physician notified by staff and patient being transferred to hospital E.D. (emergency department) for further evaluation and tx (treatment). Per nurse 'N', she had asked NP 'CC', who was on-site at the time, to see the resident. 11:04 AM Progress Note by NP 'CC': Reason for Appointment 1. Multiple wounds to the trunk region and lower extremities Resident is known to me in the past. Nursing staff reports that unfortunately he has developed multiple wounds 'within the past week' to trunk region and lower extremities and one wound to the left axilla (arm pit) region is hot to touch. Vital Signs Temp 99.5 F Res (respirations) 26/min Resident appears ill with visible rigors (chills) [MEDICAL CONDITION] noted with the pulse rate of 122 to 130 Very contracted lower exts (extremities) Multiple new wound sites 1. Decubitus ulcer, ankle, right, unstageable (full thickness skin loss with dead tissue at the base of the wound) 2. Decubitus ulcer, buttock, right, unstageable 3. Decubitus ulcer of right foot, stage 2 4. Blister (a stage 2 pressure sore) of left heel medial aspect 5. Decubitus ulcer, hip, left, unstageable 6. Stage 2 decubitus ulcer to left flank, axilla. 7. Blister of left ankle lateral aspect. 8. Blister of right foot medial Notes: Resident has a total of eight skin and wound problems seen today appears septic Sites are as follows; right lateral ankle has unstageable decubitus ulcer with necrotic (dead tissue) base that measures 3 cm in length x 3 cm in width with the depth of UTD (unable to determine). Wound base is leathery in appearance with minimal serosanguineous (bloody/yellow) drainage to the perimeter with mild [MEDICAL CONDITION]. Right buttock unstageable decubitus ulcer has 100% dry necrotic wound that measures 2 cm in length x 3 cm in width with the depth of UTD. Mild induration (inflamed, leathery) is noted to the perimeter. Minimal serosanguineous drainage. Right lateral foot, he has small stage 2 decubitus ulcer measures 1 x 1 cm x 0.1 cm. Scant serosanguineous drainage is noted. No sign of infection. Left medial heel, he has a large blood blister (stage 2 pressure sore) that measures 2 cm in length x 2 cm in width with the depth of 0.1 (cm) sanguineous filled blood blister Left hip, he has an unstageable decubitus ulcer that measures 3 cm in length x 3 cm in width with the depth of UTD. Dry necrotic wound base is noted with scant serosanguineous drainage to the perimeter with mild [MEDICAL CONDITION]. Left axilla, right has a stage 2 decubitus ulcer that measures 0.9 cm in length x 0.9 cm in width with the depth of 0.1 (cm) breakdown is noted with scant serosanguineous drainage. No sign of infection. Left lateral ankle blood blister is intact and measures 1.5 cm in length x 2 cm in width with the depth of 0.1 cm. Right medial foot, he has a fluid filled blister that measures 1 x 1 cm x 0.1 cm that is intact with no drainage. For today, absorbent foam dressings were applied to all wound sites after cleansing with wound cleanser. His medical physician was notified and it is recommended that he go to the hospital and be evaluated for further treatment of [REDACTED]. A weekly Skin assessment dated [DATE] noted that resident #224 had a left rib cage blister. When asked how the wounds could have possibly developed and gone undetected by staff until 1/19/18, nurse 'N' said that she did not know about the wounds until 1/19/18, they were not reported to her by staff and said, He was really sick. When mentioned that the resident was in poor health on admission after being on a ventilator, yet presented with only one stage 2 wound to the left buttock and the fact that the resident's wound was still capable of healing despite being inconsistently treated, nurse 'N' shrugged and said, I don't know. Nurse 'N' indicated that she did not know how a pressure sore developed to the resident's left flank/armpit region. On 6/27/18 at 3:10 PM, NP 'CC' was queried by phone regarding how and when the resident could have developed the multiple wounds that she evaluated on 1/19/18. She said, The last time I saw him, he had a pressure ulcer that had resolved. I don't know what happened after that. Resident #224's clinical record noted the following: -an order for [REDACTED].>-A Kardex (care guide used by nurse aides) noting: Resident is in yellow dot program and Turn and reposition resident every two hours and PRN (as needed) or frequently; -The TAR for 1/2018 had no documented treatments for the left rib cage/axilla region blister that was observed on 1/10/18 in the weekly Skin Assessment; -No documented care plans or treatment orders for the eight wounds until 1/19/18. Per Documentation Survey Report records, which recorded activities of daily living (ADL) for resident #224 dated 12/2017 thru 1/2018, the resident was scheduled for bathing every Monday and Thursday and was in the yellow dot program. However, the report noted that the resident was bathed three times since admission, on Thursday-12/28/17, Monday-1/15/18 and Thursday-1/18/18 and the report was blank each day for any indication that the resident was turned and repositioned. The resident's ADL (activities of daily living) care plan initiated 12/19/17, noted interventions: The resident is to (be) bathed 2 times per week on Monday and Thursday On 6/27/18 at 4:05 PM, the Director of Nursing (DON) was asked why resident #224, who was totally immobile and contracted, was placed in the yellow dot program on 1/4/18 rather than upon admission. She said, I don't know. I'll have to ask (nurse 'N). When asked how all of the wounds, some of them necrotic and unstageable, could have gone undetected by staff until 1/19/18, the DON did not respond. When shown the records indicating the resident was not turned/repositioned as directed by the yellow dot program and that three documented baths were given during admission, the DON did not respond. On 6/28/18 at 8 AM, clinical records from the previous (ventilator) facility and from the hospital were reviewed as follows: Per a Wound Progress Note from the previous facility dated 12/19/17: Resident #224 had a resolved (healed) left ischial pressure sore, a resolved ulceration to the scrotum that was cause by moisture and had only one-stage 2 pressure sore to the left buttock upon transfer to the next facility (Medilodge). Per hospital emergency room notes post transport from Medilodge on 1/19/18 at 1:07 PM: temperature prior to arrival was 101 degrees. On 1/20/18, wounds were described at the hospital as follows: right lateral ankle unstageable (USTG) pressure ulcer 3.5 cm by 3.5 cm right lateral foot USTG pressure ulcer 1.5 cm by 2 cm right buttock USTG pressure ulcer 4 cm by 2.5 cm by 0.25 cm left heel black fluid filled deep tissue injury (DTI-pressure sore underneath intact skin that looks like a dark bruise on the surface) 2.8 cm by 2.5 cm left inner buttock stage 2 pressure ulcer 0.5 cm by 0.5 cm left hip USTG pressure ulcer 7.5 cm by 4.5 cm with malodorous drainage (a sign of infection) left lateral ankle USTG pressure ulcer 3.5 cm by 3 cm. Resident #224 was placed on intravenous (IV) antibiotics. The resident was noted to have a history of [MEDICAL CONDITION]. However, per a vascular examination conducted by the hospital Podiatrist on 1/20/18: Pedal pulses are palpable bilateral feet. Capillary refill time (a test used to determine the amount of blood flow) is intact to digits both feet need to offload the ulcerations bilateral lower extremities with pressure offloading boots need to keep both feet elevated with pillows to avoid pressure ulcerations The exam indicated that the resident's sores were caused by pressure rather than due to a vascular condition, such as [MEDICAL CONDITION]. On 6/28/18 at 8 AM, per review of the facility's Pressure Ulcers/Pressure Injury Prevention and Treatment-Clinical Protocol' dated 11/28/17: 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 Because a resident at risk can develop a pressure ulcer/injury within hours of the onset of pressure, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcer/injury Because deep tissue injuries may not be visible upon admission and can develop in as little as 2 hours, they should be investigated for causation within the prior 7 days The facility should have a turning and repositioning program which allows staff to know resident's individual intervention and monitoring. The following is but one example of such a program: Yellow Dot-Residents who are at high risk for the development of pressure ulcer/injury based on the Norton's Plus evaluation will have a yellow dot on the door/nameplate of the resident's room and wheelchair: Plain yellow dot-Turned and repositioned every 2 hours

Based on observation, interview and record review, the facility failed to test and monitor for renal (kidney) functions and failed to provide timely, appropriate hospital care and services for one (#91) of 58 sampled residents reviewed for quality of care, resulting in lethargy, unresponsiveness, acute [MEDICAL CONDITION], acute kidney injury and failure, emergency hospitalization and ventilator life support. Findings include: On 6/25/18 at 9:15 AM, resident #91 was observed lying in bed. The resident was alert, able to answer most questions and was feeding himself pureed food for breakfast. When asked how the food was, he shook his head and said, not that good, continued to eat, but said he would like to get something else to eat and some juice, while pointing at a food item and saying, I don't like that. The resident was observed to have a suprapubic urinary catheter (tube inserted through the abdomen into the bladder). On 6/26/18 at 1:30 PM, the resident's Hospice documentation was reviewed in a folder at the nurses station. The Hospice nurse noted during a visit on 6/25/18 that the resident was found to be eating well and planned to discuss with staff an upgrade of the resident's diet from puree to a more advanced or regular texture. At 3:30 PM, Registered Dietician 'B' said she was unaware of the Hospice note and would look into it. On 6/27/18 at 11:33 AM, resident #91's clinical record was reviewed with the Director of Nursing (DON). The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was receiving Hospice care. The resident's [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] noted the resident had moderately impaired cognition, was ambulatory and required only supervision for care at that time. Resident #91's clinical record revealed the following: 4/1/2018-physician progress notes [REDACTED]. Reason for visit: follow-up debility and pain/[MEDICAL CONDITION]. Patient seems to have lost weight. Lungs: CTA (clear to auscultation) Abdomen: Soft; non tender Extremities: No [MEDICAL CONDITION] Neuro: Alert and oriented to name. Skin: Warm and dry. no lesion or rash 1. Debility 2. Hypertension 3. OA ([MEDICAL CONDITION]) 4. Dementia 5. CAD ([MEDICAL CONDITION]) 6. ckd ([MEDICAL CONDITION]) 7. [MEDICAL CONDITION] bladder Plan: - Continue medications - Fall precautions - Monitor VS (vital signs) - Continue exercises - Nutritional supplementation - monitor weight. and appetite. 4/15/2018-physician progress notes [REDACTED]. There were no documented nursing notes between 4/1/18 and 4/29/18. 4/29/2018 at 2:37 AM-nursing note: Resident was observed laying across the bed with his head along the foot of the bed at about 1:45 am. He appears to have a severe change in mental status with obvious generalized weakness and unable to sit up in bed as he used to. On further assessment we noted he has a very low blood pressure reading of 79/53. He appeared to have a change in metal status from what he was yesterday with a respiration of 40 bpm (breaths per minute) and noted abdominal breathing. Resident was alert X 1 (name) and with non coherent speech. Blood sugar was checked and it read Low Noted resident's hands were cold to touch and hence upon checking for capillary refill was 4 seconds (normal range below 2 seconds, above 3 seconds is a sign of dehydration or compromise in circulation). Was not able to get a reading for his SpO2 (oxygen level) using the Pulse-ox machine Nurse called the PCP (primary care physician) about 2 times, left him a message about patient status. Called the DON (Director of Nursing) and left a brief message. Considering the patient change in status, and inability to get an order from the PCP, the nurse called 911 and narrated the situated to them. The Emergency team arrived at (2:02) am and they took him out to Hospital at about (2:10) am. 4/29/2018-physician progress notes [REDACTED]. Reason for visit: altered MENTAL STATUS CHANGES, SEEMED LETHARGIC AND NOT AT BASE LEVEL (entered in all caps) Lungs: CTA Abdomen: Soft; non tender Extremities: No [MEDICAL CONDITION] Neuro: Alert and oriented 1 Skin: Warm and dry. no lesion or rash [MEDICAL CONDITION] /INFECTION; ORDERED LABS, OBSERVED IF NO IMPROVEMENT (TRANSFER) TO ER (hospital emergency room ) There were no documented orders for lab/blood testing. Upon arrival to the hospital, a hospital History and Physical exam dated 4/29/18 at 12:22 PM for resident #91 noted: Chief complaint: Altered mental changes. Chief complaint: Patient presents with low blood sugar. Patient arrived from Medilodge with a blood sugar of 14 (normal range=70-100), Medilodge reports he was weak and lethargic for 'two' days Apparently for the last 2 days, the patient progressively became lethargic, less responsiveness The patient later on became more lethargic, less responsiveness In the ER blood work done suspected [MEDICAL CONDITION] with [MEDICAL CONDITION] the patient was intubated (tube inserted into the throat for breathing) The patient was seen in the ICU bed with vent support (placed on a ventilator in the intensive care unit). The hospital noted: Past medical history for resident #91 included [MEDICAL CONDITION], urethral stricture, urinary obstruction and suprapubic catheter insertion. The resident's temperature was 99.7 degrees with dried oral mucus. The resident's BUN (blood urea nitrogen) level was high at 79 (normal range=7-21) and creatinine level was critically high at 7.12 (normal range=0.44-1.03). These tests determine the amount of waste product in the blood and are used to evaluate kidney function and to help monitor individuals with acute or [MEDICAL CONDITION], dysfunction or failure. The resident's troponin level was critically high at 0.70. (Troponin levels are usually undetected in the blood and indicate strain or damage to the heart.) The resident's active hospital problems included acute kidney injury (sudden episode of kidney failure or damage usually occurring within a few hours or days), acute kidney failure, acute [MEDICAL CONDITION] and [MEDICAL CONDITION]. [MEDICAL CONDITION] (high potassium level) most likely the patient will need [MEDICAL TREATMENT] if it did not improve, nephrology (kidney specialist) in the case Elevated troponin, etiology suspected secondary to [MEDICAL CONDITION] The resident was placed on intravenous (IV) fluids. Resident #91 was readmitted on [DATE] with [DIAGNOSES REDACTED].Difficile (a serious, potentially fatal spore-forming bacteria in the colon that causes diarrhea), was placed in isolation and was immediately placed under Hospice (end of life) care for dementia. The MDS dated [DATE] noted that the resident required extensive assistance for all care, except eating, was non-ambulatory, but his cognition level remained at moderately impaired. When all lab reports for the resident for the past year were requested from the DON, she provided a urinalysis and urine culture report dated 9/2/17, but no test results of the resident's renal functions, no BUN and creatinine and no troponin level. When asked why resident #91, with a history of renal conditions, did not have his renal functions monitored and asked if it should have been, the DON shrugged and did not respond. There was no explanation as to why the hospital transfer was delayed until after the resident was found unresponsive. On 6/27/18 at 2:21 PM, resident #91's PCP was interviewed by phone. He said, The labs (for renal function) were being monitored every three to four months. He has labs on file at the hospital. He has been in and out of the hospital about every six months and labs were done then. They (facility staff) can access them. He should have had labs done every three to four months. The MDS dated [DATE] noted however, that the resident had remained in the facility since 11/6/15 and did not go in and out of the hospital. When asked why the resident was not sent to the hospital on [DATE] when initially observed with mental status changes, seemed lethargic and not at base level and when told that staff could not reach him on 4/29/18 when the resident was found unresponsive, the PCP did not respond. At 2:30 PM, the Administrator was asked to obtain all lab test reports from the hospital data base that the PCP said were available. She said, I don't know how to do that. I will ask the nurses to do it. At 3:15 PM, the Administrator returned and said, There are no other lab reports for him per the nurses. An At Risk For Return to Hospital care plan dated 5/24/18 for resident #91 noted: Goal-Reduce the risk of return to hospital through hospital related disease process and symptom management. Interventions included: Labs as ordered and report to MD. However, there were no documented orders for periodic lab testing for renal functions.

