Every finding on record at Regency at St. Clair Shores

Based on observation, interview, and record review, the facility failed to provide nail care for one resident (R11) out of four residents reviewed for Activities of Daily Living (ADL) care. Findings include:On 07/21/2026 at 9:42 AM, an observation of R11's right hand revealed it to be in a contracted (shortening of the muscle) with long fingernails that had a dark brown material under the nails.On 07/22/2026 at 3:07 PM, an interview was conducted with R11, and they stated they do not want their fingernails to be that way and had not been offered to have them cut or cleaned. During this interview, the fingernails of R11's right hand were observed to still be long, with dark material under the nails.A review of R11's electronic medical record (EMR) revealed R11 was admitted into the facility 7/25/2022 with diagnoses of Parkinson's Disease, Major Depressive Disorder, and anxiety disorder. R11's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating impaired cognition.A review of R11's current care plan revealed R11 has a functional mobility deficit and requires assistance with self-care and mobility with an intervention to Keep fingernails trimmed and clean.A review of R11's Kardex (reference document intended to summarize a resident's care needs) documented Keep fingernails trimmed and clean.On 07/22/2026 at 3:09 PM, an interview was conducted with Licensed Practical Nurse (LPN) D who said nail trimming should be done for residents during showers or when they are asking for it and equipment is available from occupational therapy to assist with trimming nails for residents with hands in contracted positions. LPN D further said R11 is known to guard and complain of pain in their right hand, so they may be refusing nail care.On 07/23/2026 at 9:37 AM, an interview was conducted with Certified Nursing Assistant (CNA) E who stated the resident would let trim them their nails, but does sometimes say no. During this interview, CNA E was brought into R11's room to observe the fingernails and confirmed the nails did look like they should be trimmed.A review of the EMR did not reveal any recorded refusals of routine standard care, including nail care needs, between the dates of 6/24/2026 and 7/23/2026.A policy provided by the facility titled Activities of Daily Living (ADL) Program last revised 4/5/2024 documented, . Purpose: A resident requiring skill practice and/or training in activities of daily living (ADL) is evaluated for restorative nursing. ADL may include, but are not limited to, bathing, grooming, and dressing. Restorative ADL program may be provided by nursing assistants and other staff trained in provision of ADL care under the supervision of the licensed nurse. Procedure 3. Determine specific tasks and areas of ADLs . b. Grooming: May include . x. Trimming nails .

Based on observation, interview, and record review, the facility failed to provide skin tear dressing changes for one resident (R168) of three sampled residents reviewed for care and treatment.Findings include:On 07/21/2026 at 9:18 AM, R168 was observed with bandages wrapped around both arms dated 7/17/26. When asked, the resident said they had open areas and needed treatment. R168 was asked when the last time they received a dressing change and replied: Sometime last week. R168 continued and stated they were told by Registered Nurse (RN) B, Someone was coming to clean the wounds yesterday (7/20/26) and no one came saying, they were worried they could get an infection.According to the Electronic Medical Record (EMR), R168 was admitted at the facility on 7/15/26 with the diagnosis of Malignant melanoma of the left upper limb including shoulder, unspecified Atrial Fibrillation, Atherosclerotic Heart Disease.A care plan for R168 titled, At risk for impaired skin integrity related to R/T (related to): Diabetes Mellitus (DM) and impaired bed mobility was initiated on 7/16/26.A review of the wound treatment orders revealed: Cleanse skin tears to right arm and hand with wound cleanser, apply Xeroform (foam cover), cover with ABD (thick gauze) pad and wrap with Kerlix (clingy gauze wrap) every evening shift Monday, Wednesday, Friday for skin Tears. Start date 7/17/26. Upon review of the July 2026 Treatment Administration Record (TAR), the TAR documented the nurse signed out the order as the treatment being completed on 7/17/26 and 7/22/26 (despite the bandages being dated 7/17/26). On 7/20/26 (Monday) the TAR was left it blank not signed or marked with a check the treatment was completed.RN B was interviewed on 07/23/2026 at 10:29 AM and confirmed the skin tears on both arms have an order for dressing changes on Monday, Wednesday, and Friday. The nurse said if they could not perform the treatment, the night-shift nurse would complete the task.A Policy for skin care (non-pressure wound) was requested on07/23/2026 at 11:00 AM and was reviewed thereafter.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% for two residents (R133 and R177) of five reviewed during medication pass. Findings include: R133 On 07/22/2026 at 8:14 AM, an observation of the morning medication pass for R133 revealed six of their oral medications were crushed and mixed with pudding for administration by Licensed Practical Nurse (LPN) C. One of the medications crushed was a tablet of Divalproex Sodium (Depakote-an anticonvulsant medication) Extended Release (ER) 250 milligrams (mg). After the medications were crushed into the pudding and ready for administration to the resident, LPN C was asked about the crushing of the Divalproex. LPN C stated they do not work in this area every day and were not sure if the resident normally gets all their medications crushed. The nurse then pointed out an order documenting, may crush allowable meds. When LPN C was asked how they knew which medications were allowable to crush, they confirmed, they probably should not crush medications that are extended release. A review of R133's medical record revealed they were admitted into the facility on 6/30/2026 with diagnoses of Alzheimer's Disease, Hypotension (low blood pressure), and altered mental status. Review of R133's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating impaired cognition. A review of R133's medication orders revealed an active order for Divalproex Sodium ER Oral Tablet Extended Release 24 Hour 250mg, with directions to give every 12 hours. A review of a document provided by the facility titled Do Not Crush 2024 revealed Divalproex Sodium Extended-Release tablets should not be crushed. A review of a facility policy titled Medication Administration last revised 10/17/2023 noted Check the Do Not Crush list before crushing medications.If necessary, contact the ordering physician for a change to a different route of administration when the medication cannot be crushed. A review of the facility's policy titled, Medication Administration dated 10/17/2023 noted, Resident medications are administered in an accurate, safe, timely and sanitary manner . Physician orders - Medications are administered in accordance with written orders of the attending physician. If dose is inconsistent with the resident's age and condition or a medication order is inconsistent with the resident's current diagnosis or condition, contact the physician for clarification prior to administration of the medication . R177 On 7/23/2026 at 8:41 AM, during a medication administration observation, Licensed Practical Nurse (LPN) B was observed to place one tablet of Metronidazole (Flagyl-antifungal) in R177's medication cup along with their other oral morning medications. R177 was observed to take all the prepared medication by mouth. A review of R177's medication orders revealed, Order: Give 1 capsule by mouth one time a day for wound until 08/04/2026. please crush and apply under L (left) breast X (times) 14 days. A review of R177's medical record revealed, R177 was admitted to the facility on [DATE] with a diagnosis of Malignant Neoplasm of unspecified site of left breast. On 7/23/2026 at 9:43 AM, LPN B was asked about the route they administered the Metronidazole to which they then expanded the order to see the full writing of the directions. LPN B confirmed they did not see the additional directions (to apply the wound) prior to administering the medication (by mouth). A review of R177's progress note revealed, 7/22/2026 09:01 Skin/Wound Progress Entry: . Wound #1: Chronic left breast fold cancer related wound. Recommended treatment: Cleanse area, pat dry, apply crushed metronidazole to wound bed per medical team. On 7/23/2026 at 2:46 PM, the Director of Nursing (DON) was asked to review the order and confirm the route for Metronidazole who subsequently called the wound care nurse who confirmed the medication is to be applied topically and not orally.

Based on observation, interview, and record review, the facility failed to date inhalers after opening for two residents (R132 and R170) out of four carts reviewed for medication storage and labeling. Findings include:On 7/23/2026 at 10:08 AM, Torch unit medication cart was inspected with Registered Nurse (RN) A. During inspection two inhalers were observed to be opened with R132 and R170's names on them, but no date when opened. A review of R132 and R170's current physician orders noted both residents had the inhaler scheduled every twelve hours. On 7/23/2026 at 10:10 AM, RN A was asked the procedure when opening an inhaler and reported the resident's name should be on the inhaler with a sharpie, or the provided pharmacy sticker as well as the open date. RN A reported they did not know when the inhalers were originally opened.On 7/23/2026 at 2:41 PM, an interview was conducted with the Director of Nursing (DON) who stated they expect inhalers to be dated after opening. A review of a facility policy titled, Medication Administration did not address labeling inhalers.