Based on observation, interview and record review, the facility failed to ensure bilateral hand rolls (positioning device to keep the fingers from stiffening) were applied for one sampled resident (R#5) of two residents reviewed for Range OF Motion (ROM) resulting in the development of a contractures (shortening and hardening of muscles leading to deformity and ridged joints) to both hands. Findings include: On 6/25/18 at 09:11 a.m., during the initial pool, R#5 was observed lying in bed with a right-hand contracture with no splint or handroll applied. On 6/25/18 according to the clinical record review, (R#5) the ADL (activities of daily living) care plan documented, A hand roll/wash cloth to resident hands as tolerated. On 6/26/18 at 02:32 a.m., (R#5) was observed lying in bed with a right-hand contracture with no hand-roll or wash cloth. On 6/26/18 at 03:02 a.m., CNA (Certified Nursing Assistant) (U) was interviewed. When asked does the resident wear a hand-roll or wash cloth to the hands, CNA (U) stated, No. CNA (U) was asked have you seen a hand-roll or a wash cloth in (R#5) hands. CNA (U) stated, No. CNA (U) was then asked where do the CNA'S go to get information to provide care for the residents. CNA (U) stated, The Kardex (Residents Plan of Care). CNA (U) reviewed the Kardex and stated, Yes, it is on here to apply hand rolls or washcloths to bilateral hands as resident allow, but I have not seen (R#5) hands with a hand-roll nor washcloth. On 6/26/18 at 3:45 p.m., Nurse (V) was interviewed. Nurse (V) was asked should (R#5) have hand-rolls or washcloth applied to the hands. Nurse (V) stated, No. Nurse (V) was then asked have there been a hand roll or wash cloth applied to (R#5) hands. Nurse (V) stated, No. On 6/26/18 at 3:47 p.m., upon entering the Resident's room, someone was sitting beside the Resident's bed whom identified themselves as being the Resident's family member. (R#5's) family member was asked during visits, has a washcloth or a handroll been observed in the Resident's hands. The family member stated, There was only one time in two years a wash cloth was in my mom's hands. The family member was asked how often you visit. The family member stated, I visit every day. I have asked staff to get my mother into a therapy or restorative program, but I guess they didn't, because her hand is closed so tight. On 6/26/18 at 04:14 P.M., the Therapy Program Manager (TPM) was interviewed. The TPM asked when the last time was (R#5) was on their case load. The TPM stated, For physical and occupational therapy, (MONTH) (YEAR) through (MONTH) (YEAR). The TPM was asked what was (R#5) treated for [REDACTED].O.M., strengthening of upper extremities, and positioning'. When asked was the hand roll and wash cloth their recommendation, the TPM stated, I will look and see if anything was recommended. After looking into the Resident's clinical record, the TPM stated, I did not see a recommendation for a hand-roll or washcloth. The TPM was then asked why no recommendations for a hand roll was there. The TPM stated, If we didn't recommend a splint, hand roll, or washcloth to the hands, it is because we didn't see a need to apply them. When the TPM was asked why R#5 did not need a hand roll or wash cloth at that time, the TPM stated, Because R#5 did not have any contracture to the hands. The TPM was informed a handroll or wash cloth was documented on the care plan, if it was not therapy's recommendation, where did the recommendation come from. The TPM stated, Restorative can apply handrolls or washcloths, but usually restorative nursing would have to refer the patient back to therapy to screen and evaluate them. We did not get a referral to evaluate or screen the Resident. The Resident was evaluated by occupational therapy on 11/28/17, the elbow, hands and forearm were all in functional limit at that time. On 6/26/18 at 04:25 p.m., review of the Occupational Therapy Discharge Summary dated 11/28/17 to 1/4/18 did not document the recommendation for handrolls or other positioning devices. On 6/27/18 at 10:08 a.m., (R#5) was observed in the room, sitting in a high back wheelchair with wash cloths applied to both hands. CNA (U) and the TMP were also present in the room. The TPM was asked the reason for now applying a wash cloth to the hands. The TPM stated, It could be several reasons, for instance to keep the Resident's fingernails from tearing into the skin or to prevent contractures. The TPM asked CNA (U) to assist (R#5) with extending both hands. CNA (U) informed the Resident the wash cloth was going to be removed from the right hand. CNA (U) removed the washcloth from the Resident's right hand and directed the Resident to open the hand. The right hand opened some, but the first four fingers did not extend out. The four fingers appeared in a permanent clinched position. CNA (U) then removed the washcloth from the left hand and directed the Resident to open the hand. The Resident attempted to open the left hand but was unable to open the hand at all. The entire left hand appeared to be in a permanent fist like position. The TPM was asked would this resident be a candidate for evaluation and treatment now. The TPM stated, Yes, for R.O.M. The hands are still seventy five percent functionable. CNA(U) then stated, The left hand can't open at all now. On 06/27/18 at 12:48 p.m., the Director of Nursing (DON) was interviewed. The DON was asked who is responsible for monitoring the positioning devices. The DON stated, The restorative aides are responsible for applying positioning devices. The DON stated not being aware positioning devices were not being applied according to the care plan. On 6/27/18, (R#5's) clinical record documented, the Resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. According to annual Minimum Data Set ((MDS) dated [DATE], documented (R#5) was severely cognitively impaired and required extensive assistance with two-person physical assist for mobility and functional limitation in range of motion, upper extremity (shoulder, elbow, wrist and hand) no impairment, and lower extremity (hip, knee, ankle and foot) no impairment. On 6/27/18 4:30 at p.m. review of facility's policy titled Restorative Nursing Program revision date 9/2017 documented, The goal of Restorative Nursing includes improving and/or maintaining independence in activities of daily living and mobility . A restorative nursing program, when appropriate based on the comprehensive assessment and resident goals, can enable a resident to attain or maintain their highest practicable level of physical, mental, and psychosocial function, increased independence, foster self-esteem, and promote a positive quality of life . The following types of residents could benefit from a restorative program (s) but limited to: Contracture prevention and/or management . Any can make a referral to the restorative program. Physician, Dietary, Activities, Social Services, Nursing, Therapy, or anyone who identifies a change in the resident's condition . Areas that may indicate a referral to restorative is warranted: End of therapy to continue goal achievement or maintenance and prevent decline.

Based on interview and record review the facility failed to act upon a crucially high laboratory result (INR-International Normalized Ratio-the amount of time, in seconds, that it takes for your blood to clot. Reference Range: Anticoagulation; Low intensity: 2.0-3.0, High Intensity: 2.5-3.5) for one sampled resident (#703) out of a total of eight residents, resulting in hospitalization with a [DIAGNOSES REDACTED]. Finding Include: On 6/3/18 at 9:30 a.m., record review revealed that R#703 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment ((MDS) dated [DATE] indicated the resident cognition was intact. R#703 was discharged from the facility per a nurses note on 4/20/18, due to increased confusion, oxygen saturation 86%, blood pressure 84/51 and pulse rate of 110 beats per min. Sent ER (emergency) 911 for further eval. Review of the physician's orders [REDACTED]. Give 4 mg by mouth in the evening for anticoagulants. Review of the Medication Administration Records (MAR's) from 4/6/18 to 4/20/18 documented that R#703 was administered the [MEDICATION NAME] 4 mg daily for 15 days. An Anticoagulant care plan dated 4/10/18 had an intervention of obtain and monitor lab/diagnostic work if ordered. Report results to MD (physician) and follow up as indicated. The laboratory result dated 4/6/18 documented an INR 2.1 (H-high) Reference Range 0.8-1.2. The laboratory result dated 4/13/18 documented an INR 2.8 (H-high) Reference Range 0.8-1.2. A physician's progress noted dated 4/14/18 documented, Reason for visit: upper back mass .Suspected upper back abscess; start Bactrim (antibiotic) DS twice a day x 10 days . The physician's note did not address the upward trending INR results. A Drug to Drug Interaction note dated 4/14/18 documented, Bactrim DS tablet 800-160 mg. Give one tablet by mouth two time a day for abscess until 4/24/18 .The system has identified a possible drug interaction with the following orders: [MEDICATION NAME] Sodium Tablet 4 mg .Severity: Severe. Interaction: the [MEDICATION NAME] (impaired blood clotting reaction, leading to an increased physiological risk for spontaneous bleeding) effects of [MEDICATION NAME] Sodium 4 mg may be increased during concurrent administration of Bactrim DS tablet 800-160 mg. Review of the Medication Administration Records (MAR's) from 4/6/18 to 4/20/18 documented that R#703 was concurrently administered the Bactrim DS 800-160 mg and [MEDICATION NAME] Sodium 4 mg for 7 days from 4/14/18 to 4/20/18 (when R#703 was discharged 911 to the hospital). The laboratory result dated 4/16/18 documented an INR 3.6 (H-high) Reference Range 0.8-1.2. A physician's noted dated 4/18/18 documented, Reason for visit: Upper back mass . There was no notation in the physician's progress note addressing the elevated INR results from 2 days earlier. Review of the emergency room hospitalization records dated 4/20/18 documented, Patient presents as a priority 1. Patient is febrile (fever), [MEDICAL CONDITION] (increased heart rate), hypotensive (low blood pressure) .Patient given Intravenous fluid (IV) boluses .Patient's INR came back elevated at 10.5 .CAT scan of his head showed a right frontal bleed . At 3:00 p.m., the facility's Director of Nursing (DON) provided a copy of the 4/16/18 INR result with undated hand writing on it. The hand written message documented, [MEDICATION NAME] 4 mg every bed time .paged (name of attending physician) x's 3. The lab report also contained an undated signature. The DON indicated that the attending physician signed the laboratory result and gave no new physician orders. On 6/13/18 at 3:50 p.m., during a phone interview (along with the DON) R#703's attending physician was asked about the elevated INR levels. Attending Physician (AP) B indicated the when a resident is on an antibiotic it could change the INR levels to either go lower or higher depending on the resident and type of infection. The AP stated he was aware of the drug interaction warning and that the labs are monitored for each individual patient. AP B stated an INR level between 2.0-3.0 is where he liked to maintain his patients, If the INR goes above 3.0, I hold the [MEDICATION NAME] and redraw the INR until stable. The AP was asked if he recalled seeing the laboratory result of R#703 when the INR was 3.6 (4/16/18) to which he responded, I don't know who's signature is on that lab slip. If the nursing staff had tried to call me, I usually am pretty good about returning they're calls. That is a crucially high result, I would have held the [MEDICATION NAME] and redrew the INR. Review of the facility's Physician and Representative Notification-Change in a Resident's Condition or Status policy dated 10/7/10 documented, The Nurse Supervisor/Charge Nurse will notifying the resident's Attending Physician or On-call Physician when there has been: .A need to alter the resident's medical treatment significantly.

This citation pertains to intake #MI 664. Based on interview and record review, the facility failed to prevent neglect (provide necessary treatments, medications, assessments, and monitoring) to one (#703) of three sampled Residents reviewed for abuse/neglect, resulting in harm due to the delay in acquiring and provision of necessary medications (including pain meds for new amputation), lack of adequate pain management (including alternate interventions), delayed identification of and treatment for [REDACTED]. Findings include: On 12/7/17 at 11:40 a.m. and 2:50 p.m., interviews were conducted with Resident #703's legal representative (LR) by phone. At that time, the LR reported the Resident was at another facility and would attempt to have him return the call, however that did not occur by the end of the survey. The LR reported the following concerns: He arrived at the facility roughly around 5:30 pm on 11/22/17 (Wednesday) and left approximately 2:30 pm on 11/28/17 (Thursday). I had to get him out of there, and he transferred to another facility. He was only at the other facility for a day and was sent to the hospital. He didn't get the medication he was supposed to for five days the Doctor didn't sign off on meds, and the pharmacy was closed on Thanksgiving. I understand places are closed on Thanksgiving, but even after that, there was a delay in getting him his medications and treatments. That's unacceptable. He would call me in pain for his butt and excruciating pain for the right leg (amputation site). This was a fresh amputation. When he came into the facility, on the right butt cheek was only a red mark. The day he left (7 days after arrival to the facility), he seen the wound nurse for the first time and all of a sudden saw an inch to inch and a half crack with necrotic tissue. No one else bothered to look about his skin. I feel it's from lack of turning and being left in wet briefs for long periods of time. Why would they (facility) take him if they knew his needs could not be met? The nurses left his wound open on his leg (amputation site). He had a right leg amputation. When I demanded to wrap it up, they (nurses) didn't wash or clean it, just put gauze on, wrapped it up and that was it. On 12/7/17 at 12:30 p.m., review of the clinical record revealed R#703 was admitted into the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. According to the discharge return not anticipated minimum data set (MDS) assessment with an assessment reference date (ARD) of 11/28/17, R#703 was cognitively intact (scored 15/15 on mental status exam); had no communication concerns; required extensive assistance of two people for transfers, dressing, hygiene, bathing, and toilet use; had a stage three pressure ulcer (full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss; often includes undermining and tunneling.) which was not present on admission and measured 1.5 centimeters (cm) length, by 3.0 cm width; had a surgical wound; had been on a scheduled pain medication regimen, received prn (as needed) pain medication, and received non-medication intervention for pain. The section JO200 (Should Pain Assessment Interview be Conducted?) was identified with an - (incomplete). Review of the care plans revealed there were no care plans initiated for this admission (only available care plans were from the Resident's previous stay at the facility in March of 2017). Further review of the clinical record revealed there was no admission nursing assessment completed during R#703's time within the facility; There were no nursing skin assessments or documentation that any assessment/monitoring of the Resident's skin condition had been completed; There was no documented evidence that any skin care treatments had been provided; There was no identified pain management goals, consistent pain monitoring and effectiveness of the few medications that were provided; And there was no physician documentation that identified any concern regarding the Resident's complaints of pain, wound/skin status, or medications. (There was only one physician progress notes [REDACTED].) Review of R#703's hospital discharge physician orders [REDACTED]. [MEDICATION NAME] 50 mcg/hr Start taking on: 11/23/2017 (pain medication) [MEDICATION NAME] 100 MG caps take 300 mg by mouth once daily (pain medication) [MEDICATION NAME] 100 MG caps take 200 mg by mouth once every night at bedtime [MEDICATION NAME] 500 MG take 1 tablet every 8 hours (diabetic medication) [MEDICATION NAME] 30 MG take 1 tab by mouth every 12 hours (pain medication) [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]) 10-325 MG take 1 tab by mouth every 6 hours as needed FOR PAIN (break through pain) Pregabalin ([MEDICATION NAME]) 100 MG take 100 mg by mouth every 8 hours (pain medication) Review of the Norton Plus Pressure Ulcer Scale-V2 dated Lock Date: 11/23/2017 00:22 documented R#703 was alert and had a score of 12.0 (at moderate risk). Review of the progress notes revealed there was no documentation completed for the Resident's date of admission (11/22/17). Further review of the progress notes included: On 11/23/17 at 08:04 (8:04 am - the first documented entry for R#703 since admission) which read, Pt. Arrives from (name of local hospital) .Had a Rt BKA .Pt. is offered 2 extra strength Tylenol which he accepted and is explained to him that the Doctor was contacted and we are waiting for a call back . (No documented evidence that R#703 received Tylenol as indicated in the progress note identified on the Medication Administration Record.) On 11/23/17 at 16:08 (4:08 pm), [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth three times a day for pain n/a (not available) from pharm script wrotten (sp) for MD (physician). (Medication not given.) On 11/23/17 at 23:08 (11:08 pm), .c/o (complained of) pain R (right) mid thigh and back pain PRN [MEDICATION NAME] admin, provided some relief .Dr paged no return call at this time . (No further documentation of any break through pain intervention provided.) On 11/24/17 at 08:11 (8:11 am), [MEDICATION NAME] Capsule 300 MG Give 1 capsule by mouth every day shift for nerve pain Meds on order, new admit. (Medication not given.) On 11/24/17 at 13:02 (1:32 pm), [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth three times a day for pain not available. (Medication not given.) On 11/24/17 at 13:36 (1:36 pm), [MEDICATION NAME] Tablet 30 MG Give 1 tablet by mouth every day and evening shift for pain Not available. (Medication not given.) On 11/24/17 at 13:37 (1:37 pm), [MEDICATION NAME] Patch 72 Hours 50 MCG/HR Apply 1 patch [MEDICATION NAME] every 72 hours for pain apply one patch Q (every) 72 hours and remove per schedule Not Available. (Medication not given.) On 11/25/17 at 00:27 (12:37 am), [MEDICATION NAME] Tablet 30 MG Give 1 tablet by mouth every day and evening shift for pain not available. (Medication not given.) On 11/25/17 at 11:50 (11:50 am), MD (Physician) paged regarding control form for [MEDICATION NAME] 30 mg. On 11/25/17 at 15:21 (3:21 pm), [MEDICATION NAME] Tablet 10-325 MG Give 1 tablet by mouth every 6 hours as needed for pain .PRN Administration was: Unknown stated med provided some relief. (No further documentation of any break through pain intervention provided.) On 11/25/17 at 20:59 (8:59 pm), [MEDICATION NAME] Tablet 30 MG Give 1 tablet by mouth every day and evening shift for pain not in from pharm gave [MEDICATION NAME]. (Medication not given.) On 11/25/17 at 23:01 (11:01 pm), [MEDICATION NAME] HCl Tablet 500 MG Give 1 tablet by mouth three times a day for DM (diabetes mellitus) not in cart. (Medication not given.) On 11/25/17 at 23:01 (11:01 pm), [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth three times a day for pain not in cart. (Medication not given.) On 11/26/17 at 05:07 (5:07 am), [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth three times a day for pain not in cart. (Medication not given.) On 11/26/17 at 06:38 (6:38 am), [MEDICATION NAME] Tablet 10-325 MG Give 1 tablet by mouth every 6 hours as needed for pain; PRN Administration was: Ineffective; Follow-up Pain Scale was: 5; MD paged for break through pain meds. (No further documentation of any break through pain intervention provided.) On 11/26/17 at 22:29 (10:29 pm), [MEDICATION NAME] Tablet 30 M Give 1 tablet by mouth every day and evening shift for pain; Awaiting for medication to arrive from pharmacy. pRN given for c/o pain. (Medication not given.) On 11/26/17 at 22:29 (10:29 pm), [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth three times a day for pain; Awaiting for medication to arrive from pharmacy. PRN given for c/o pain. (Medication not given.) On 11/27/17 at 02:25 (2:25 am), Resident is alert and is able to voice his needs .c/o stump pain, PRN given. Awaiting for [MEDICATION NAME] and [MEDICATION NAME] to arrive from pharmacy . (Medication not given.) On 11/27/17 at 05:01 (5:01 am), [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth three times a day for pain; Awaiting for medication to arrive from pharmacy. (Medication not given.) On 11/27/17 at 05:02 (5:02 am), [MEDICATION NAME] Tablet 10-325 MG Give 1 tablet by mouth every 6 hours as needed for pain; Resident c/o stump pain. On 11/27/17 at 08:30 (8:30 am), [MEDICATION NAME] Tablet 10-325 MG Give 1 tablet by mouth every 6 hours as needed for pain; PRN Administration was: Ineffective; Follow-up Pain Scale was: 5. (No further documentation of any break through pain intervention provided.) On 11/27/17 at 08:30 (8:30 am), [MEDICATION NAME] Tablet 30 MG Give 1 Tablet by mouth every day and evening shift for pain; Not available, on order awaiting cII. (Medication not given.) On 11/27/17 at 13:41 (1:41 pm), [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth three times a day for pain; Awaiting CII. (Medication not given.) On 11/28/17 at 08:11 (8:11 am), [MEDICATION NAME] Tablet 30 MG Give 1 tablet by mouth every day and evening shift for pain; Order needs clarification, not available. Dr. notified. (Medication not given.) On 11/28/2017 at 09:44 (9:44 am), New Admit wound care skin assessment: Left Buttocks: 1.5 x 3.0 cm stage III with moderate serosanguinous drainage (fluid leaving a wound that may be yellowish with small amounts of blood). On 11/30/2017 at 12:26 (pm, two days after the Resident's discharge from the facility), the only available physician progress notes [REDACTED]. Patient is alert and oriented and no distress recovering from [MEDICAL CONDITION] of lower leg . (There is no mention of the amputation wound site, pain evaluation, or identification of any skin concerns.) Review of the Resident's Pain Levels per the Wts/Vitals section of the clinical record included the following elevated pain levels on a scale of 1-10 (10 is highest level of pain; none identified for day of admission - 11/22/17) which had no supporting documentation of what was done to help alleviate the pain (either scheduled, prn, or non-medication intervention) on: 11/23/17 at 16:07 (4:07 pm) = 10 11/24/17 at 08:05 (8:05 am) = 7 11/24/17 at 13:03 (1:03 pm) = 7 11/25/17 at 11:56 (11:56 am) = 8 11/25/17 at 20:59 (8:59 pm) = 7 11/26/17 at 05:07 (5:07 am) = 8 11/26/17 at 22:30 (10:30 pm) = 6 11/27/17 at 12:12 (12:12 pm) = 10 11/27/17 at 13:40 (1:40 pm) = 7 11/28/17 at 08:11 (8:11 am) = 8 11/28/17 at 11:27 (11:27 am) = 6 Review of the Medication and Treatment Administration Records (MARs & TARs) for R#703 revealed discrepancies within the documentation on the MAR which documented that some medications were administered as evidenced by a check mark and staff initials, however other documentation revealed these medications not able to be administered as they were yet to be received from the pharmacy. The TAR revealed treatments for barrier cream Q shift and PRN were not completed as evidenced by blank entries on: 11/23 at evening shift; 11/24 at day shift; 11/25 at day and night shift; 11/26 at day and evening shift; and 11/27 at day, evening, and night shift. On 12/7/17 at 11:30 a.m., Wound Care Nurse (Licensed Practical Nurse/LPN D) was asked about the Resident's skin condition and reported, I saw R#703 for one day, was off over Thanksgiving and weekend that same morning I saw him, about 9:00 am, he left per daughters request. I'll see what I can find out about the wound. At that time, LPN D was also requested to have the facility provide documentation of any admission and skin nursing assessments, MAR and TAR records, admission orders [REDACTED]. On 12/7/17 at 1:30 p.m., LPN D and the Director of Nursing (DON) provided some additional documentation for R#703. At that time, LPN D reported there was no further wound/skin documentation other that her note on 11/28/17 and that there had been no admission nursing assessment completed. Neither LPN D nor the DON were unable to offer any explanation as to why this had not been completed for R#703. The DON was asked about the facility's process of acquiring and obtaining medications for newly admitted Residents and reported, There is a process of back up box, not sure myself. Let me find out. When asked about the delay in receipt of medications from pharmacy, the DON reported, Facility only gets delivery one time a day. Pharmacy wasn't open on Thanksgiving day. When asked about whether R#703 had received any medication on 11/22 since there was nothing documented as such, the DON reported, If (R#703) entered late on 11/22, the MARs would show as start on 11/23. When asked about clarifying the conflicting documentation on the MARs which identified the staff had administered some medication despite other documentation these medications were not available, the DON reported, I will check the back up box documentation to see, I'm not sure. When asked about the Resident's delay in adequate pain management by the facility following an amputation, the DON reported, Yes he had quite a few elevated (complaints of pain). When asked about why the facility had accepted the Resident without ensuring the necessary treatments and services could be provided, the DON reported, We are discussing that as a team. On 12/7/17 at 2:45 p.m., the Administrator was asked to follow up with the DON in regards to the requested documentation and indicated she would follow up. On 12/7/17 at 3:05 p.m., the DON reported, This is the documentation we received. That's all I've got for you. Review of this documentation provided revealed four forms, two which were an Emergency Kit Usage Record which documented on 11/22/17 (no time noted) a quantity of four tablets of [MEDICATION NAME], and on 11/28/17 (no time noted) a quantity of one tablet of [MEDICATION NAME] (no dosage noted) for R#703 were obtained. (There is no documentation verifying R#703 actually received the [MEDICATION NAME] on 11/22/17.) Another form indicated it was a pharmacy Electronic Shipping Manifest dated 11/27/17 1:57 pm) which identified one medication for R#703 was included in the delivery for [MEDICATION NAME] 300 MG Capsule. On 12/7/17 at 3:45 p.m., during a meeting with the Administrator, Assistant Administrator, and DON, while discussing the aforementioned concerns, when asked about how these events occurred if effective systems had been in place, and why R#703 had been accepted into the facility knowing it was a late admission, and that pharmacy would not be open the following day due to holiday, all present offered no further explanation to the questions asked. Review of the facility's Pharmacy Services Agreement dated 12/4/15 and 12/11/15 included: .Pharmacy shall promptly fill Orders from Customer .Pharmacy shall deliver Products in accordance with Pharmacy's routine deliverable schedule .On Monday through Friday, Pharmacy will make two (2) scheduled deliveries per day .Pharmacy shall provide, maintain, and replenish emergency drug supple kits (the Emergency Kits) as permitted by Applicable Law . Review of the following facility policies and procedures included: Abuse Prevention Program policy dated 9/27/17 documented, .Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or mental illness . Administering Medications policy dated 11/28/16 documented, Medications shall be administered in a safe and timely manner, and as prescribed .Medications must be administered in accordance with the orders, including any required time frame .Medications ordered for a particular resident may not be administered to another resident . Accepting Delivery of Medications policy dated 11/18/2010 documented, .Any errors noted in receiving medications shall be brought to the attention of the Pharmacist and Director of Nursing Services . Pain-Clinical Record policy dated 03/22/2011 documented, .The staff will reassess the individual's pain and consequences of pain at regular intervals .Periodically the physician will evaluate and summarize the status of an individual with chronic or fluctuating pain including active conditions that exacerbate pain .and effectiveness of current interventions for pain .The staff will discuss significant changes in levels of comfort with the Attending Physician who will adjust interventions accordingly. The may include adjustments of regular and PRN [MEDICATION NAME] doses to find the best combination of effectiveness . Pressure Ulcers/Skin Breakdown - Clinical Record policy dated 11/28/2017 documented, .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 .An admission evaluation helps identify residents at risk of developing pressure ulcer/pressure injury (PU/PI) .Because a resident at risk can develop a PU/PI within hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to prevent PU/PI. The admission evaluation helps define those initial care approaches .Complete the Nursing Data Evaluation and/or admission skin assessment upon admission to the facility (Skin assessment portion completed preferable within the first 8 hours of admission) .The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing .dressings .and application of topical agents .