Based on observation, interview and record review, the facility failed to properly store nebulizer mask for two residents (R59 and R2) out of three residents reviewed for infection control practices.Findings include: R59On 07/21/2026 at 9:57 AM, an observation of R59's room revealed a nebulizer mask, machine, and tubing lying out on their dresser with no protective barrier and uncovered. During this observation, R59 confirmed that's how their nebulizer equipment is normally stored. On 07/22/2026 at 9:20 AM, an observation of R59's room revealed the nebulizer mask, machine, and tubing lying out on R59's dresser in the same position and remained uncovered. During this observation, R59 said they use it (the nebulizer machine) when they get congested and have trouble breathing and believed it was not supposed to be out like that. On 07/22/2026 at 12:38 PM, an observation of R59's room revealed the nebulizer mask, machine, and tubing in the same position on R59's dresser, and a pair of rolled up socks also on the dresser was observed to be touching the nebulizer mask.A review of R59's electronic medical record (EMR) revealed they were admitted into the facility 9/1/2023 with diagnoses of Chronic Kidney Disease, Generalized Anxiety Disorder, and Type 2 Diabetes. Review of R59's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating impaired cognition.On 07/22/2026 at 1:45 PM, an interview was conducted with Registered Nurse (RN) F who confirmed if a nebulizer mask has just been cleaned it will be put on a paper towel to dry, then put into a bag to store. When not in use it should be kept covered in a plastic bag. RN F was brought into R59's room to observe the storage of the nebulizer equipment and demonstrated the nebulizer mask can be stored by attaching it to a stand built into the nebulizer machine. They stated the mask does not need to be stored in a bag if the resident isn't using the device and it is kept upright on the attached stand. R2On 07/21/2026 at 9:40 AM, an observation of R2's room revealed a nebulizer mask, machine, and tubing lying out on dresser with no bag, barrier, or covering. The mask not attached to the built-in stand on the nebulizer machine.On 07/21/2026 at 1:37 PM and on 07/22/2026 at 9:16 AM, observations of R2's room revealed the nebulizer mask, machine, and tubing in the same position on R2's dresser. A review of R2's electronic medical record (EMR) revealed they were admitted into the facility 12/31/2025 with diagnoses of malignant neoplasm (cancer) of tongue, end stage renal (kidney) disease, and chronic Hepatitis B (Viral infection of the liver). Review of R2's most recent Minimum Data Set (MDS) dated [DATE] revealed a Brief interview for Mental Status (BIMS) score of 11, indicating impaired cognition.On 07/22/2026 at 9:18 AM, an interview was conducted with Licensed Practical Nurse (LPN) G who said R2 does not currently have an order for nebulizer treatments, but does have breathing problems sometimes. On 07/22/2026 2:19 PM, an interview was conducted with the Director of Nursing (DON) who said nebulizer masks should be stored in a bag.A policy on nebulizer equipment storage was requested from the facility, and the policy provided titled Policy 5.3.16 Nebulizer Inhalation Administration with effective date of 6/10/2022 did not address storage of nebulizer masks.

Based on observation, interview, and record review, the facility failed to maintain a functional call light system (system in which a resident can call for assistance) for one (R170) of 15 residents reviewed for call light function.Findings include:A review of the Electronic Medical Record (EMR) on 7/21/26 at 3:30 PM revealed that Resident 170 (R170) was admitted to the facility on [DATE] with the diagnoses of Syncope and Collapse, Urinary Tract Infection (UTI), arthrodesis, and cardiomegaly, in addition to other diagnoses.R170's 7/15/26 care plan documented they have a functional ability deficit requiring assistance with self-care/ mobility related to weakness with goals and interventions of R170 will improve Activities of Daily Living (ADL) function through the review date 10/13/26, by Encourage resident to use the bell/call light to call for assistance, keep the resident's environment as safe as possible with: even floors free from spills and/or clutter; adequate lighting; call light within reach, avoid repositioning furniture and keep the bed in appropriate position. And lastly, put the call light within reach and encourage they're to use it for assistance as needed.R170 Minimum Data Set (MDS) Assessment, Brief Interview of Mental Status (BIMS) SCORE assessment was 15/15 indicating the resident is cognitively intact.Upon Interview with R170 on 7/21/26 at 9:45 AM, they indicated their call light was not working saying, I push the button, and nothing happens. It's been like that for 3 days now. Confirming they had reported it to the nurses who said, They will get it fixed, but no one came to fix my call light.On 07/21/2026 at 9:53 AM, during an interview with Nurse D, who was assigned to R170 confirmed the call light was not working after checking the wall connections. On 7/21/26 at 9:55 AM, R150 (R170's roommate), confirmed during an interview, It (the call light) had not been working for about 3 days. Every time they (R170) needed help. I pressed my call light for them.Maintenance Director R was interviewed on 7/21/26 at 10:23 AM and he confirmed he recently completed fixing it.