This citation pertains to intake #MI Based on observation, interview and record review, the facility failed to ensure adequate assistance during a transfer for one (#603) of five sampled Residents reviewed for falls with injury in a total sample of 14, resulting in a preventable fall with major when the Resident was transferred by one person instead of two persons, subsequently sustaining a supracondylar fracture of femur (left femur fracture) which required a fiberglass cast and hospitalization for further evaluation and treatment. Findings include: On 11/15/17 at 2:17 p.m., Resident #603 was observed seated in the activities area, engaging with another resident. Both legs were observed to be elevated with leg rest and padding on the leg rest for support. The Resident was alert and oriented to person only with hearing impairment. The Resident was unable to recall the incident. The Resident denied being in pain at that time. Review of the clinical record revealed Resident #603 was initially admitted into the facility on [DATE] and readmitted on [DATE] following a hospitalized from [DATE] - 7/21/17 with [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #603 had severe cognitive deficits, required extensive assistance of two persons for transfers, hygiene/bathing, dressing, toileting and, had range of motion impairment to bilateral lower extremities (one side), and was always incontinent of bladder and bowel. According to the Resident's ADL-Self-care care plan initiated 10/21/16, with a revision date of 4/11/17, identified interventions which included, 2 PERSON MECHANICAL LIFT FOR ALL TRANSFERS which had a date initiated and revised on 7/25/17. (This identified that since 10/21/16 and at the time of the fall on 7/16/17, the Resident's transfer status had not been care planned, however required two person assistance per MDS assessments dated 9/13/17 and 10/25/17). Review of the Resident's Incident and Accident Report dated 7/16/17, documented the incident was unobserved, not witnessed, incident occurred in resident's room, and no mobility device was used. According to the report completed by the nurse on shift under the brief description documented, Called into room at approximately 3:30-3:45 a.m., by CENA. Resident in bed, supine left leg/knee edema, left heel outward, lateral. Resident facial grimacing and holding her thigh rubbing it . Treatment: Sent to hospital .Action taken: Resident education and staff re-education. Upon review of Employee Witness Statement dated 7/17/17 revealed, On Sunday 7/16/17 at approximately 5:00 p.m. CENA (CENA's name) was transferring resident from the bed to the wheelchair. During the transfer, CENA held onto the right side of the resident's pants, and under her right shoulder, while positioning her leg between the resident legs. When attempting to turn the resident to the left side, the resident said ouch and CENA lower her to the floor. CENA stated that he did not wait when standing the resident to ensure the resident was in proper body alignment before turning her to the left. CENA stated that she went get another CENA to help get resident off the floor. CENA stated she did not notify the nurse of the fall because she lowered the resident to the floor and did not consider it to be a fall. CENA also stated she had not reviewed the resident's kardex (care guide) prior to transferring the resident. CENA also stated not using a gait belt during the transfer. Review of the Nurse's Progress Note dated 7/17/17 documented: Approximately 3:45 a.m. nurse called to room by CENA to assess resident. Upon assessment, left lower leg hyper - extended to the left. Resident winced in pain upon minimal movement, edema noted at knee . transferred to (name of hospital) . 2 EMS to resident to hospital . Review of the Progress Note - Admission note dated 7/21/17 documented: On 7/21/17 at 14:00 (2 p.m.), Resident readmitted approx. 13:50 (1:50 p.m.) . admitting dx: supracondylar fracture of femur, left leg cast from thigh to ankle .purple bruises observed to BUE (bilateral upper extremity) . Review of the kardex (electronic care guide), under Task: ADL - Transferring, with a look back of 30 days (10/17/17 - 11/15/17) documented: TRANSFER: SUPPORT PROVIDED - How resident moves between surfaces to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet) indicated on the following dates and times staff continued to transfer the resident with one person with a check mark under the One person physical assist option included: 10/18/17 at 12:44 p.m. - One person physical assist. 10/27/17 at 01:58 a.m. - One person physical assist. 10/31/17 at 14:31 (2:31 p.m.) - One person physical assist. 11/1/17 at 19:55 (7:55 p.m.) - One person physical assist. 11/3/17 at 14:40 (2:40 p.m.) - One person physical assist. 11/6/17 at 10:28 a.m. - One person physical assist. 11/7/17 at 1:24 a.m. - One person physical assist. 11/12/17 at 16:54 (4:54 p.m.) - One person physical assist. 11/13/17 at 6:59 a.m. - One person physical assist. 11/13/17 at 11:53 a.m. - One person physical assist. 11/14/17 at 6:24 a.m. - One person physical assist. On 11/15/17 at 4:45 p.m., CENA S was interviewed. CENA S verified being the Resident's CENA on the afternoon shift (3 pm to 11 pm) for that shift. CENA S was asked if being the Resident's regular CENA. CENA S stated, I don't have her on a regular bases. I have only had her twice. This is my second week working here. CENA S was asked what R #603's transfer status was. CENA S stated, She is a two person assist with a Hoyer lift but I haven't had to transfer her yet. CENA S was then asked how often she checks the kardex. CENA S stated, I try to check it every other day to see if anything has changed. CENA S was then asked if the kardex should be checked daily for residents in case something does change. CENA S stated, I guess I should check it every day. On 11/15/17 at 4:55 p.m., review of the facility's undated, Falls - Clinical Protocol policy included: .Interventions should be developed and implemented per the assessed needs. Additional items to remember when developing the plan of care include; a. Resident's abilities and deficits b. Balance (sitting/standing) c. Adaptive equipment needs d. Proper use of mechanical lifts and transfer devices .

This citation pertains to intakes: MI 831, MI 244, and MI 507. Based on interviews and record reviews, the facility failed to implement interventions and treatments to prevent the development and worsening of pressure ulcers in one of four residents (R#503) reviewed for pressure ulcer care, from a total sample of seven, resulting in R#503 developing a stage four pressure ulcer (total loss of tissue with muscle, tendon, and/or bone exposed) that required hospitalization and surgical treatment. Findings include: A closed medical record review was conducted on 1/25/17. The face sheet revealed that R#503 had admitted to the facility with multiple [DIAGNOSES REDACTED]. The resident was transferred out to the hospital on [DATE], for [MEDICAL CONDITION] (infection throughout the body) and had not returned. According to the Minimum Data Set ((MDS) dated [DATE], R#503 was alert and oriented with a brief interview for mental status (BIMS) score of 12/15. R#503 was identified as having no pressure ulcers. A Braden's skin assessment identified R#503 as being 'at risk' for developing pressure ulcers. A care plan for 'At risk for pressure ulcer', with a goal of 'will maintain skin integrity' dated 11/25/16, identified the following two interventions; 1) assist with turning and repositioning, 2) monitor for skin breakdown and notify wound care if such occurs. There are no additional updates, or interventions added to this care plan. During an interview on 1/25/17 at 1:00 p.m., with the wound care nurse, Licensed Practical Nurse LPN 'C', she said on 12/5/16, R#503 was observed to have excoriation and redness to his left buttock area. The wound care nurse prescribed cleanser, a skin prep lotion and then a [MEDICATION NAME] over the area, three times a week. LPN 'C' said she was asked to see R#503 on 12/12/16, by another staff member because his left buttocks pressure ulcer had changed. LPN 'C' said she noticed a significant difference on the resident's left buttock area. LPN 'C' said the area was blackened with yellow edges and the size of small lemon. She notified the 'Wound Care Nurse Practitioner' to see the resident on 12/14/16, and changed the treatment to medi-honey with a foam dressing two times a day. LPN 'C' said when she observed R#503's wound on 12/14/16, the area was completely necrotic (dead tissue, black leather-like) and notified the Physician. The Physician orders [REDACTED].>The nurse's note, written by Licensed Practical Nurse (LPN) 'C' on 12/12/16 at 1:13 p.m., reads as follows; left buttocks appears to be declining. A 7.0 x 6.0 cm (centimeter) area of discoloration noted, yellow tissue noted to edges. Resident to be seen by wound care on 12/14/16. There is no documentation to support a change or update on the resident's care plan. The nurse's note, written by LPN 'C' on 12/14/16 at 1:26 p.m., reads as follows; in to complete treatment to left buttocks. Resident appeared different than usual. Resident unable to hold arm up and unable to help with turning repositioning. Left buttocks area 7.0 x 6.0 cm with necrotic base (blackened) .area has declined since last treatment on 12/13/16. According to R#503's TAR (treatment administration record) for December 2016, R#503 had the following skin treatment orders; 12/7/16: cleanse left buttocks with wound cleanser, apply skin prep and cover with [MEDICATION NAME] every day shift on Mon, Wed, Fri. 12/12/16: cleanse left buttocks with wound cleanser, apply [MEDICATION NAME] gel and cover with foam dressing two times a day. During a phone interview on 1/26/17 at 8:00 a.m., with Certified Nursing Assistant, CNA 'I' she said that she cared for R#503 regularly and had noticed a change, like an opening of the resident's left buttocks earlier in the week, and notified the nurse of it. CNA 'I' said she provided care R#503 again over the week-end and noticed that his left buttocks pressure ulcer was 'way worse', and she told the nurse. She said that the nurse did not look at the resident's pressure ulcer during that shift, so she went to the 'day shift' nurse (LPN 'K') and told her. CNA 'I' said she tried to keep the resident off of his left buttocks with pillow, but could not. The resident was too heavy for the pillows, and would just crush them flat, and end up lying on his back again. CNA 'I' said it would have helped to have bolsters cushions to be able to reposition the resident off his buttocks, but none were made available. They have to come from therapy. A review of R#503's 'CNA's documentation survey report' for Skin observations read as follows: Skin assessment 12/8/16, day shift: '4' = open area, 'N' = not new Skin assessment 12/11/16, day shift: '4' = open area, 'Y' = new area, 'Y'= nurse notified. The 'bathtime' skin assessment sheet dated 12/7/16 which reads, 'Perform a complete body check with each bath or shower and give to charge nurse when finished', documents the following: 'had patch on bottom'. During an interview with the DON on 1/25/17 at 5:45 p.m., she did not provide any additional information regarding the prevention of the pressure ulcer development or updated interventions for the care plan regarding positioning for R#503. The DON did not offer any explanation as to why the resident's 'open area' was discovered on 12/5/16 yet no treatments were rendered until 12/8/16. ( )

This citation pertains to MI 903 Based on interview and record review, the facility failed to timely treat, evaluate, and use assessment data gathered in progress notes and other medical record documents of an anxious cognitively impaired resident after a fall that resulted in left [MEDICAL CONDITION] for 1 of 3 (# 901) sampled residents from a total of three sampled residents, by failing to perform a timely x-ray, notify facility physician on time, and transport Resident to the hospital for emergency treatment immediately, resulting in Resident #901 falling and being hospitalized after 3 days with a [DIAGNOSES REDACTED]. Findings include: An abbreviated survey was conducted on [DATE] in response to a complaint which alleged that there was a delay in assessment, evaluation, and treatment of [REDACTED].