Based on observation, interview, and record review, the facility failed to respond to call lights in a timely manner for 11 residents (R47, R110, and a confidential group of nine residents) out of 11 residents reviewed for call lights. Findings include: R110 On 8/4/25 at 10:03 AM, R110 revealed “This place is short of help on nights, everyone knows we are short, it doesn't get better, it gets worse, not recently getting showers”. R110 further revealed once they were in bed, no one checked on them all night. R110 further explained when they put on their light, staff would take a long time to come, then turn it off and go out without addressing their needs. R110 reported finally in the morning the staff got them up. On 8/4/25 at 2:15 PM, another resident approached and indicated they were looking for a surveyor. This resident then related that on the weekend, R110, was calling out very early in the morning around 5:45 AM. This went on for quite some time when that resident finally got up to see what the problem was and went into the hall and found a staff member and asked why someone was yelling all night. The staff member first indicated no one was yelling all night. Approximately 5-10 minutes later the same resident was yelling again, The resident recognized where it was coming from and asked the staff if they were going to answer the call, and the staff proceeded into R110's room. A review of resident council meeting notes for the months of March 2025 through July 2025 revealed issues related to Call lights being answered promptly. On 8/5/25 at 1:15 PM, a confidential group meeting was conducted with seven confidential group residents, and they were asked about the timeliness of call light response by facility staff. All group residents present indicated that call light response on the night shift (11:00 PM to 7:00 AM) was slow. The group indicated that at night they needed assistance with receiving snacks, toileting, brief changes, bed repositioning, and other miscellaneous care type needs. The group was asked what the facility had done to address the concerns regarding call light response on the night shift. The group reported that this had been an ongoing concern since March 2025 and had been brought up at each resident council meeting. The group further indicated that although the facility had informed them that they were working on it, nothing had changed. On 8/6/25 at 11:30 AM, Certified Nursing Assistant (CNA) H was interviewed regarding staff coverage at the facility on the night shift. CNA H revealed that they filled in on the night shift as scheduled and indicated there was not enough staff to meet the residents' needs. CNA H indicated there was typically one CNA per unit with thirteen to fifteen residents to care for and the acuity (severity of illness) of the residents at the facility was typically high, and many residents required two-person assistance for transfers which could be problematic on the night shift. On 8/6/25 at 11:35 AM, CNA I was interviewed regarding staff coverage at the facility on the night shift. CNA I revealed that they filled in on the night shift as scheduled and indicated that there was not enough staff scheduled to adequately meet the residents' needs. CNA I expressed feelings of anxiety and stress when assigned to work on a night shift. On 8/6/25 at 11:40 AM, CNA J was interviewed regarding staff coverage at the facility on the night shift and confirmed they filled in on the night shift as scheduled and said they were typically assigned sixteen to seventeen residents to care for on the night shift. CNA J stated, That's too much. On 8/6/25 at 11:46 AM, CNA K was interviewed regarding staff coverage at the facility on the night shift. CNA K revealed they filled in on the night shift as scheduled and said when two staff are needed for resident assistance, it takes away from being able to assist other residents. On 8/6/25 at 1:30 PM, the acting Director of Nursing (DON) was interviewed regarding expectations related to call light response by facility staff. The ADON said the policy was call lights should be answered within twenty minutes. The acting DON was asked about there being five consecutive months of resident council meeting notes (March 2025 to July 2025) which indicated ongoing issues related to call light response times and said they were not aware this was a resident concern. R47 On 8/5/25 at 9:30 AM R47 was observed lying in the bed in room. When queried about care, R47 said there is a long wait to be changed during the evening and the midnight shift. R47 stated they have waited for assistance at times from thirty minutes up to an hour before staff would answer the call light. A review of the medical record revealed R47 was admitted on [DATE] with the diagnoses of Cellulitis, Mild Cognitive Impairment, Chronic Obstructive Pulmonary disease and depressive episodes. A review of the Minimum Data Set assessment dated [DATE] noted a Brief Interview for Mental Status (BIMS) of 12/15 which indicates moderate cognitive impairment. Further review of the medical record revealed R47 required extensive assistance from facility staff with their activities of daily living. On 8/6/25 at 12:30 PM, the Nursing Home Administrator (NHA) was asked if they were aware of the residents' concerns regarding long waits with call lights for assistance on the midnight shift and reported they were not aware of the concerns. The NHA confirmed the expectation is, all resident call lights should be answered in a timely manner. On 8/6/25 at 1:00 PM, the Activity Director (AD) was queried about the process of handling the resident council concerns. The AD said resident council concerns are brought to each department head at the interdisciplinary department management team (IDT) meetings which were held each morning and evening. The AD confirmed the department heads were notified of the resident concerns after each meeting. A review of the facility policy titled Call Lights effective 3/12/25 revealed, Call lights will be placed within resident's reach and answered in a timely manner.