#901 in pain for three days. The complainant alleged post- fall injuries were not timely assessed by a registered nurse or physician until after three days of incident with a hospitalization that resulted in left leg injury. The facility's investigation report, Resident #901's clinical record, and the incident report of the fall that occurred on [DATE] were initially reviewed on [DATE] at 10:15 a.m. According to the facility's investigation report dated [DATE] with no specified time, Resident #901 fall incident was not witnessed, injury of unknown origin. Resident #901 complained of left hip pain. X-ray obtained. Results Left femoral neck fracture. Incident happened in residents room and roommate was present. Residents family visited earlier in the day before the incident. Resident stated he sat on the floor. The family stated left candy on table that he may have been reaching for. Resident was transferred to the hospital. Review on [DATE] at 10:20 AM, of the statement of witness dated [DATE] at 4:30 PM, indicated that the physical therapist assistant PTA#2 statement of witness revealed that on Thursday, [DATE] th after 2 PM, We went in to go see him and he was covered in bowel movement, so we took him to the shower. He stood up for five minutes with no complaints of pain. On Friday, [DATE] th I brought him down to the gym and I tried to stand him and he complained of pain in left leg. his daughter was present. I commented to daughter that's odd because the surgery was on his right leg. She replied maybe it was his dementia and he was confused about which leg hurts. I stopped anymore standing activities and stretched his leg. I took him back to his room. On Monday [DATE]nd 2016, I helped PTA#1 with a bathroom transfer and Resident #901 stated something is wrong and kept grabbing at left leg. I didn't do anymore standing activities. On [DATE] at 10:35 AM, during an interview with the physical therapist assistant (PTA#1), she revealed that on [DATE]th at about 2:00Pm, she went to see Resident #1 in room and observed Resident in bed soiled and in the company of another (PTA#2) assisted Resident #901 with a shower. Resident #901 was able to stand and bent down to wash his legs and feet. I went back before dinner and worked on some bed mobility and Resident #901 never mentioned having pain or complaints of pain. The PTA #1 stated the next day Friday [DATE]th between 10 AM and 11 AM, when Resident #901 was approached for therapy, he complained of pain and was holding the left hip. When attempting a toilet transfer Resident #901 was hesitant to move lower left extremity and complained of pain in leg. We reported this incident to the nurse on duty. On [DATE] at 10:43 AM, during an interview with the Rehab Director, she indicated that Resident #901 upon admission was meeting his goals, was stable, but that after the hospitalization that resulted in left [MEDICAL CONDITION] declined as documented on the physical therapy progress notes. The rehab director also, indicated that her staff notified the nurse immediately about Resident #901 experiencing pain on his left lower extremities and unable to function at therapy on [DATE] day shift. An interview was conducted with the the Director of nurses DON on [DATE] at 11:15 AM, regarding the fall on [DATE] that resulted in fracture for Resident #901 and she stated Resident #901 was admitted into the facility for therapy for right [MEDICAL CONDITION]. Therapy on [DATE], noticed Resident #901 was not participating and complained of pain. Resident #901 was taken back to his unit. Nurse went in to assess him and he was more concerned about the right hip but it was the left hip that was an issue. On [DATE], daughter inlaw came in and wanted to make sure if an x-ray was done, but it wasn't done. The x-ray later came back that Resident #901 had left [MEDICAL CONDITION]. Resident #901 was sent to the hospital and an investigation was started. His roommate with a BIMs score of 15 revealed that Resident fell on [DATE] at midnight and was on the floor by his bed. The incident report was not reported because the nurse thought it was a behavior since Resident #901 has Dementia diagnosis. Their was a delay in treatment for 3 days and pain was involved. Nurse was educated not to make that determination that resident has behavior. On [DATE] at 12:15 PM, during an interview with the unit nurse, she stated the therapist came and told me that the resident was in pain, on his left lower extremities, upon assessment, in the presence of the residents daughter in law, resident had no complaints of pain, but on the right leg, resident did show pain and had gaps/opening of the staples sutures used to hold the right hip. The resident had severe dementia. I felt like like he was thinking of his opposite leg. Have I been told by him or seen a facial expression or grimace for the left leg, I would have done an x-ray. No x-ray was ordered and the physician was not notified. After the incident, I was inserviced by the DON because of delay in treatment, and because I did not document or make a note that I assessed the resident but the fall which happened on midnight fell on me. I came in at 6:30 AM to 7:0 AM on that day [DATE], but the midnight nurse failed to notify me that the resident fell . The residents roommate told me that the resident fell at night, rolled under his bed and was on the floor for long. The resident was sent out to the hospital, after 3 days had another left hip surgery, came back, developed respiratory distress, was sent out again and expired In an interview on [DATE] at 12:35 PM with the residents certified nursing assistant CNA#1, she revealed that on the day of the incident, went to wake up my resident and he wouldn't wake up, so I went and got the nurse and he wouldn't wake up for her so I went to the other nurse who was his family member to come and try to wake him up. The therapist has said that the resident was in some pain and the nurse came in to check him and he wouldn't wake up. The roommate stated that the resident was probably tired because he was under the bed in the middle of the night for a long time and 2 staff member put him back in bed. On [DATE] at 2:01 PM, in an interview with Resident #901's grand- daughter, a nurse at the facility in a different unit, she revealed My Grandpa fell , nobody reported it, I guess over the next few days, he was letting the nurses over the days that he was in a lot of pain and nobody was doing anything about it. I didn't want to overstep my boundaries and I informed the nurse. The x-ray technician also notified the nurse and stated What is Resident #901 still doing here, I took his x-ray, he had a fracture and should be at the hospital for treatment and the nurse indicated that she did not get the result or report regarding Resident #901 having a fracture. My Grandpa was left in pain for 4 days at the facility after he fell on Thursday night [DATE], and nothing was done about it or reported. After the left hip surgery he came back and was shipped out because he was hypoxic and didn't come back after that. On [DATE] at 2:12 PM, during an interview with the complainant, she stated My father in-law had a fall, had his right hip replaced beginning of [DATE]. A week after surgery, he was transferred to this facility for therapy and rehabilitation. Resident #901 started therapy on Monday, doing very good with therapy, the following Thursday [DATE] th 2016, in the middle of the night, he took a fall, and we found out when somebody reported it after a week. His roommate told the DON that Resident #901 was on the floor. Friday morning [DATE], Resident #901 was in severe pain and facility did nothing about it. I went in on Monday, and found that nobody has done anything to address his increased pain, or perform an x-ray or notify the facility physician, so I called my daughter a nurse at this facility on a different unit, and she called the Doctor. Resident #901 was then ordered an x-ray that showed that his left hip broke into half. Resident #901 had another surgery on Wednesday, he went downhill and never recovered and died on the 7 th of [DATE]. I was very traumatized when you called on [DATE] for an interview and was unable to talk because I was preparing for his funeral at that time. According to Nursing Plan of care with an onset date of [DATE] indicated Resident #901 has potential for pain, falls and self care deficit related to general weakness. The Radiology report dated [DATE], concluded acute left femoral neck fracture with modest angulation and displacement. The Daily Skilled Nursing charting dated [DATE], Resident #901 was described as: . alert to person, extensive assistance for bed mobility self performance, personal hygiene and bathing, 2 person physical assist, total dependent for transfer, no changes to mood and behavior noted, incontinent of urine and bowel, verbalizes pain as 1 on a scale of ,[DATE], skilled services are physical and occupational therapy. The skilled daily charting dated [DATE], and [DATE], failed to address any incident, fall, pain was coded blank without any location or notes. Request for the Hospital medical record relating to left hip surgery was not made available by the end of the survey. A review of the clinical record on [DATE] at 1:38 p.m. revealed that Resident #901 had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MD'S) dated [DATE] signed by an RN assessment coordinator revealed that Resident #901 required one person physical assist from staff with all Activities of Daily Living (ADLS) including bed mobility, transfers, locomotion on unit ,and toileting. Resident #901's Brief Interview for Mental Status (BIMS) score of 07 (A score of 7 indicates long and short term memory loss). The Care Area Assessment worksheet on Care plan considerations indicated that Resident #901 was admitted with [DIAGNOSES REDACTED].#901 is at high risk for falls and that a prevention protocol should be initiated immediately and documented on the care plan. Review of the medical record on [DATE] at 2:08 PM, revealed an order noted on [DATE] at 01:40 to transfer Resident #901 to the hospital per MD for left [MEDICAL CONDITION]. Review of the physician order [REDACTED].#901 was prescribed [MEDICATION NAME]-[MEDICATION NAME] ,[DATE] mg 1 tablet by mouth every 8 hours as needed for pain, Tylenol 325 mg tablet every 6 hours as needed for pain, monitor surgical sight daily for infection. Review of the Medication Administration Record [REDACTED]. Their was no pain assessment documented to address if Resident #901's pain was being managed or stable. On [DATE] at 2:45 PM, the facility was asked to provide their policy pain, fall prevention policy, and abuse; The Pain Assessment revised [DATE] indicated The purpose of this procedure is to assess the resident's pain level and provide optimal comfort through a pain control plan which is mutually established with the resident, family and members of the health care team. Continuing pain assessment and management will occur daily, evaluation of pain medication .will occur within 2 hours of administration. Comprehensive pain assessment with a significant change in status. However the fall policy was not provided by the DON at the end of the survey. No fall policy document was provided. ( )

Based on observations, interviews, and record reviews, the facility failed to implement preventive measures and consistently conduct skin assessments or treatments for two of five sampled residents reviewed for pressure ulcers, (#805 and #806), from a total sample of 24, resulting in the development of an unstageable pressure ulcer (unable to stage because wound bed is covered with blacken tissue or slough) to resident #805's left heel, and significant worsening of an existing buttocks/coccyx pressure ulcer that caused pain and required surgical treatment, and the development of an unstageable pressure ulcer on resident #806's sacral (buttocks) area that required hospitalization with intravenous antibiotics. Findings include: Resident #805: During an observation and interview on 4/18/16 at 8:00 a.m. resident #805 was observed seated in her cushioned wheelchair, eating breakfast in the dining room. No heel protectors were in place. Resident #805 complained of pain around her buttocks. At 12:30 p.m., resident #805 was laying on her right side in the bed with her heels flat on the mattress. At 3:00 p.m., the resident was laying in her bed on her back, complaining of pain in the buttocks area. No heel protectors were in place. During an observation on 4/19/16 at 7:45 a.m., resident #805 was in a wheelchair, in the dining room with heels directly on the foot rests, no heel protectors in place. At 9:30 a.m., the resident was returned to bed on her right side with heels flat on the mattress. During interviews with staff 'F' and staff 'C' at 9:30 a.m., both staff acknowledged that resident #805 had a pressure ulcer to her heel. On 4/19/16 at 1:30 p.m., the wound care nurse (staff 'D') said that resident #805's buttocks/coccyx wound significantly worsened, and the left heel pressure ulcer developed while she was at the facility. Wound care observations with staff 'D' revealed that resident #805's buttocks/coccyx pressure ulcer had recently been debrided (surgically remove the dead tissue from wound). Staff 'D' said that the wound care consultant had debrided the resident's pressure ulcer at the bedside to promote healing. During the wound care it was observed that resident #805 was incontinent of urine and stool, and a small amount of stool was on the dressing, and some urine soaking up the resident's shirt. A medical record review was conducted on 4/19/16 at 10:00 a.m. According to the initial minimum data set ((MDS) dated [DATE], resident #805 admitted to the facility from the hospital on [DATE] for symptoms of a stroke and one sided weakness. Resident #805 was identified to have one stage 2 (partial loss of skin, shallow crater/blister) on the buttocks/coccyx area, with no measurements documented. The initial skin assessment dated [DATE] indicated that wound care was consulted for compromised area to coccyx. A care plan was initiated on 1/25/16 that included the following interventions; inspect skin and apply barrier cream as needed, and to turn and reposition resident every 2 hours. The care plan was updated on 4/6/16 to include a cushion to wheelchair, an air mattress, and heel protectors. The wound care notes dated 2/3/16 documented that the buttocks/coccyx wound is opened and measured 0.3 cm (centimeters) x 0.3 cm / 0.0 cm. A treatment of [REDACTED]. There were no additional skin assessments, updated care plan interventions, or wound care notes until 3/7/16. A review of the resident's treatment administration record (TAR) from January, February, and March of 2016 revealed sporadic documentation to support that prescribed skin treatments were administered in accordance to the physician's orders [REDACTED]. According to the wound care consultation note dated 3/7/16, resident #805 acquired two stage 3 pressure ulcers (full thickness tissue loss with fat layer visible) to the buttocks/coccyx area and a deep tissue injury to the left heel. (deep tissue injury is an unstageable pressure ulcer due to blackened tissue or slough covering area). A wound progress note dated 3/10/16 documented that the resident was complaining of pain around the buttocks area and the resident's buttocks/coccyx pressure ulcer had an 'odor' and necrotic tissue (blackened) that measured 4.0 cm x 3.0 cm and an undeterminable depth. Resident #805's left heel pressure ulcer measured 1.2 cm x 1.2 cm x 0.1 cm depth. A MDS for significant change for resident #805 was initiated on 3/11/16. Resident #805 was now identified to have one stage 3 pressure ulcer, one unstageable pressure ulcer due to blackened tissue, and one unstageable pressure ulcer that was a deep tissue injury. A wound care note dated 3/23/16, described the resident's buttocks/coccyx wound as stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) that measured 4.0 cm x 4.2 cm x 2.0 cm depth. The left heel pressure ulcer was a stage 3, and measured 1.0 cm x 1.2 cm x 0.2 cm. The resident was prescribed antibiotics. It was noted that the resident was complaining of pain on a daily basis. Resident #806: During observation on 4/18/16 at 8:30 a.m., resident #806 was observed in her bed, in a seated position eating her breakfast with a speech therapist at her bedside. Resident #806 did not have any specialty mattress in place and wore a wrap around her right lower leg and an air boot to her left foot. At 12:30 p.m., the resident was in the same position, seated in her bed, eating her lunch. During an observation at 4/18/16 at 4:00 p.m., the resident was asleep, flat on her back, with right leg wrapped and air boot to her left foot. During an interview at 4/18/16 at 4:15 p.m., the Director of nursing (DON)said that the resident #806's sacral/coccyx wound developed while she was at the facility. The DON said the resident had a specialty low air loss mattress prior to her hospitalization , but when she returned from the hospital (4/15/16) the specialty mattress did not get reordered. The DON said the specialty mattress would be ordered immediately. During an observation of wound care on 4/19/16 at 2:00 p.m., resident #806 was observed laying on her back, incontinent of stool, with the sacral pressure ulcer dressing contaminated with stool. The resident did have a low-air loss mattress in place. The wound care nurse ( staff 'D') said the resident was usually incontinent during sacral wound care. Resident #806's sacral pressure ulcer was extremely large, with yellow slough and pink drainage, the area was mostly covered with gray and blackened tissue. Staff 'D' did not measure the wound, and said that the wound care team would be in tomorrow. Staff 'D' said resident #806's wound had worsened since she last treated it, and new treatment orders would be needed. A medical record review was conducted on 4/18/16 at 2:00 p.m. According to the MDS, dated [DATE], the resident admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The resident was identified to have one unstageable pressure ulcer to her left heel, that was coded as a suspected deep tissue injury in evolution and had no measurements. A care plan for impaired skin was initiated on 3/7/16, and included the following interventions, monitor the skin for any signs/symptoms of skin breakdown and notify the physician, and turn/reposition resident every two hours. A review of the TAR from 3/7/16 - 4/11/16 revealed sporadic documentation to support that prescribed skin treatments were administered in accordance to the physician's orders [REDACTED]. A wound care note dated 3/14/16 documented that resident's left heel developed an intact blister. A wound care note dated 3/16/16 indicated the left heel was 50% necrotic (blackened tissue), measuring 3.5 cm x 5.0 cm, no depth. Skin assessments and wound care notes on 3/17/16 and 3/23/16 are the same, and have no documentation regarding the sacral area. According to the wound care note on 3/30/16, resident #806 now has a sacral wound that is necrotic, and measures 2.5 cm x 7.0 cm. The left heel pressure ulcer is now opened, and measures 3.5 cm x 3.5 cm with drainage. A low air loss mattress was recommended to be place on the resident as soon as possible. A review of the physician's progress notes dated 3/11/16, 3/18/16, 3/21/16, 3/22/16, 3/24/16, 3/28/16, and 4/11/16 revealed no documentation in regard to the left heel pressure ulcer or the sacral area pressure ulcer. However, a physician's orders [REDACTED]. According to a nurse's note dated 4/11/16, resident #806 had a follow up appointment with the orthopedic surgeon, and was sent out to his office. The resident did not return to the facility, but was sent directly to the hospital by the orthopedic surgeon, for concerns with a foul smelling and draining pressure ulcer on her sacral/coccyx area. According to the hospital records dated 4/15/16, resident #806 was admitted to the hospital directly from the orthopedic surgeon's office on 4/11/16 at 12:12 p.m., with multiple [DIAGNOSES REDACTED]. A culture from the sacral wound was obtained and revealed heavy gram negative bacilli and the presence of multiple pathogens (micro organism capable of producing disease) the resident was discharged back to the facility on [DATE] (4 days later) with orders for intravenous antibiotics. A review of the facility's policy for 'prevention of pressure ulcers' (not dated) revealed the following interventions and preventive measures: 2.b. determine if resident needs a special mattress. c. If a special mattress is needed, use the one .as indicated. 9. Routinely assess and document the condition of the resident's skin. ( )

Based on observation, interview, and record review, the facility failed to provide adequate supervision and safety interventions for three (#'s 803, 807, and 813) of six sampled residents reviewed for accidents from a total of 24, resulting in falls, bruises, skin tears, abrasions, a fracture and emergency hospitalization . Findings include: Resident #813- On 4/18/16 at 1:15 PM, resident #813 was observed in bed. The resident was alert and confused. At 3:30 PM, the resident's clinical record and Incident/Accident (I/A) reports were reviewed with the Director of Nursing (DON). The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum data set ((MDS) dated [DATE], noted that the resident had moderately impaired cognition and required limited assistance for ambulation, transfers, and bed mobility. A Fall Risk assessment dated [DATE] noted however, that the resident was disoriented, chairbound and had 3 or more falls in the past 3 months. A Fall care plan initiated on 2/29/16, noted that the resident had frequent falls and did not list supervision as an intervention. I/A reports noted the following: 1. 2/28/16 at 7:25 AM-found on the floor next to the bed while attempting to self transfer from bed to chair and heard yelling for help; sustained a 2 centimeter (cm) by 3 cm skin tear to the left hand; corrective intervention, per safety notes dated 2/29/16: activity staff to assess the resident's customary routine, care plan will be adjusted accordingly. Care plan reviewed. There was no documented assessment by activity staff following this fall. The DON was unable to respond why, when asked. 2. 2/29/16 at 7 PM-found on floor at end of the bed lying on his left side, unable to state what happened; sustained a skin tear to the left elbow and resident states he thinks he broke his shoulder on left side; corrective action per safety notes dated 3/1/16: Due to Sundowning (increased confusion in the evening hours found in some residents with dementia), activities (staff) to encourage resident to attend evening activities after dinner. Care plan updated. A visitor of a resident in another room notified staff that resident #813 was on the floor. Portable X-rays of the head, hip, shoulder and elbow on 2/29/16 were ordered and were negative for fracture or displacement, per review of the reports. New care plan interventions dated 3/1/16: Offer evening activities, hipsters (hip pads to help prevent fracture) at all times and take the resident to the dining room for all meals. There was no documented activity assessment after this fall, no documented indication that meals were eaten in the dining room or participation in evening activities. When queried, the DON said, He wouldn't come out of the room or sit in the hallway (in a common area for increased supervision). It should be in notes or on the care plan. The DON was unable to find documentation of this occurring. Per a physician progress notes [REDACTED]. There was no mention of the falls, the resident complaining of the shoulder being broken or the X-ray results on 2/29/16. 3. 3/2/16 at 4:15 PM-found on floor next to bed Confused and disoriented and stating he was getting into a chair; sustained a 2 cm by 3 cm skin tear to the right arm; Per a staff statement, I put him in the recliner .He was sitting 'up high' in the recliner. When asked to explain this 'up high' position, the DON was unable; safety note intervention dated 3/3/16: Activities (staff) to develop regimen for resident with appropriate activities for resident to engage him during the day. Care plan reviewed and updated. A care plan intervention was added on 3/3/16: Activities to provide appropriate activities to engage resident throughout day. There was no documented indication that this was done. The DON deferred to Activity Director 'K' for further information, however by the end of the survey, Director 'K' provided only the following: An initial Activity assessment dated [DATE], before any of the falls occurred, and an Activity Attendance record for 2/2016, which noted: On 2/27/16 thru 2/29/16, the resident had visits from family members and one visit from activity staff in his room. The Activity staff also inappropriately recorded that the resident watched TV and went to PT (therapy) on 2/30/16 and 2/31/16. On 3/4/16 per nursing notes, the resident had a swollen left arm and complained of pain. A STAT(immediate) X-ray was ordered and was performed at approximately 2 PM, which was negative for fracture or displacement, per review of the report. That same day, the following occurred: 4. 3/4/16 at 5:30 PM-found on the floor after attempting self transfer; The bed was noted to be in its' lowest position; no documented injury; Corrective actions per safety notes dated 3/7/16 included: The resident is to be encouraged to go to a dining room for all meals. The care plan intervention dated 3/8/16: Know that (resident) has Sundowners and will try to (get) up often without assistance. Per the Activity Attendance record, the resident had family and room visits from 3/1/16 thru 3/7/16 with attendance to a special event once on 3/5/16. There was no documented indication that meals were eaten in the dining room or that additional supervision occurred. 5. 3/7/16 at 8:50 PM-found on floor lying on right side and saying he was trying to self transfer to the chair; no documented injury; Per the safety note dated 3/8/16: Nursing staff reports that resident has been more confused than baseline and a urine culture was ordered to rule out a urinary tract infection, which was negative per the DON. When asked what the status of the left arm edema and pain noted on 3/4/16 was, the DON said she did not know and there was no further mention in nursing notes. When asked if the resident's arm was assessed by the physician prior to 3/8/16 when the edema and pain became apparent, the DON said that she could find no indication that this occurred. Per a physician progress notes [REDACTED]. Left arm weakness, rule out stroke recommend to send patient to hospital to rule out stroke and fracture. The resident was transported to the hospital on [DATE] and returned to the facility on [DATE] diagnosed with [REDACTED]. There was no mention that the resident had a stroke. Care plan interventions dated 3/15/16 included: activities throughout the day, evening activities, dining room for all meals, and staff to know that he had Sundowners. Per nursing notes dated 3/16/16, the resident was restless with attempts to self-transfer and indicated that he was in his room. 6. 3/30/16 at 3:10 PM-observed on knees trying to self-transfer; no noted injury; At 3:15 PM, family arrived for a visit. Per care plan interventions dated 3/31/16: One hour checks for one week and Activities (staff) to provide in room activities that are appropriate for resident. When queried, there was no documented indication that the hourly checks were provided. The DON could not explain this or why activities were to be in the room and not in common areas. Per the Activity Attendance record, the resident had room visits and family visits from 3/15/16 thru 3/31/16. The DON deferred to the Assistant DON (ADON) for further information regarding the resident's falls. On 4/20/16 at 8:50 AM, all of the resident's falls and interventions were reviewed with the ADON. When asked for verification of the one hour checks being done and why this was not implemented after previous falls, the ADON said that the checks were done, but not documented. She said, We were trying to engage him in activities rather than doing one hour checks before this fall (on 3/30/16). When asked, she was unable to explain why the resident remained alone in his room during the falls and could not provide documentation that the resident refused to come out of his room. Resident #803- On 4/19/16 1:45 PM and on 4/20/16 at 8:10 AM, resident #803 was observed lying in bed with the bed not placed in its' lowest position. The resident was alert with a flat affect and had an indwelling urinary catheter. On 4/20/16 at 9:30 AM, the resident's clinical record and I/A reports were reviewed with the ADON. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] noted that the resident had severe cognitive impairment, was non-ambulatory, required extensive assistance for transfers and mobility and had two or more falls with minor injuries. Fall Risk Assessments dated 8/25/15, 4/4/16, and 4/5/16 noted that the resident was at high risk. A Fall care plan intervention initiated on 8/25/15 and on-going, noted: Bed in lowest position. I/A reports revealed the following: 1. 8/25/15-on floor lying on left side stating that he rolled out of bed; abrasions to both knees; care planned intervention: bed in lowest position. 2. 4/3/16-on floor by bed; abrasions to both knees. 3. 4/5/16-on floor next to bed; skin tear to left knee. There was no documented indication that the bed was in the lowest position on 4/3/16 or 4/5/16. The ADON did not explain why the bed was not low during the observations on 4/19/16 and 4/20/16 to help prevent serious injury should a fall occur. Resident #807- On 4/19/16 at 9:20 AM and 1:50 PM, and on 4/20/16 at 8:35 AM, the resident was observed lying in bed that was not in its' lowest position. The resident was alert with some confusion. On 4/20/16 at 9:40 AM, the resident's clinical record and I/A reports were reviewed with the ADON. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. MDS' dated 12/11/15 and 3/11/16 noted that the resident had severe cognitive impairment, was non-ambulatory, required extensive assistance for transfers and mobility and had two or more falls with zero to minor injuries. Self Care Deficit care plan interventions included: Bed against wall so environment is conducive to safety, in effect from 7/2/15 thru 3/31/16. Fall Risk Assessments dated 9/18/15, 10/19/15, 11/16/15, 1/1/16, 2/28/16 and 3/18/16 noted that the resident was at high risk. I/A reports revealed the following: 1. 7/1/15-on floor by bed with redness to knees; A fall safety alarm was in use, but did not sound to alert staff. There was no documented reason why. 2. 7/11/15-on floor in room; sustained a split fingernail on right hand. 3. 9/18/15-observed leaning forward and falling out of wheelchair; sustained abrasion and hematoma to head. 4. 10/18/15-on floor next to bed; no noted injury. 5. 11/16/15-on floor next to bed; abrasions to both knees and left elbow. 6. 12/31/15-on floor by bed; no noted injury. 7. 2/28/16-on floor face down by bed with bed in lowest position; no noted injury. 8. 3/18/16-on floor next to bed with redness to forehead and knees; Hipsters were not available and Bed is supposed to be against the wall, perpendicular to wall. The report noted that these interventions were care planned, but not in place. There was no mention whether the bed was low. When queried about the interventions not being implemented, the ADON did not respond. On 4/20/16 at 2 PM, per review of the facility's policies on Fall Prevention Process Guidelines dated 2/12/15 and Falls-Clinical Protocol dated 3/2015: Provide on-going risk reducing interventions as needed; Evaluate the resident's response to interventions; Monitor for falls; Track falls and monitor trends; Interventions should be developed and implemented per the assessed needs. ( )