Based on observation, interview, and record review, the facility failed to treat one resident (R24) of one resident reviewed with dignity and respect. Findings include: On 8/05/2025 at 9:30 AM, the surveyor was standing at the Station 1 Unit C nurse's station when R24 stopped and engaged in conversation and asked for two cups of ice from the surveyor. R24 was advised to ask an unidentified staff member, later identified as Licensed Practical Nurse A (LPN A) for assistance as she sat at the nurse's station looking at her phone. On 8/05/2025 at 9:32 AM, R24 was observed wheeling toward LPN A, and politely asked her for two cups of ice. LPN A appeared visibly annoyed by R24's request by barely providing eye contact with the resident and sounded curt and dismissive as she indicated that someone else would be around for them to obtain the request. R24 rolled away from LPN A as they waited for another staff member to appear and assist them.On 8/05/2025 at 9:34 AM, the surveyor approached LPN A and asked her why she didn't assist R24 with their request, and she explained that her shift ended at 7:00am and was supposed to be off work but was documenting two resident falls from last night. No other explanation was provided.A review of R24's medical record revealed they were admitted into the facility on 6/26/25 with diagnoses that included Staphylococcal Arthritis, Left knee, Adult T-Cell Lymphoma/Leukemia, Anemia, and Diabetes. Further review revealed the resident was cognitively intact, and required partial to moderate assistance for transfers, toileting, and personal hygiene.Further review of R24's medical record revealed the following care plan, .Focus: [R24] is at risk for nutritional decline r/t (related to): PMH (past medical history) of uncontrolled DM (diabetes mellitus) with therapeutic diet and IV (intravenous) therapy .Interventions: Encourage and provide intake of fluids throughout the day. Initiated 6/26/2025 .On 8/06/2025 at 12:00 PM, the Nursing Home Administrator (NHA) was asked about their expectation for ensuring residents are treated with dignity and respect and explained that their [NAME] is Customer Service first.On 8/06/2025 at 2:32 PM, the acting Director of Nursing (DON) was informed of the interaction between R24 and LPN A and explained the nurse should have provided the resident with their request. A review of the facility's Resident Rights policy revealed the following, The facility protects and promotes the rights of each resident. The resident has a right to dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility .

Based on observation, interview, and record review the facility failed to develop or revise care plans for two residents (R11, and R13) of three residents reviewed for care plans. Findings include:R11On 8/4/25 at 10:47 AM, R11 was observed to have a PEG (Percutaneous Endoscopic Gastrostomy [feeding tube]), visible under their t-shirt. R11 indicated it was currently not being used. A review of the Electronic Medical Record (EMR) revealed R11 was admitted to the facility on [DATE] with the following relevant diagnoses: Myasthenia Gravis (autoimmune disorder causing weakness in voluntary muscles, affecting communication between nerves and muscles), Moderate Protein Calorie Malnutrition, Renal Dialysis, Dysphagia (difficulty swallowing), and Gastrostomy Insertion (PEG tube). Further record review revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. R11 required supervision/touching assistance for Activities of Daily Living (ADLs). R11 was independent with mobility using a walker.Further review of the EMR care plans revealed there was not a care plan addressing the care and interventions for the PEG tube.R13On 8/4/25 at 9:03 AM, R13 was observed in bed, verbally requesting to get up. R13 was asked about their urinary elimination, they patted to their abdomen where nephrostomy tubes were noted.A review of the Electronic Medical record (EMR) revealed R13 was admitted to the facility initially on 11/30/21 and readmitted on the following dates: 2/17/25, 4/7/25, 5/20/25, 7/3/25 and 7/8/25, with the following relevant diagnoses: Multiple Sclerosis, Obstructive and Reflux Uropathy, Neuromuscular Dysfunction of Bladder, and Artificial Opening of Urinary Tract (Nephrostomy Tube-a tube placed inside the kidney and connected to a drainage device located on R13's back) and urinary diversion (a urostomy connected to a drainage bag on R13's abdomen). R13 required substantial/maximal assistance for all activities of daily living and mobility.Further review of the EMR documentation revealed a progress note on 2/15/25, R13 was transferred to the hospital for a nephrostomy tube that was dislodged by Licensed Practical Nurse (LPN) M. A 72-hour admission Conference form dated 2/19/25 documented, (Name of resident) remains for LTC (long term care) .Baseline care plans left at bedside. The care plan was not noted to be updated with interventions to prevent dislodgement after this readmission.Review of the documentation revealed on 4/6/25, R13 was again transferred to the hospital for nephrostomy bag was not attached to the resident by LPN N. The care plan was not noted to be updated with interventions to prevent dislodgement after this readmission.Review of the documentation revealed on 5/16/25, R13 was again transferred to the hospital for nephrostomy tube replacement by LPN O. A 72-hour admission Conference form revealed, admitted following hospitalization for nephrostomy replacement. The care plan was not noted to be updated with interventions to prevent dislodgement after this readmission.Further review of the documentation by LPN N revealed on 7/1/25, R13 was complaining about pain in arm. R13's husband transported them to hospital. Nurse Practitioner (NP) P received notification, pt has disconnected their nephrostomy tube . readmitted [DATE] following hospitalization for nephrostomy replacement.Baseline care plans left at bedside. The care plan was not noted to be updated with interventions to prevent dislodgement after this readmission.On 8/5/25 at 1:00 PM, Registered Nurse (RN) B indicated care plan updates are done by the Minimum Data Set (MDS) nurse and Social Work.On 8/6/25 at 10:40 AM, SW E revealed the issue was not necessarily behavior because it was related to a medical device and should be addressed by nursing. On 8/6/25 at 1:43 PM, Attending Physician (AP) F revealed they were aware of frequent issues with R13's nephrostomy tube.

Based on observation, interview, and record review, the facility failed to provide psychotropic medications in a timely manner for one resident (R80) of one reviewed for pharmacy services. Findings include: On 8/04/2025 at 2:10 PM, R80 was observed in their room and asked about their time spent in the facility. R80 explained they are prescribed a lot of medications, and their guardian had expressed concerns about them not obtaining a shot when they were supposed to.A review of R80's medical record revealed they were admitted into the facility on 4/11/25 with diagnoses that included Schizoaffective Disorder, Anxiety Disorder, and Other Recurrent Depressive Disorders. Further review revealed the resident was cognitively intact and required supervision for activities of daily living (ADL's).Further review of R80's medical record revealed the following: Abilify Maintena (extended-release psychotropic injection is used to treat Schizophrenia and Bi-Polar Disorder) Intramuscular Prefilled Syringe 400 MG (milligrams) Inject 400 mg intramuscularly one time a day starting on the 19th and ending on the 19th every month for Bipolar Disorder-Start Date: 05/19/2025. This order was discontinued on 6/16/25.Further review revealed an active physician's order dated 6/16/25, Abilify Maintena injection Intramuscular Prefilled Syringe 400 MG (Aripiprazole) Inject 400 mg intramuscularly one time a day starting on the 2nd and ending on the 2nd every month for Bipolar Disorder.A review of R80's May 2025 and August 2025 Medication Administration Record (MAR) revealed the resident did not receive their injectable medication as ordered. Further review of the medical record revealed the following progress notes:7/19/2025 07:47 (7:47am) Social Services Note: During care conf (conference) yesterday, sister/LG (legal guardian) indicated R80 told her [they are] having auditory hallucinations of a sexual nature, which did not cause [them] distress. Psych to re-eval at next visit.Date of Service: 2025-07-21 08:15:00. Chief Complaint. Psychiatric follow up, medication review, hx (history) schizophrenia. History of Present Illness.today for follow up to review medication and to assess mood. Patient was last seen for psychiatry on May 20, 2025 at which time no psychotropic changes were made. Patient does have an extensive history of paranoid schizophrenia, anxiety, depression, and history of psychoactive substance abuse. At last visit in May, [R80] was not receiving [their] Abilify Maintena long acting injectable correctly and since then has had the dosing changed to be given on the second of every month. [R80] continues to remain on Abilify Maintena intramuscular syringe 400 mg (milligrams)/2 ML (milliliters) 2 ML IM on the second of the month once a month. [R80] received this injection on June 2 and July 2 but did not get the injection in May per documentation Assessment and Plan .Paranoid schizophrenia: Patient has been on a long-standing psychotropic regimen that includes Abilify 5mg oral daily, Abilify Maintena 400mg IM monthly, Haldol 10mg at bedtime, and benztropine 2mg twice daily. There were recent concerns about patient having sexually inappropriate auditory hallucinations, which were reported by [their] sister. Patient was not receiving his Abilify Maintena consistently and did not receive it in the month of May, but did receive it consistently in June and July. Sometimes it can take up to 2-3 months of receiving the injectable consistently to fully cover psychosis .7/24/2025 13:22 (1:22pm). Resident At Risk, Reviewed Clinical Indicator: Auditory hallucinations of a sexual nature. Verbalizing a desire to discharge, not verbalized previously .Psych eval. (evaluation) Reminded nursing to watch [R80 take their] medications. Looking for a ltc (long-term care) facility to accommodate [R80] long term. Previous referrals unsuccessful .No med changes at this time, likely needs to continue with antipsychotic injection consistently.On 8/06/2025 at 9:04 AM, R80's assigned nurse, Licensed Practical Nurse (LPN) G was asked why R80 had not received their Abilify injection, and explained she did not know why however, there was a new order for the medication Invega placed today. A review of R80's physician's orders dated 8/6/25, Invega Sustenna (an extended-release antipsychotic medicine given by injection).156 mg/1mL IM Q30 (every 30 days) days along with oral Invega 3 mg daily.Further review revealed the following progress note:8/5/2025 08:00BH -Psychiatry Follow up .seen today for follow up to review medication and to assess mood at the request of social services and patient's sister due to concerns of an increase in psychotic symptoms. Patient has an extensive history of paranoid schizophrenia, anxiety, previous mood disturbance, and history of psychoactive substance abuse. [R80] is on Abilify Maintena long acting injectable 400 mg IM on the second of each month, but did not receive the injection on August 2 as the building did not have the injection available .[R80's] sister has concerns even prior to the injection being missed about the control of his psychosis with the use of Abilify. She informed social services that roughly around 4 to 5 months ago, [R80] was on Invega Sustenna long acting injectable one time monthly and that was better for coverage of [their] psychosis, but that the medication was causing gynecomastia (enlargement of breast tissue in men and boys), and therefore ]R80] had been switched to Abilify long-acting injectable On 8/06/2025 at 12:00 PM, a telephone Interview was completed with R80's guardian in which they expressed concern regarding the resident not obtaining their injection due to the pharmacy not providing the medication to the facility. On 8/06/2025 at 1:24 PM, the acting Director of Nursing (DON) explained they had spoken to the resident's assigned nurse on 8/2/25, and she explained that upon opening the medication to administer to R80, she noticed the medication appear to have a white substance in it and therefore discarded it and reordered it from the pharmacy. The DON explained the medication was delivered yesterday however, the resident's order had been discontinued.On 8/06/2025 at 1:41 PM, LPN L was interviewed via phone regarding R80's injection, and she explained that upon preparing R80's injection, she noticed the syringe had white stuff in it and discarded it. She further explained she reordered the medication through the pharmacy, ordering it STAT (immediately). LPN L explained she notified the oncoming nurse of the issue and upon arriving for her shift the following day, the medication had not arrived therefore, she contacted the pharmacy again who reported they didn't have the medication in stock and had to deliver it within the next two days. On 8/06/2025 at 2:32 PM, the acting DON was asked about issues the facility has been having with pharmacy and acknowledged they have been working through some challenges however the expectation is residents receive their medication per physician's order. The DON was not sure what occurred in May when R80 did not receive their injection. A review of the facility's Medication Ordering and Receipt policy revealed the following, .3. If the unavailable medication does not become available within 8 hours of the scheduled administration time, the facility will be notified by the pharmacy and an alternate procurement method will be established (i.e. obtaining partial fill from a local pharmacy) .