REFER TO INTAKE MI 521. BASED ON INTERVIEWS AND RECORD REVIEWS, FACILITY STAFF FAILED TO MEET PROFESSIONAL STANDARDS OF CARE BY FAILING TO CONDUCT WOUND ASSESSMENTS ON ADMISSION AND OBTAIN PHYSICIAN ORDERS [REDACTED].#502, #503) OF 4 SAMPLED RESIDENTS WITH PRESSURE SORES IN A TOTAL SAMPLE OF 4 RESIDENTS, RESULTING IN DELAYED WOUND TREATMENTS AND A NEW PRESSURE SORE FOR RESIDENT #500. FACILITY STAFF ALSO FAILED TO MEET PROFESSIONAL STANDARDS OF CARE BY FAILING TO DISCUSS AN ORDER WITH A PHYSICIAN FOR 1 (#502) OF 4 RESIDENTS SAMPLED REGARDING STANDARDS OF CARE IN A TOTAL SAMPLE OF 4 RESIDENTS PLACING THE RESIDENT AT RISK FOR INAPPROPRIATE DISCHARGE ORDERS. FINDINGS INCLUDE: ACCORDING TO GUIDO IN "LEGAL AND ETHICAL ISSUES IN NURSING," 3RD EDITION, STANDARDS OF CARE "MEANS THAT A NURSE MUST HAVE AND USE THE KNOWLEDGE AND SKILL ORDINARILY POSSESSED AND USED BY NURSES ACTIVELY [MEDICATION NAME] IN THE NURSE'S SPECIALITY AREA." (P. ,[DATE]). GUIDO DESCRIBES "EXTERNAL STANDARDS" THAT ESTABLISH STANDARDS OF PRACTICE, SUCH AS STATE BOARDS OF NURSING, PROFESSIONAL ORGANIZATIONS, SPECIALTY NURSING ORGANIZATIONS, FEDERAL ORGANIZATIONS, AND FEDERAL GUIDELINES. (P. 65) THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, PUBLIC HEALTH SERVICE, AGENCY FOR HEALTH CARE POLICY AND RESEARCH HAVE DEVELOPED CLINICAL PRACTICE GUIDELINES FOR PRESSURE ULCERS. IN AN ARTICLE, "AHCPR SUPPORTED CLINICAL PRACTICE GUIDELINES", 2010, IT SAYS THAT STEPS TO REVERSE DETERIORATION SHOULD BE TAKEN IMMEDIATELY. INITIAL ASSESSMENT AND PERIODIC ASSESSMENT MUST INCLUDE: SIZE, DEPTH, AND THE PRESENCE OF EXUDATE, [MEDICATION NAME], GRANULATION TISSUE, AND FINDINGS SUCH AS NECROTIC TISSUE, SINUS TRACTS, UNDERMINING, TUNNELING, AND PURULENT DRAINAGE OR OTHER SIGNS OF INFECTION. "WOUND CARE" BY HESS STATES THAT TREATMENT ORDERS MUST BE OBTAINED BEFORE APPLYING OR CHANGING A DRESSING. THE ORDER SHOULD INCLUDE SPECIFIC SITE, CLEANING SOLUTION AND METHOD, PRIMARY DRESSING, SECONDARY DRESSING IF APPLICABLE, AND FREQUENCY OF DRESSING CHANGES. (P. 35) RESIDENT #500 RESIDENT #500 WAS admitted to the facility on [DATE], PER THE FACILITY ADMISSIONS RECORD. HOSPITAL RECORDS WERE REVIEWED ON [DATE] AT 3 P.M. A CRITICAL CARE FLOW SHEET, DATED [DATE], DESCRIBED 5 WOUNDS; 1) A STAGE IV SACRAL WOUND WITH A RED/BLACK WOUND BED, MODERATE SEROUS DRAINAGE, AND A FOUL ODOR; 2) A STAGE IV RIGHT (R) [MEDICAL CONDITION] (BKA) WOUND WITH A RED/BLACK WOUND BED, MODERATE SEROUS DRAINAGE, AND A FOUL ODOR; 3) AN UNSTAGEABLE LATERAL LEG ULCER WITH A RED/BLACK WOUND BED; 4) AN UNSTAGEABLE LEFT LATERAL ANKLE PRESSURE SORE WITH ESCHAR (DEAD, DEVITALIZED TISSUE); AND 5) AN UNSTAGEABLE LEFT HEEL ULCER WITH ESCHAR. CRITICAL CARE FLOW SHEETS DATED [DATE] AND [DATE] DID NOT INCLUDE A RIGHT BUTTOCK WOUND. ON [DATE], A NURSE DOCUMENTED ON A "BODY EDITOR," A DIAGRAM ALLOWING NURSES TO DOCUMENT THE LOCATION OF BODY [MEDICAL CONDITION] AND DESCRIBE THE [MEDICAL CONDITION] ACCORDING TO COLOR, ODOR, DRAINAGE, DRAIN COLOR, AND SIZE. THE BODY EDITOR INDICATED RESIDENT #500 HAD "OPEN WOUNDS TO COCCYX, LEFT HEEL AND RIGHT STUMP". NO OTHER INFORMATION WAS DOCUMENTED ABOUT THE WOUNDS. FACILITY STAFF DID NOT PROVIDE COMPLETE WOUND ASSESSMENTS FOR RESIDENT #500 PRIOR TO [DATE]. AT THAT TIME 7 WOUNDS WERE DESCRIBED: 1) RIGHT BUTTOCKS, 2) SACRAL, 3) (L) LATERAL FOOT, 4) (R) BKA, 5) (L) POSTERIOR CALF, 6) (L) LATERAL ANKLE, AND 7) (L) LATERAL AND POSTERIOR HEEL. A RIGHT BUTTOCKS WAS NOT DESCRIBED IN ANY OF THE HOSPITAL WOUND ASSESSMENTS. THE EARLIEST WOUND CARE ORDERS FOR RESIDENT #500, PROVIDED BY FACILITY STAFF, WAS [DATE] FOR THE SACRAL WOUND AND THE (R) BKA STUMP WOUND, AND [DATE] FOR THE (L) LOWER EXTREMITY AND (R) BUTTOCKS WOUND. WOUND CARE FOR RESIDENT #500, PER THE TREATMENT RECORDS PROVIDED BY THE FACILITY, INDICATED THAT WOUND CARE TO THE SACRAL AREA WAS STARTED ON [DATE]. WOUND CARE FOR RESIDENT #500, PER THE TREATMENT RECORDS PROVIDED BY THE FACILITY, INDICATED THAT WOUND CARE TO THE (R) BKA STUMP WOUND, THE (L) LOWER EXTREMITY WOUNDS, AND THE (R) BUTTOCKS WOUND WAS STARTED ON [DATE]. ( ) RESIDENT #502 RESIDENT #502 WAS admitted to the facility on [DATE], ACCORDING TO THE FACILITY ADMISSIONS RECORD. ON [DATE] A NURSE DOCUMENTED ON THE FACILITY "BODY EDITOR" THAT THE RESIDENT HAD AN "OPEN AREA" ON THE SACRUM. NO OTHER INFORMATION WAS DOCUMENTED ABOUT THE OPEN AREA. ON [DATE] THE WOUND CARE NURSE DOCUMENTED THE FOLLOWING INFORMATION ABOUT RESIDENT #502'S PRESSURE SORE. "RESIDENT HAS 8 CM X 8 CM AREA OF MASD (MOISTURE ASSOCIATED SKIN DAMAGE) WITH FUNGAL DENUDED SKIN AND DARK PURPLE NON BLANCHABLE DISCOLORATION THAT IS EVIDENT OF DEEP TISSUE INJURY TO SACRAL/BUTTOCKS AREA." THE EARLIEST WOUND CARE ORDERS FOR RESIDENT #502, PROVIDED BY FACILITY STAFF, WAS [DATE]. WOUND CARE FOR RESIDENT #502, PER THE TREATMENT RECORD PROVIDED BY THE FACILITY, INDICATED THAT WOUND CARE TO THE SACRAL AREA WAS STARTED ON [DATE]. ( ) RESIDENT #503 RESIDENT #503 WAS REadmitted to the facility on [DATE], PER THE ADMISSIONS RECORD. ACCORDING TO A [DATE] HISTORY & PHYSICAL REPORT, RESIDENT #503 HAD THE FOLLOWING DIAGNOSES; [MEDICAL CONDITION] WITH A [MEDICAL CONDITION], PNEUMONIA, [MEDICAL CONDITION] DISORDER, [MEDICAL CONDITION], STROKE, DEMENTIA, AND [MEDICAL CONDITION]. NURSING DOCUMENTATION ON RESIDENT #503'S BODY EDITOR ON [DATE] INCLUDED; 1) "BROKEN SKIN AROUND RECTUM AREA", 2) "OPEN AREA SURROUNDING RECTUM", 3) "OPEN LESION" AT RECTAL AREA, 4) "RAW AREA SURROUNDING RECTUM", 5) "OPEN SORE" ON LEFT BUTTOCK, 6) "OPEN QUARTER-SIZED LESION" ON THE LEFT BUTTOCK, 6) "OPEN AREA WITH SURROUNDING DISCOLORATION" ON THE LEFT LATERAL OUTER FOOT ANTERIOR TO THE HEEL, 7) "OPEN LESION WITH SURROUND DISCOLORATION" ON THE LEFT LATERAL OUTER FOOT ANTERIOR TO HEEL, 8) "OPEN LESION WITH SURROUNDING DISCOLORATION" ON THE LEFT LATERAL OUTER FOOT ANTERIOR TO HEEL, 9) "THREE SMALL OPEN AREAS TO LEFT LATERAL FOOT, SURROUNDED WITH NECROTIC TISSUE", AND 10) "SKIN BREAKDOWN NOTED BETWEEN LEFT GREAT AND SECOND TOES". THERE WAS NO OTHER DOCUMENTATION REGARDING WOUND COLOR, ODOR, DRAINAGE, DRAIN COLOR, SIZE. ON [DATE] THE WOUND CARE NURSE DESCRIBED THE FOLLOWING WOUNDS, "RESIDENT HAS 2 CM X 1.5 CM UNSTAGEABLE FIRMLY ADHERED ESCHAR TO LEFT MEDIAL FOOT ON BUNION FOOT ON BUNION AREA. RESIDENT ALSO HAS 0.5 CM X 0.5 MC UNSTAGEABLE FIRMLY ADHERED ESCHAR TO LEFT LATERAL FOREFOOT NEAR TOE. RESIDENT HAS 3 CM X 2.5 CM UNSTAGEABLE FIRMLY ADHERED ESCHAR TO LEFT LATERAL MID FOOT. RESIDENT HAS CALLUSES TO BILATERAL HEELS WITH HISTORY OF WOUNDS, BUT REMAINS SAFETY RISK IF HEEL PROTECTORS ARE APPLIED DUE TO ATTEMPTS TO TRANSFER SELF AND WALK WITHOUT ASSISTANCE. RESIDENT HAS UNSTAGEABLE SLOUGH COVERED WOUND TO LEFT BUTTOCKS MEASURING 3 CM X 2 CM WITH SCANT AMOUNT OF SEROUS DRAINAGE AND BLANCHABLE REDNESS TO PERI WOUND AREA." THE EARLIEST WOUND CARE ORDERS FOR RESIDENT #503, PROVIDED BY FACILITY STAFF, WAS [DATE]. WOUND CARE FOR RESIDENT #503, PER THE TREATMENT RECORDS PROVIDED BY THE FACILITY, INDICATED THAT WOUND CARE BEGAN ON [DATE]. ( ) THE DON, IN AN INTERVIEW ON [DATE] AT 10:30 A.M., WAS ASKED WHY RESIDENTS WITH WOUNDS HAD NO WOUND ORDERS ON ADMISSION. SHE SAID ORDERS ON HOSPITAL TRANSFER SHEETS WERE USED IF THEY WERE AVAILABLE. SHE PROVIDED THE SURVEYOR A POLICY ENTITLED, "ADMISSION SKIN ASSESSMENT." THIS WAS NOT ON A LETTERHEAD AND HAD NO DATE. IT STATED, IN PART, "THE RESULTS OF THE SKIN ASSESSMENT WILL BE DOCUMENTED IN THE NURSING ADMISSION NOTES. FOLLOW TRANSFER ORDERS IF PRESENT. IF NO ORDER PRESENT AND IF ANY ABNORMALITIES ARE NOTED BY THE ASSIGNED STAFF, TREATMENT WILL BE PER PROTOCOL. ANY WOUND THAT IS CLEAN AND ABSENT OF NECROTIC TISSUE WILL BE COVERED BY A DRY DRESSING UNTIL THE TREATMENT NURSE OBTAINS FURTHER ORDERS. ANY WOUND THAT IS NECROTIC OR HAS A FOUL ODOR WILL BE CLEANSED WITH [MEDICATION NAME] AND A DRY DRESSING APPLIED. THE TREATMENT NURSE WILL ASSESS THE WOUND AND OBTAIN FURTHER ORDERS." THERE WAS NO PHYSICIAN NAME IDENTIFIED ON THE POLICY. NO SOURCE FOR THE ABOVE STATEMENTS WAS IDENTIFIED. THE ADMINISTRATOR, ON [DATE] AT 1 P.M., STATED THAT THE NURSES DO NOT STAGE ULCERS; THAT SKILL WAS NOT IN THEIR SCOPE OF PRACTICE. ( ) IN "LAW EVERY NURSE SHOULD KNOW", 5TH EDITION BY CREIGHTON, IT STATES THAT NURSES MUST NOT DO ANY ACT THAT MIGHT BE INTERPRETED AS THE THE PRACTICE OF MEDICINE. NURSES ARE ONLY ALLOWED TO DO WHAT IS STATED IN THE STATE'S NURSE PRACTICE ACT. RESIDENT #502 RESIDENT #502, [AGE] years OLD, WAS admitted to the facility on [DATE], PER THE ADMISSION FORM. A HOSPITAL HISTORY & PHYSICAL (H&P) FORM FOR RESIDENT #502, DATED [DATE], STATED THAT THE RESIDENT WAS admitted FOLLOWING A FALL AT HOME. A CAT (COMPUTERIZED AXIAL TOMOGRAPHY) SCAN ON [DATE] DOCUMENTED A STROKE. AN MDS (MINIMUM DATA SET) ASSESSMENT ON [DATE] INDICATED THAT RESIDENT #502 HAD COGNITIVE AND MEMORY IMPAIRMENT AND REQUIRED TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING. ACCORDING TO THE MDS, THERE WAS AN UNSTAGEABLE PRESSURE SORE PRESENT ON ADMISSION. THE RESIDENT HAD TWO FALLS SINCE ADMISSION, ON [DATE] AND [DATE], ACCORDING TO NURSES' NOTES. IN AN INTERVIEW ON [DATE] AT 9:45 A.M., FAMILY MEMBER #12 EXPRESSED CONCERN ABOUT RESIDENT #502'S DISCHARGE. THE FAMILY MEMBER SAID THE FAMILY FELT THEY COULD NOT CARE FOR HER AT HOME DUE TO THE PHYSICAL DEMANDS OF CARE THAT WOULD BE NECESSARY. ON [DATE] AT 12 P.M. NURSE #8 SAID SHE WROTE THE [DATE] ORDER, "DC (DISCHARGE) WITH (NAME) HOME HEALTH CARE WITH PT/OT(PHYSICAL THERAPY/OCCUPATIONAL THERAPY, HHA (HOME HEALTH AIDE), NSG (NURSING). DME (DURABLE MEDICAL EQUIPMENT): SHOWER CHAIR, RAIL/GRAB BARS BY TOILET AND TUB, HOSPITAL BED OR RAILS ON BED, WHEELCHAIR WITH RIGHT FOOT REST AND HALF LAP TRAY ON RIGHT SIDE, AND SENSOR ALARMS. DX (DIAGNOSES) FEMUR NOS-CLOSED FX (FRACTURE), HISTORY OF FALL, ORTHOPEDIC AFTER CARE, LATE EF (EFFECT) HEMIPGLA ([MEDICAL CONDITION]) DOM (DOMINANT) SIDE,[MEDICAL CONDITION](HYPERTENSION), CAD ([MEDICAL CONDITION]), DM 2 (DIABETES MELLITUS), [MEDICAL CONDITION], MENTAL DISORDER." THE ORDER WAS WRITTEN AS A "VERBAL" ORDER (TELEPHONE ORDER). THE NAME OF THE PHYSICIAN WAS DOCUMENTED ON THE ORDER. NURSE #8 SAID SHE DID NOT SPEAK WITH THE PHYSICIAN ABOUT HOME CARE BEFORE WRITING THE ORDER. SHE SAID A REPRESENTATIVE OF THE HOME CARE COMPANY WAS IN THE FACILITY AND SAID IT WOULD SAVE HIM A RETURN TRIP IF HE COULD OBTAIN INFORMATION ABOUT THE POSSIBLE REFERRAL THAT DAY. NURSE #8 SAID SHE WROTE THE ORDER. THE SOCIAL WORKER #9 WAS INTERVIEWED ON [DATE] AT 12:15 P.M. THE SOCIAL WORKER SAID SHE DID NOT SPEAK WITH THE PHYSICIAN ABOUT HOME CARE. ( )

REFER TO INTAKE MI 521. BASED ON OBSERVATIONS, INTERVIEWS, AND RECORD REVIEWS, FACILITY STAFF FAILED TO ENSURE THAT PRESSURE SORE ASSESSMENTS WERE COMPLETED ON ADMISSION, ORDERS WERE OBTAINED AND FOLLOWED FOR TREATMENT, AND PREVENTIVE MEASURES WERE PROVIDED IN 3 (#500, #502, AND #503) OF 4 SAMPLED RESIDENTS WITH PRESSURE SORES IN A TOTAL SAMPLE OF 4 RESIDENTS RESULTING IN A NEW PRESSURE SORE FOR RESIDENT #500 AND PLACING ALL THREE RESIDENTS AT RISK FOR DELAYED HEALING, INFECTION, AND THE DEVELOPMENT OF NEW PRESSURE SORES. FINDINGS INCLUDE: RESIDENT #500 RESIDENT #500 WAS admitted to the facility on [DATE], PER THE FACILITY ADMISSIONS RECORD. ACCORDING TO THE HISTORY AND PHYSICAL EXAM, DATED 12/18/11, RESIDENT #500'S [DIAGNOSES REDACTED]. THE HOSPITAL CRITICAL CARE FLOW SHEET, DATED 12/14/11, DESCRIBED 5 WOUNDS: 1) A STAGE IV SACRAL WOUND WITH A RED/BLACK WOUND BED, MODERATE SEROUS DRAINAGE, AND A FOUL ODOR; 2) A STAGE IV RIGHT (R) [MEDICAL CONDITION] (BKA) WOUND WITH A RED/BLACK WOUND BED, MODERATE SEROUS DRAINAGE, AND A FOUL ODOR; 3) AN UNSTAGEABLE LATERAL LEG ULCER WITH A RED/BLACK WOUND BED; 4) AN UNSTAGEABLE LEFT LATERAL ANKLE PRESSURE SORE WITH ESCHAR (DEAD, DEVITALIZED TISSUE); AND, 5) AN UNSTAGEABLE LEFT HEEL ULCER WITH ESCHAR. THE HOSPITAL CRITICAL CARE FLOW SHEETS DATED 12/15/11 AND 12/16/11 DID NOT INCLUDE A RIGHT BUTTOCKS WOUND. ON 12/17/11 A FACILITY NURSE DOCUMENTED ON A "BODY EDITOR," A DIAGRAM ALLOWING NURSES TO DOCUMENT THE LOCATION OF BODY [MEDICAL CONDITION] AND DESCRIBE THE [MEDICAL CONDITION] ACCORDING TO COLOR, ODOR, DRAINAGE, DRAIN COLOR, AND SIZE. THE BODY EDITOR INDICATED RESIDENT #500 HAD "OPEN WOUNDS TO COCCYX, LEFT HEEL AND RIGHT STUMP." NO OTHER INFORMATION WAS DOCUMENTED ABOUT THE WOUNDS. THE WOUND CARE NURSE PROVIDED WOUND ASSESSMENTS FOR RESIDENT #500 ON 12/19/11. AT THAT TIME 7 WOUNDS WERE DESCRIBED: 1) RIGHT BUTTOCKS, 2) SACRAL, 3) (L) LATERAL FOOT, 4) (R) BKA, 5) (L) POSTERIOR CALF, 6) (L) LATERAL ANKLE, AND 7) (L) LATERAL AND POSTERIOR HEEL. A WOUND ON RESIDENT 500'S RIGHT BUTTOCKS WAS NOT DESCRIBED IN ANY OF THE HOSPITAL WOUND ASSESSMENTS. THE EARLIEST WOUND CARE ORDERS FOR RESIDENT #500, PROVIDED BY FACILITY STAFF, WAS 12/18/11 FOR THE SACRAL WOUND AND THE (R) BKA WOUND, AND 12/19/11 FOR THE (L) LOWER EXTREMITY AND (R) BUTTOCKS WOUND. IN REGARDS TO THE SACRAL WOUND: WOUND CARE FOR RESIDENT #500, PER THE TREATMENT RECORDS PROVIDED BY THE FACILITY, INDICATED THAT WOUND CARE TO THE SACRAL AREA WAS STARTED ON 12/18/11. WOUND CARE TO THE SACRAL AREA WAS ORDERED DAILY, PER PHYSICIAN ORDERS [REDACTED]. WOUND CARE WAS NOT DONE, PER TREATMENT RECORDS PROVIDED BY THE FACILITY, ON 12/16/11, 12/17/11, 12/25/11, 1/1/12, 1/7/12, 1/8/12, AND 1/13/12. THIS WAS 7 MISSED TREATMENTS FOR 29 TREATMENT OPPORTUNITIES. IN REGARDS TO THE BKA WOUND: WOUND CARE FOR RESIDENT #500, PER THE TREATMENT RECORDS PROVIDED BY THE FACILITY, INDICATED THAT WOUND CARE TO THE (R) BKA WOUND WAS STARTED ON 12/19/11. WOUND CARE TO THE (R) BKA SITE WAS ORDERED DAILY ON 12/18/11 AND 12/19/11 PER PHYSICIAN ORDERS. WOUND CARE WAS NOT DONE, PER TREATMENT RECORDS PROVIDED BY THE FACILITY, ON 12/16/11, 12/17/11, AND 12/18/11. ON 12/23/11 THERE WAS A physician's orders [REDACTED]. WOUND CARE, PER TREATMENT RECORDS PROVIDED BY THE FACILITY WERE NOT DONE ON 1/13/12. THIS WAS 4 MISSED TREATMENTS FOR 17 TREATMENT OPPORTUNITIES. IN REGARDS TO THE LEFT LOWER EXTREMITY WOUND: WOUND CARE FOR RESIDENT #500, PER THE TREATMENT RECORDS PROVIDED BY THE FACILITY, INDICATED THAT WOUND CARE TO THE (L) LOWER EXTREMITY WAS STARTED ON 12/19/11. WOUND CARE TO THE (L) LOWER EXTREMITY WAS ORDERED EVERY MONDAY, WEDNESDAY, AND FRIDAY, PER PHYSICIAN ORDERS [REDACTED]. WOUND CARE, PER TREATMENT RECORDS PROVIDED BY THE FACILITY WERE NOT DONE ON 12/16/11, 12/17/11, 12/18/11, AND 1/13/12. THIS WAS 4 MISSED TREATMENTS FOR 15 TREATMENT OPPORTUNITIES. IN REGARDS TO THE RIGHT BUTTOCKS WOUND: WOUND CARE FOR RESIDENT #500, PER THE TREATMENT RECORDS PROVIDED BY THE FACILITY, INDICATED THAT WOUND CARE TO THE (R) BUTTOCKS WAS STARTED ON 12/19/11. WOUND CARE TO THE (R) BUTTOCKS WAS ORDERED DAILY ON 12/19/11, 12/23/11, AND 1/6/12, PER PHYSICIAN ORDERS. THE (R) BUTTOCKS WOUND WAS NOT PRESENT PER HOSPITAL "WOUND ASSESSMENTS," DATED 12/16/11. THE (R) BUTTOCKS WOUND WAS FIRST DESCRIBED IN A NURSE'S NOTE ON 12/19/11, WRITTEN BY THE WOUND CARE NURSE. WOUND CARE, PER TREATMENT RECORDS PROVIDED BY THE FACILITY WERE NOT DONE ON 12/25/11, 1/1/12, 1/7/12, 1/8/12, AND 1/13/12. THE RESIDENT WAS TRANSFERRED TO THE hospital on [DATE] AND DID NOT RETURN TO THE NURSING HOME. NURSE #2 DOCUMENTED IN A NURSE'S NOTE ON 1/14/12 THAT RESIDENT #500'S FAMILY WAS IN THE FACILITY ON 1/13/12, AFTER 7 P.M., AND WERE "UPSET" BECAUSE THE RESIDENT'S WOUND CARE HAD NOT BEEN DONE THAT DAY. IN A TELEPHONE INTERVIEW ON 2/13/12 AT 8:25 A.M., NURSE #2 SAID THE DATE ON THE DRESSINGS WAS 1/12/12. RESIDENT #500 WAS TRANSFERRED TO THE HOSPITAL, PER A NURSE'S NOTE ON 1/14/12 AT 8:02 A.M., "DUE TO ABNORMAL LAB RESULTS." HOSPITAL RECORDS FOR RESIDENT #500 WERE REVIEWED ON 2/13/12 AT 2 P.M. A PHYSICIAN HISTORY & PHYSICAL REPORT, DATED 1/14/12, LISTED THE FOLLOWING DIAGNOSES;[MEDICAL CONDITION], PNEUMONIA, DEHYDRATION, URINARY TRACT INFECTION, [MEDICAL CONDITION] (ELEVATED SERUM SODIUM), HYPOKALEMIA (LOW SERUM POTASSIUM), ELEVATED TROPONINS (HEART PROTEIN), MULTIPLE SACRAL DECUBITUS, NECROTIC RIGHT BELOW-KNEE AMPUTATION STUMP. ACCORDING TO THE OPERATIVE REPORT, DATED 1/20/12, THE RESIDENT'S LARGE SACRAL WOUND WHICH EXTENDED DOWN ALMOST TO THE SACRAL BONE, THE NECROTIC (R) AMPUTATION STUMP WOUND, AND NECROTIC AND INFECTED WOUNDS OF THE LEFT LOWER EXTREMITY WERE SURGICALLY DEBRIDED. ( ) RESIDENT #502 RESIDENT #502 WAS admitted to the facility on [DATE], ACCORDING TO THE FACILITY ADMISSIONS RECORD. ON 1/13/12 A NURSE DOCUMENTED ON THE FACILITY "BODY EDITOR" THAT RESIDENT #502 HAD AN "OPEN AREA" ON THE SACRUM. NO OTHER INFORMATION WAS DOCUMENTED ABOUT THE OPEN AREA. ON 1/16/12 THE WOUND CARE NURSE DOCUMENTED THE FOLLOWING INFORMATION ABOUT RESIDENT #502'S PRESSURE SORE: "RESIDENT HAS 8 CM X 8 CM AREA OF MASD (MOISTURE ASSOCIATED SKIN DAMAGE) WITH FUNGAL DENUDED SKIN AND DARK PURPLE NON BLANCHABLE DISCOLORATION THAT IS EVIDENT OF DEEP TISSUE INJURY TO SACRAL/BUTTOCKS AREA." THE EARLIEST WOUND CARE ORDERS FOR RESIDENT #502, PROVIDED BY FACILITY STAFF, WERE DATED 1/14/12. WOUND CARE FOR RESIDENT #502, PER THE TREATMENT RECORD PROVIDED BY THE FACILITY, INDICATED THAT WOUND CARE TO THE SACRAL AREA WAS STARTED ON 1/16/12. THE PRESCRIBED CREAM, ACCORDING TO THE physician's orders [REDACTED]. WOUND CARE WAS NOT DONE, PER TREATMENT RECORDS PROVIDED BY THE FACILITY, ON 1/21/12, 1/22/12, 1/24/12, 1/28/12, AND 2/4/12 ON THE FIRST SHIFT. WOUND CARE WAS NOT DONE, PER TREATMENT RECORDS PROVIDED BY THE FACILITY, DURING THE SECOND SHIFT ON 1/18/12-1/23/12, 1/25/12-1/27/12, 2/1/12-2/4/12, AND 2/9/12-2/10/12. THE DON, IN AN INTERVIEW ON 2/13/12 AT 10 A.M., STATED THAT CERTIFIED NURSING ASSISTANTS (CNA) APPLY THE CREAM WHEN THEY CHANGE THE RESIDENT'S BRIEF. THE DON PROVIDED CHARTING FORMS FOR CNAS. THERE WAS A PLACE TO DOCUMENT THAT BRIEFS WERE CHANGED, BUT THERE WAS NO PLACE TO DOCUMENT THAT THE WOUND CREAM WAS APPLIED. ( ) RESIDENT #503 RESIDENT #503 WAS REadmitted to the facility on [DATE]. ACCORDING TO A 2/4/12 HISTORY & PHYSICAL REPORT, RESIDENT #503 HAD THE FOLLOWING Diagnoses: [REDACTED]. NURSING DOCUMENTATION ON RESIDENT #503'S BODY EDITOR ON 2/4/12 INCLUDED: 1) "BROKEN SKIN AROUND RECTUM AREA", 2) "OPEN AREA SURROUNDING RECTUM", 3) "OPEN LESION" AT RECTAL AREA, 4) "RAW AREA SURROUNDING RECTUM", 5) "OPEN SORE" ON LEFT BUTTOCK, 6) "OPEN QUARTER-SIZED LESION" ON THE LEFT BUTTOCK, 6) "OPEN AREA WITH SURROUNDING DISCOLORATION" ON THE LEFT LATERAL OUTER FOOT ANTERIOR TO THE HEEL, 7) "OPEN LESION WITH SURROUND DISCOLORATION" ON THE LEFT LATERAL OUTER FOOT ANTERIOR TO HEEL, 8) "OPEN LESION WITH SURROUNDING DISCOLORATION" ON THE LEFT LATERAL OUTER FOOT ANTERIOR TO HEEL, 9) "THREE SMALL OPEN AREAS TO LEFT LATERAL FOOT, SURROUNDED WITH NECROTIC TISSUE", AND 10) "SKIN BREAKDOWN NOTED BETWEEN LEFT GREAT AND SECOND TOES". THERE WAS NO OTHER DOCUMENTATION REGARDING WOUND COLOR, ODOR, DRAINAGE, DRAIN COLOR, SIZE. ON 2/6/12 THE WOUND CARE NURSE DESCRIBED THE FOLLOWING WOUNDS, "RESIDENT HAS 2 CM X 1.5 CM UNSTAGEABLE FIRMLY ADHERED ESCHAR TO LEFT MEDIAL FOOT ON BUNION FOOT ON BUNION AREA. RESIDENT ALSO HAS 0.5 CM X 0.5 MC UNSTAGEABLE FIRMLY ADHERED ESCHAR TO LEFT LATERAL FOREFOOT NEAR TOE. RESIDENT HAS 3 CM X 2.5 CM UNSTAGEABLE FIRMLY ADHERED ESCHAR TO LEFT LATERAL MID FOOT. RESIDENT HAS CALLUSES TO BILATERAL HEELS WITH HISTORY OF WOUNDS, BUT REMAINS SAFETY RISK IF HEEL PROTECTORS ARE APPLIED DUE TO ATTEMPTS TO TRANSFER SELF AND WALK WITHOUT ASSISTANCE. RESIDENT HAS UNSTAGEABLE SLOUGH COVERED WOUND TO LEFT BUTTOCKS MEASURING 3 CM X 2 CM WITH SCANT AMOUNT OF SEROUS DRAINAGE AND BLANCHABLE REDNESS TO PERI WOUND AREA." THE EARLIEST WOUND CARE ORDERS FOR RESIDENT #503, PROVIDED BY FACILITY STAFF, WAS 2/6/12. WOUND CARE FOR RESIDENT #503, PER THE TREATMENT RECORDS PROVIDED BY THE FACILITY, INDICATED THAT WOUND CARE BEGAN ON 2/6/12. RESIDENT #503 WAS OBSERVED ON 2/10/12 DURING WOUND CARE. THE RESIDENT WAS THIN (WEIGHT, 101.2 LBS). HE HAD A [MEDICAL CONDITION] AND A FEEDING TUBE IN PLACE. HIS EYES WERE CLOSED, AND HE DID NOT ACKNOWLEDGE ANYONE DURING THE PROCEDURE. HIS LOWER EXTREMITIES WERE CONTRACTED. CNA (CERTIFIED NURSING ASSISTANT) DOCUMENTATION IN A 2/10/12 PROGRESS NOTE DESCRIBED RIGIDNESS AND DISCOMFORT DURING RANGE OF MOTION EXERCISES. RESIDENT #503 HAD A CARE PLAN FOR "SKIN", DATED 2/13/12. THE CARE PLAN INCLUDED AN INTERVENTION TO "TURN, REPOSITION AND PROVIDE INCONTINENT CARE EVERY 2 HOURS ATTEMPTING TO KEEP OFF AFFECTED AREA." THE RESIDENT WAS OBSERVED ON 2/10/12 AT 9:45 A.M. ON HIS BACK IN BED WITH THE HEAD OF THE BED ELEVATED TO 45 DEGREES. PILLOWS WERE PROVIDING PRESSURE RELIEF TO THE LEGS AND FEET. AT 11 A.M. RESIDENT #503 WAS ON HIS BACK, SLIGHTLY TILTED TO THE LEFT SIDE. THE HEAD OF THE BED WAS ELEVATED TO 45 DEGREES. HE WAS MOVING HIS LEGS IN BED. THERE WERE NO PILLOWS PROVIDING PRESSURE RELIEF TO THE LEGS AND FEET. AT 12:15 P.M. RESIDENT #503 WAS OBSERVED ON HIS BACK WITH THE HEAD OF THE BED ELEVATED TO 45 DEGREES. HIS HIPS AND KNEES WERE FLEXED WITH FEET RESTING ON THE MATTRESS. THERE WERE NO PILLOWS PROVIDING PRESSURE RELIEF TO THE LEGS AND FEET. ( ) IN AN INTERVIEW ON 2/9/12 AT 1:30 P.M.,THE WOUND CARE NURSE SAID HE DID WOUND CARE DURING THE WEEK. HE SAID NURSES WITH THE ASSISTANCE OF CNA (CERTIFIED NURSING ASSISTANT) #1, "MY ASSISTANT," DID WOUND CARE ON THE WEEKENDS. IN AN INTERVIEW ON 2/10/12 AT 2:30 P.M., THE DON (DIRECTOR OF NURSING) SAID CNA #1 WAS A "TREATMENT TECH," WHO "PERFORMS SOME OF THE TREATMENTS ON THE WEEKEND." THE DON SAID CNA #1 HAD SPECIAL TRAINING WITH WOUND CARE, QUALIFYING HER FOR DOING TREATMENTS. THE DON SAID THE CNA PERFORMANCE APPRAISAL HAD A "REQUIREMENT" TO "PERFORM SPECIAL SKIN CARE AS DIRECTED" WHICH QUALIFIED HER AS A TREATMENT TECH. THE JOB DESCRIPTION FOR CERTIFIED NURSING ASSISTANT" INCLUDED THAT PARTICULAR REQUIREMENT AS PART OF THE JOB DESCRIPTION FOR EVERY "CERTIFIED NURSING ASSISTANT." THERE WAS NO EDUCATION, TRAINING, OR EVALUATION CRITERIA IN CNA #1'S PERSONNEL FILE ADDRESSING treatment of [REDACTED].#1 COULD NOT DOCUMENT WOUND CARE ON THE COMPUTER. THEN, THE DON STATED THAT THE CNA DID NOT APPLY ANY MEDICATIONS TO WOUNDS AND THAT THE NURSES DID THE WOUND CARE ON THE WEEKENDS. THE DON, IN AN INTERVIEW ON 2/13/12 AT 10:30 A.M., WAS ASKED WHY RESIDENTS WITH WOUNDS HAD NO WOUND ORDERS ON ADMISSION. SHE SAID ORDERS ON HOSPITAL TRANSFER SHEETS WERE USED IF THEY WERE AVAILABLE. SHE PROVIDED THE SURVEYOR A POLICY ENTITLED, "ADMISSION SKIN ASSESSMENT." THIS WAS NOT ON A LETTERHEAD AND HAD NO DATE. IT STATED, IN PART, "THE RESULTS OF THE SKIN ASSESSMENT WILL BE DOCUMENTED IN THE NURSING ADMISSION NOTES. FOLLOW TRANSFER ORDERS IF PRESENT. IF NO ORDER PRESENT AND IF ANY ABNORMALITIES ARE NOTED BY THE ASSIGNED STAFF, TREATMENT WILL BE PER PROTOCOL. ANY WOUND THAT IS CLEAN AND ABSENT OF NECROTIC TISSUE WILL BE COVERED BY A DRY DRESSING UNTIL THE TREATMENT NURSE OBTAINS FURTHER ORDERS. ANY WOUND THAT IS NECROTIC OR HAS A FOUL ODOR WILL BE CLEANSED WITH [MEDICATION NAME] AND A DRY DRESSING APPLIED. THE TREATMENT NURSE WILL ASSESS THE WOUND AND OBTAIN FURTHER ORDERS." THERE WAS NO PHYSICIAN NAME ON THE POLICY. NO SOURCE FOR THE ABOVE STATEMENTS WAS IDENTIFIED. THE DON DID NOT OFFER ANY EXPLANATION AS TO WHY WOUND CARE WAS NOT ALWAYS DOCUMENTED IN THE MEDICAL RECORD. ( )

THIS CITATION PERTAINS TO INTAKE MI 606. BASED ON INTERVIEWS AND RECORD REVIEWS, THE FACILITY FAILED TO FOLLOW THEIR POLICY/PROCEDURE FOR ENSURING THAT MEDICATIONS NOT GIVEN BECAUSE THE RESIDENT WAS NOT PHYSICALLY PRESENT AT THE SCHEDULED TIME OF THE MEDICATION PASS WERE ADMINISTERED WHEN THE RESIDENT RETURNED, FOR 3 OF 5 SAMPLED RESIDENTS (#101, #107, #108) ON [MEDICAL TREATMENT], FROM A TOTAL SAMPLE OF 8, ALL REVIEWED FOR MEDICATION ADMINISTRATION, RESULTING IN THE 3 RESIDENTS NOT RECEIVING THEIR CARDIAC MEDICATIONS AS PRESCRIBED ON THE DAYS THEY RECEIVED THEIR [MEDICAL TREATMENT] TREATMENTS. RESIDENT #101 WAS SUBSEQUENTLY hospitalized for [REDACTED]. FINDINGS INCLUDE: ACCORDING TO THE FACILITY'S MEDICATION ADMINISTRATION POLICY (UNDATED), FOR MEDICATIONS THAT ARE "HELD" (THAT IS, NOT GIVEN), "THE LICENSED NURSE SHOULD DOCUMENT THEIR INITIALS AND THEN AN 'H' IN THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THE 'HELD' MEDICATION IS THEN TO BE 'CHECKED' ON THE '24 HOUR REPORT' SECTION OF THE SCREEN THEREBY NOTIFYING THE NEXT SHIFT THAT THE MEDICATION WAS 'HELD' AND THE REASON." RESIDENT #101: ACCORDING TO THE MEDICAL RECORD, RESIDENT #101 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH SEVERAL [DIAGNOSES REDACTED]. RESIDENT #101 REQUIRED [MEDICAL TREATMENT] THAT HAD HER PHYSICALLY OUT OF THE FACILITY FOR SEVERAL HOURS AT A TIME, 3 TIMES A WEEK. A REVIEW OF RESIDENT #101'S MAR FROM 9/29/11 TO 10/7/11 (TOTAL OF 8 DAYS) REVEALED THAT RESIDENT #101 DID NOT RECIEVE ALL PRESCRIBED DOSES OF HER CARDIAC MEDICATIONS: 1) [MEDICATION NAME] (BETA BLOCKER, USED FOR HEART FAILURE AND HIGH BLOOD PRESSURE), 3.125 MG, TWICE A DAY. THE RESIDENT MISSED 6 OF 19 PRESCRIBED DOSES (9/29/11, 10/1/11, 10/3/11, 10/4/11, 10/5/11, 10/6/11). 2) [MEDICATION NAME] (ANGIOTENSIN USED FOR HEART FAILURE), 16 MG, TWICE A DAY. THE RESIDENT MISSED 7 OF 19 PRESCRIBED DOSES, (9/29/11, 10/1/11, 10/3/11, 10/4/11, 10/5/11, 10/6/11). 3)[MEDICATION NAME]([MEDICATION NAME] USED FOR [MEDICAL CONDITION]). THE RESIDENT MISSED 3 OF 10 PRESCRIBED DOSES (10/4/11, 10/6/11, 10/7/11). THE MISSED DOSES HAD DOCUMENTATION THAT RANGED FROM COMPLETELY BLANK, TO "H", "A" (ABSENT), OR "NOT" WITH NO EXPLANATION OF WHY THE MEDICATION WAS NOT ADMINISTERED. THE MISSING MEDICATION WERE NOT "CHECKED" ON THE 24 HOUR REPORT. DURING AN INTERVIEW WITH LICENSED PRACTICAL NURSE (LPN) #7, SHE SAID SHE DID NOT ADMINISTER RESIDENT #101 HER MEDICATIONS ON THE DAYS SHE WENT TO [MEDICAL TREATMENT] BECAUSE SHE (#101) WAS NOT PRESENT DURING THE ADMINISTRATION TIMES. LPN # 7 SAID SHE DOCUMENTED THE MEDICATIONS AS BEING "HELD," BUT DID NOT FULLY DOCUMENT WHY THE MEDICATION WAS HELD AND DID NOT CHECK THE "24 HOUR REPORT" SECTION ON THE MAR indicated HELD" MEDICATIONS. ACCORDING TO THE physician's orders [REDACTED].M., RESIDENT #101 WAS TRANSFERRED TO THE emergency room FOR SHORTNESS OF BREATH AND MENTAL STATUS CHANGES. A REVIEW OF RESIDENT #101 emergency room RECORD DATED 10/7/11 REVEALED THE RESIDENT WAS diagnosed with [REDACTED]. RESIDENT #107: ACCORDING TO THE MEDICAL RECORD, RESIDENT #107 WAS A [AGE] year OLD MALE WHO WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. RESIDENT #107 REQUIRED [MEDICAL TREATMENT] THAT HAD HIM PHYSICALLY OUT OF THE FACILITY FOR SEVERAL HOURS AT A TIME, 3 TIMES A WEEK. A REVIEW OF RESIDENT #107'S MAR FROM 10/1/11 TO 11/14/11 REVEALED THAT RESIDENT #107 DID NOT RECIEVE ALL PRESCRIBED DOSES OF HIS CARDIAC MEDICATIONS: 1) [MEDICATION NAME] (CALCIUM CHANNEL BLOCKER), 10 MG 1 TIME PER DAY. THE RESIDENT MISSED 12 OF 24 PRESCRIBED DOSES (10/3/11, 10/5/11, 10/7/11, 10/10/11, 10/12/11, 10/14/11, 10/15/11, 10/17/11, 10/19/11, 10/23/11, 10/24/11, 10/26/11). 2) [MEDICATION NAME] (BETA BLOCKER USED FOR HEART FAILURE), 6.25 MG, TWICE A DAY. BETWEEN 10/27/11 AND 11/14/11 (TOTAL OF 19 DAYS), RESIDENT #107 MISSED 13 OF 38 PRESCRIBED DOSES, TWICE DAILY ON 10/27/11, 10/28/11, 11/2/11, 11/9/11, AND ONCE DAILY ON 10/28/11, 10/31/11, 11/4/11, 11/6/11, 11/7/11, 11/11/11. THE MISSED DOSES HAD DOCUMENTATION THAT RANGED FROM COMPLETELY BLANK, TO "H", "A" (ABSENT), OR "NOT" WITH NO EXPLANATION OF WHY THE MEDICATION WAS NOT ADMINISTERED. THE MISSING MEDICATION WERE NOT "CHECKED" ON THE 24 HOUR REPORT. DURING AN INTERVIEW WITH REGISTERED NURSE (RN) #4, SHE SAID SHE DID NOT ADMINISTER RESIDENT #107 HIS CARDIAC MEDICATIONS ON THE DAYS HE WENT TO [MEDICAL TREATMENT] BECAUSE ALL BLOOD PRESSURE MEDICATIONS SHOULD BE HELD UNTIL AFTER [MEDICAL TREATMENT]. RN #4 SAID SHE DOCUMENTED THE MEDICATIONS AS BEING "HELD," BUT DID NOT FULLY DOCUMENT WHY THE MEDICATION WAS HELD AND DID NOT CHECK THE "24 HOUR REPORT" SECTION ON THE MAR indicated HELD" MEDICATIONS. RESIDENT #108: ACCORDING TO THE MEDICAL RECORD, RESIDENT #108 WAS A [AGE] year OLD FEMALE admitted to the facility on [DATE] WITH MULTIPLE [DIAGNOSES REDACTED]. RESIDENT # 108 REQUIRED [MEDICAL TREATMENT] THAT HAD HER PHYSICALLY OUT OF THE FACILITY FOR SEVERAL HOURS AT A TIME, 3 TIMES A WEEK. A REVIEW OF RESIDENT #108'S MAR FROM 10/4/11 TO 11/15/11 REVEALED THAT RESIDENT #108 DID NOT RECIEVE ALL PRESCRIBED DOSES OF HER CARDIAC MEDICATIONS: 1) [MEDICATION NAME] (BETA BLOCKER, TREATS HIGH BLOOD PRESSURE), 50 MG 2 TIMES A DAY. THE RESIDENT MISSED 23 OF 80 PRESCRIBED DOSES, (2 TIMES DAILY ON 10/6/11, 10/8/11, 10/19/11, 10/22/11 AND ONCE DAILY ON 10/5/11, 10/11/11, 10/12/11, 10/13/11, 10/15/11, 10/18/11, 10/24/11, 10/26/11, 10/27/11, 10/31/11, 11/1/11, 11/3/11, 11/5/11, 11/10/11, AND 11/15/11). DURING AN INTERVIEW WITH REGISTERED NURSE (RN) # 4, SHE SAID SHE DID NOT ADMINISTER RESIDENT #108 HER CARDIAC MEDICATIONS ON THE DAYS SHE WENT TO [MEDICAL TREATMENT] BECAUSE ALL BLOOD PRESSURE MEDICATIONS SHOULD BE HELD UNTIL AFTER [MEDICAL TREATMENT]. RN #4 SAID SHE DOCUMENTED THE MEDICATIONS AS BEING "HELD," BUT DID NOT FULLY DOCUMENT WHY THE MEDICATION WAS HELD AND DID NOT CHECK THE "24 HOUR REPORT" SECTION ON THE MAR indicated HELD" MEDICATIONS. DURING AN INTERVIEW WITH THE REGISTERED NURSE EDUCATOR ON 11/15/11 AT 11:25 A.M., SHE EXPLAINED THAT THE FACILITY HAD BEGUN TO USE A COMPUTERIZED SYSTEM FOR TO DOCUMENT MEDICATION ADMINISTRATION. THE REGISTERED NURSE EDUCATOR SAID THAT THE NURSES WERE INSTRUCTED TO DOCUMENT AN "H" ON THE Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. THE REGISTERED NURSE EDUCATOR THEN WENT TO DESCRIBE THE PROCEDURE TO BE USED: THE "HELD" MEDICATION SHOULD ALSO BE "CHECKED" ON THE 24 HOUR REPORT SECTION OF THE SCREEN, ENSURING THE NURSE ON THE NEXT SHIFT WOULD BE AWARE OF THE MEDICATION THAT WAS HELD. IF THE MEDICATION HAD BEEN HELD BECAUSE THE RESIDENT HAD LEFT THE FACILITY FOR [MEDICAL TREATMENT] TREATMENT, THE NEXT SHIFT NURSE COULD THEN ADMINISTER THE MEDICATION WHEN THE RESIDENT RETURNED FROM [MEDICAL TREATMENT], IF IT WAS APPROPRIATE. THE NURSE EDUCATOR REVIEWED THE MEDICATION ADMINISTRATION RECORDS (MARS) FOR RESIDENTS #101, #107 AND #108 AND COULD NOT EXPLAIN WHY THE "HELD" MEDICATIONS WERE NOT DOCUMENTED CORRECTLY, OR WHY THEY (THE MEDICATIONS) WERE NOT ADMINISTERED TO THE RESIDENT UPON RETURNING FROM [MEDICAL TREATMENT]. DURING AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) ON 11/18/11 AT 10:00 A.M., SHE SAID THE NURSES HAD BEEN EDUCATED ON "CHECKING" THE 24 HOUR REPORT SECTION OF THE MAR FOR MEDICATIONS THAT HAVE BEEN HELD WHEN THE RESIDENT WAS UNAVAILABLE FOR ANY REASON ([MEDICAL TREATMENT], PERSONAL LEAVE OF ABSENCE, OR OTHER) TO ALERT THE NEXT SHIFT THAT THE MEDICATIONS MAY NEED TO BE ADMINISTERED UPON THE RESIDENT'S RETURN TO THE FACILITY. THE DON REVIEWED THE MARS FOR RESIDENTS #101, #107 AND #108 AND COULD NOT EXPLAIN WHY THE "HELD" MEDICATIONS WERE NOT DOCUMENTED CORRECTLY, OR WHY THEY (THE MEDICATIONS) WERE NOT ADMINISTERED TO THE RESIDENT UPON RETURNING FROM [MEDICAL TREATMENT]. ( )

THIS CITATION PERTAINS TO INTAKE MI 606. BASED ON INTERVIEWS AND RECORD REVIEWS THE FACILITY FAILED TO ADMINISTER 11 (ELEVEN) PRESCRIBED MEDICATIONS TO 1 OF 8 RESIDENTS (#101), ALL REVIEWED FOR MEDICATION ADMINISTRATION, RESULTING IN RESIDENT #101 NOT RECEIVING HER SCHEDULED INSULIN AND CARDIAC MEDICATIONS FOR 8 DAYS. RESIDENT #101 WAS SUBSEQUENTLY hospitalized for [REDACTED]. FINDINGS INCLUDE: ACCORDING TO THE MEDICAL RECORD, RESIDENT #101 WAS A [AGE] year OLD FEMALE WHO WAS admitted to the facility on [DATE] WITH SEVERAL [DIAGNOSES REDACTED]. REVIEW OF THE MEDICATION ADMINISTRATION RECORDS (MAR), DATED 9/20/11 THROUGH 9/29/11, REVEALED NO EVIDENCE THAT 11 MEDICATIONS THAT WERE PRESCRIBED UPON ADMISSION HAD BEEN ADMINISTERED DURING THAT TIME PERIOD. DURING AN INTERVIEW ON 11/14/11 AT 2:00 P.M., LPN #7 SAID THAT ON 9/29/11, IN THE AFTERNOON, SHE (#7) HAD A CONVERSATION WITH RESIDENT #101'S DAUGHTER. ACCORDING TO LPN #7, THE DAUGHTER SAID HER MOTHER (RESIDENT #101) WAS NOT GETTING ANY BETTER AND ASKED TO REVIEW WHAT MEDICATIONS SHE (RESIDENT #101) WAS RECEIVING. LPN #7 SAID THAT WHEN SHE (#7) WAS REVIEWING THE MEDICAL RECORD WITH THE RESIDENT'S DAUGHTER , THEY FOUND THAT THE 1ST PAGE OF THE MEDICAL RECORD HAD BEEN PLACED BACKWARDS AND UPSIDE DOWN. LPN #7 SAID THAT WHEN SHE (#7) REVIEWED THAT FIRST PAGE OF THE MEDICAL RECORD, IT WAS DETERMINED TO BE PHYSICIAN admission orders [REDACTED]. LPN # 7 SAID SHE IMMEDIATELY NOTIFIED HER CHARGE NURSE AND THE MEDICATIONS WERE PRESCRIBED. LPN #7 COULD NOT EXPLAIN HOW THE admission orders [REDACTED] A REVIEW OF RESIDENT # 101'S MEDICAL RECORD REVEALED 2 (TWO) DISCHARGE INSTRUCTION SHEETS FOR RESIDENT #101 FROM THE HOSPITAL DATED 9/20/11. THE FIRST DISCHARGE INSTRUCTION SHEET WAS CLEARLY MARKED "1 OF 2." THE PRESCRIBED 11 MEDICATIONS ON THE FIRST DISCHARGE INSTRUCTION SHEET WERE NOT TRANSCRIBED ONTO THE RESIDENT'S MAR AND SHE MISSED 8 TOTAL DAYS OF THOSE PRESCRIBED MEDICATIONS. DURING AN INTERVIEW ON 11/14/11 AT 1:30 P.M., REGISTERED NURSE (RN) #9 SAID THAT ON 9/29/11 DURING THE AFTERNOON SHIFT, IT WAS BROUGHT TO HER ATTENTION BY LICENSED PRACTICAL NURSE (LPN) #7, THAT PART OF RESIDENT #101'S admission orders MISSED." RESIDENT #101 HAD 2 SHEETS OF MEDICATION ORDERS AND ONLY 1 SHEET HAD BEEN TRANSCRIBED ON TO THE RESIDENT'S MEDICAL RECORD, THE physician's orders [REDACTED]. ACCORDING TO RN #9, THE FOLLOWING MEDICATIONS WERE NOT GIVEN TO RESIDENT #101 DURING THE TIME PERIOD FROM 9/20/11 TO 9/29/11: 1) [MEDICATION NAME] (BETA BLOCKER USED FOR MILD TO SEVERE HEART FAILURE)., 3.125 MG, TWICE A DAY. 2) ONE BABY ASPIRIN ( BLOOD THINNER), ONCE A DAY. 3) [MEDICATION NAME] (ANGIOTENSIN USED FOR HEART FAILURE), 16 MG, TWICE A DAY. 4) [MEDICATION NAME] (USED FOR HEART FAILURE TO PREVENT STROKE AND [MEDICAL CONDITION]), 20 MG, ONCE A DAY. 5)[MEDICATION NAME]([MEDICATION NAME]), 30 MG, ONCE A DAY. 6) [MEDICATION NAME] (PREVENT BLOOD CLOTS), 75 MG, ONCE A DAY. 7) QUESTRAN (LOWERS CHOLESTEROL), 4 GMS, TWICE A DAY. 8) [MEDICATION NAME] (ANTIDEPRESSANT), 20 MG, ONCE A DAY. 9) [MEDICATION NAME] (VITAMINS AND MINERALS SPECIFIC FOR [MEDICAL TREATMENT] PATIENTS), 1 CAP PER DAY. 10) INSULIN, [MEDICATION NAME] 12 UNITS DAILY AT BEDTIME. 11) [MEDICATION NAME], 7.5 MG/325 MG, EVERY 8 HOURS AS NEEDED FOR PAIN. AFTER 9/29/11, THE 11 MEDICATIONS WERE PRESCRIBED, TRANSCRIBED ONTO THE MAR, AND ADMINISTERED TO RESIDENT #101. HOWEVER, RESIDENT #101 STILL MISSED THE FOLLOWING CARDIAC MEDICATIONS BECAUSE THE FACILITY WAS NOT FOLLOWING THEIR POLICY/PROCEDURE FOR ENSURING THAT MEDICATIONS THAT WERE BEING HELD WHILE RESIDENT #101 WAS RECEIVING [MEDICAL TREATMENT] WERE ADMINISTERED WHEN SHE RETURNED: 1) [MEDICATION NAME] (BETA BLOCKER, USED FOR HEART FAILURE AND HIGH BLOOD PRESSURE), 3.125 MG, TWICE A DAY. THE RESIDENT MISSED 6 OF 19 PRESCRIBED DOSES (9/29/11, 10/1/11, 10/3/11, 10/4/11, 10/5/11, 10/6/11). 2) [MEDICATION NAME] (ANGIOTENSIN USED FOR HEART FAILURE), 16 MG, TWICE A DAY. THE RESIDENT MISSED 7 OF 19 PRESCRIBED DOSES, (9/29/11, 10/1/11, 10/3/11, 10/4/11, 10/5/11, 10/6/11). 3)[MEDICATION NAME]([MEDICATION NAME] USED FOR [MEDICAL CONDITION]). THE RESIDENT MISSED 3 OF 10 PRESCRIBED DOSES (10/4/11, 10/6/11, 10/7/11). DURING AN INTERVIEW ON 11/15/11 AT 10:00 A.M., THE ADMINISTRATOR SAID THE FACILITY'S ADMISSION POLICY REQUIRES THE NURSE WHO ADMITS A NEW RESIDENT AND THE UNIT MANAGER TO REVIEW THE admission orders [REDACTED]. THE ADMINISTRATOR COULD NOT OFFER ANY EXPLANATION AS TO HOW RESIDENT #101 HAD 11 MEDICATIONS MISSED DURING THE ADMISSION PROCESS. DURING AN INTERVIEW ON 11/15/11 AT 11:40 A.M., THE PHYSICIAN SAID THAT RESIDENT #101 WAS TRANSFERRED TO THE hospital on [DATE] WITH MULTIPLE SYMPTOMS THAT COULD NOT BE DIRECTLY RELATED TO MISSING CARDIAC MEDICATIONS FOR 8 DAYS. ACCORDING TO THE physician's orders [REDACTED].M., RESIDENT #101 WAS TRANSFERRED TO THE emergency room FOR SHORTNESS OF BREATH AND MENTAL STATUS CHANGES. A REVIEW OF RESIDENT #101 emergency room RECORD DATED 10/7/11 REVEALED THE RESIDENT WAS diagnosed with [REDACTED]. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE SUPERVISION TO PREVENT ACCIDENTS FOR TWO ( #'S 801 AND 804) OF 20 RESIDENTS REVIEWED FOR FALLS OUT OF 24 SAMPLED RESIDENTS, RESULTING IN FEMUR AND CLAVICLE FRACTURES AND BRUISES. FINDINGS INCLUDE: DURING THE INITIAL TOUR OF THE FACILITY ON 3/22/11 AT 9:15 A.M., RESIDENT #801 WAS OBSERVED WITH A RIGHT ARM SLING. MEDICAL RECORD REVIEW ON 3/23/11, AT 2:00 PM REVEALED, THE ADMITTING FACE SHEET RECORD DATED 3/08/11, INDICATED RESIDENT # 801 WAS ORIGINALLY admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE ADMISSION MINIMUM (MDS) data set [DATE] INDICATED RESIDENT #801 COGNITION WAS MODIFIED INDEPENDENCE FOR DECISION MAKING, NON-AMBULATORY, REQUIRED STAFF ASSISTANCE WITH BED MOBILITY, TRANSFERS, AND TOILETING. THE FALLS ASSESSMENT INDICATED RESIDENT #801 had a history of [REDACTED]. THE FALLS CARE PLAN DATED 9/30/10 INDICATED RESIDENT #801 WAS AT RISK FOR FALLS RELATED TO A HISTORY OF FALLS, SYNCOPE AND COLLAPSE. REVIEW OF AN INCIDENT AND ACCIDENT REPORT DATED 2/12/11, ON 3/23/11, FOR RESIDENT #801 DOCUMENTED, " CNA (CERTIFIED NURSE ASSISTANT) ALERTED NURSE THAT RESIDENT (#801) HAD TRIED TO SELF TRANSFER WHILE IN THE BATHROOM FROM TOILET TO WHEELCHAIR. RESIDENT HAS UNSTEADY GAIT AND fell on TO FLOOR, HITTING HEAD ON DOORWAY AND ONTO (R) RIGHT HIP ... " REVIEW OF A NURSING NOTE DATED 2/11/11, 8:00 A.M., DOCUMENTED, "...RESIDENT HIT HEAD AND fell on HIP. KNOT APPEARING ON BACK OF HEAD. RESIDENT UNABLE TO MOVE (R) RIGHT LEG AT THE HIP. STAT SKULL AND HIP X-RAYS ORDERS BY DOCTOR. 10:00 A.M., X-RAY RESULTS -SKULL X-RAY WAS NEG. (NEGATIVE). RECENT DISPLACED (RIGHT) INTERTROCHANTERIC (FRACTURE FEMUR). RESIDENT TO BE SENT TO LOCAL HOSPITAL..." REVIEW OF A PHYSICIAN ORDER [REDACTED].M., INDICATED RESIDENT (#801) WAS TRANSFERRED TO A LOCAL HOSPITAL FOR TREATMENT. REVIEW OF A HOSPITAL REPORT DATED 2/11/11 (NO TIME PROVIDED) DOCUMENTED, "RESIDENT (# 801) PRESENTED WITH A RIGHT INTERTROCHANTERIC FEMUR FRACTURE AND RIGHT LATERAL CLAVICLE FRACTURE AND UNDERWENT AN OPEN REDUCTION AND INTERNAL FIXATION (SURGICAL REPAIR) FOR THE RIGHT FEMUR FRACTURE." THE HOSPITAL DISCHARGE NOTE/FORM DATED 2/16/11, INDICATED RESIDENT #801 RETURNED to the facility on [DATE] AFTER A FIVE DAY HOSPITAL STAY, WITH A SURGICAL WOUND AND STAPLES TO THE RIGHT HIP/THIGH AND WITH HER RIGHT ARM/SHOULDER IN A SLING. ON 3/23/11 AT 10:00 AM., AN OBSERVATION OF RESIDENT #801'S SURGICAL WOUND AND SKIN REVEALED A LINEAR SCAR ON THE RIGHT THIGH THAT MEASURED 13.0 CENTIMETERS (CM) WITH SEVERAL STAPLE IMPRESSIONS. THERE WAS BRUISING (PURPLE, BLUE AND DARK RED) ON RESIDENT #801'S RIGHT BREAST THAT MEASURED 7.0 CM BY (X) 2.0 CM, RIB CAGE AND SIDE THAT MEASURED 15.0 CM X 3.0 CM. ON 3/23/11 AT 10:00 A.M., THE FACILITY'S SAFETY COORDINATOR "C" WAS INTERVIEWED REGARDING RESIDENT #801'S FALL THAT OCCURRED ON 2/11/11 THAT RESULTED IN FRACTURES. THE SAFETY COORDINATOR STATED, "RESIDENT (#801) HAD BEEN ASSISTED TO THE TOILET/BATHROOM BY CERTIFIED NURSE ASSISTANT (CNA) "D" AND CNA "D" LEFT RESIDENT #801 ALONE AND UNATTENDED IN THE BATHROOM. THE RESIDENT ATTEMPTED TO TRANSFER HERSELF FROM THE TOILET AND fell TO THE FLOOR. IT WAS THE RESPONSIBILITY OF CNA "D" TO ENSURE RESIDENT #(801) WAS TRANSFERRED SAFELY FROM THE TOILET BACK INTO THE WHEELCHAIR." CNA (D) WAS UNAVAILABLE FOR INTERVIEW. ( ) REVIEW OF THE CLINICAL RECORD AND FACE SHEET ON 3/23/11, AT 1:00 PM, REVEALED, RESIDENT #804 WAS admitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. REVIEW OF A NURSING ADMISSION ASSESSMENT, DATED 3/15/11, RESIDENT #804 WAS ALERT,ORIENTED, WITH GENERAL WEAKNESS AND LIMITED MOBILITY. REVIEW OF THE FALL'S RISK ASSESSMENT DOCUMENTED THAT RESIDENT #804 WAS AT RISK FOR FALLS. REVIEW OF THE FALLS RISK CARE PLAN, DATED 3/15/11, DOCUMENTED THE FOLLOWING APPROACHES: 1. CALL LIGHT IN REACH. 2. SAFETY DEVICE AS ORDERED (PERSONAL BODY ALARM). ON 3/23/11, AT 1:00 PM, REVIEW OF INCIDENT/ACCIDENT REPORTS REVEALED THE FOLLOWING: 1. ON 3/17/11, RESIDENT #804 WAS FOUND ON THE FLOOR NEXT TO THE HEATER AND SUSTAINED A SKIN TEAR TO THE RIGHT FOREARM AND 3 SMALL ABRASIONS TO THE LEFT SIDE OF BACK. THE FACILITY INVESTIGATION OF THE INCIDENT, DATED 3/17/11, DOCUMENTED THAT RESIDENT #804 DID NOT HAVE ON A PERSONAL BODY ALARM AT THE TIME OF THE INCIDENT. 2. ON 3/20/11, RESIDENT #804 WAS FOUND BY A LAUNDRY AIDE, LYING ON THE FLOOR IN FRONT OF THE BED. THE FACILITY INVESTIGATION OF THE INCIDENT, DATED 3/20/11, DOCUMENTED THAT RESIDENT #804'S PERSONAL BODY ALARM HAD NOT BEEN PROPERLY APPLIED AND DID NOT SOUND WHEN ATTEMPTED TO GET OUT OF BED. ON 3/24/11 AT 1:00 PM, OBSERVATION OF RESIDENT #804'S BACK, WITH THE TREATMENT NURSE, REVEALED THAT RESIDENT #804 HAD SUSTAINED A 15 CM X 4.8 CM BRUISE, THAT WAS DARK BLUE, PURPLE AND REDDENED IN COLOR AND WAS SHAPED LIKE A QUARTER MOON. ON 3/24/11 AT 2:00 PM, THE SAFETY COORDINATOR WAS INTERVIEWED REGARDING RESIDENT # 804 FALLS AND WAS NOT ABLE TO EXPLAIN WHY THE PERSONAL BODY ALARM WAS NOT APPLIED ON 3/17/11 AND WHY THE PERSONAL BODY ALARM WAS NOT PROPERLY APPLIED ON 3/20/11 TO LIMIT THE POTENTIAL FOR FURTHER FALLS AND INJURIES. ( )