This citation pertains to Intakes MI00153087 and MI00153316. Based on observation, interview, and record review the facility failed to prevent incidents of misappropriation of narcotic pain medication for four residents (R901, R902, R903, R904) of four residents reviewed for misappropriation of property. Findings include: A review of a complaint submitted to the State Agency (SA) revealed the following, .The first few nights [R901] was a resident [at] this facility [they] complained about not receiving medication. When I had the phone conference with the social workers. I believe someone in the room indicated that [R901] was given meds at 9pm and again 5am. But doses was [were] missing in between those times .May 14th [R901] called indicating, [they hadn't] received pain medicine since 5 PM the previous day, which was May 13th . The nurse indicated that they have to put in a request for more medication . R901 On 5/29/25 at 9:17 AM, R901 was interviewed via phone and explained that following back surgery, they were admitted into the facility with severe pain, which was not resolved to the point that they transferred back out to the hospital. R901 explained when their pain pill was asked for, they were advised by the assigned nurse, additional pain medication had to be ordered. A review of R901's medical record revealed they were admitted into the facility on [DATE] and discharged on [DATE] with diagnoses which included Fusion of Spine, Lumbar Region, Diabetes, and Hyperlipidemia. Further review revealed the resident was cognitively intact and required assistance with transfers and toileting. Further review of R901's medical record revealed the following physician order dated for 5/9/25, Hydrocodone (narcotic pain medication) Acetaminophen Oral Tablet 10-325 MG (milligrams). Give 1 tablet by mouth every 4 hours as needed for pain. Further review of R901's medical record revealed a Controlled Substances Proof of Use form dated for 5/9/25 noting 18 pills were received, and all 18 pills had been administered to the resident prior to discharge 6 days later. Further review of R901's medical record revealed a Medication Administration Record (MAR) for the month of May which documented the resident was administered 16 narcotic pain pills. R902 A review of R902's medical record revealed they were admitted into the facility on [DATE] with diagnoses which included Periprosthetic Fracture around internal prosthetic right hip, Anemia and Dementia. Further review revealed the resident was cognitively impaired and required substantial assistance for bathing and bed mobility. Further review revealed the resident was severely cognitively impaired. Further review of the medical record revealed an active physician order dated for 4/30/25, Order Summary: Oxycodone (narcotic pain medication) HCI Oral Tablet 5 MG. Give 1 tablet by mouth every 4 hours as needed for Pain. A review of the resident's Controlled Drug Receipt/Record/Disposition Form revealed the resident received their narcotic pain pill on the following dates: 5/7/25 (2 doses), 5/8/25 (2 doses), 5/9/25 (3 doses), 5/12/25 (3 doses) and 5/13/25 (3 doses). A review of R902's May MAR revealed the resident did not received one dose of medication on 5/7/25, 5/8/25, 5/9/25, and 5/12/25. On 5/13/25, it was documented that the resident received 2 doses. R904 A review of R904's medical record revealed they were admitted into the facility on [DATE] with diagnoses that included Metabolic Encephalopathy, Dysphagia, and Type II Diabetes. Further review revealed the resident had a severe cognitive impairment and required maximum assistance with activities of daily living. Further review of the resident's medical record revealed the following physician order dated 5/1/25, Hydrocodone Acetaminophen Oral Tablet 5-325 MG. Give 1 tablet by mouth every 4 hours as needed for Pain. Further review of the resident's medical record revealed a Controlled Drug Receipt/Record/Disposition Form dated 5/2/25 documenting the medication had been dispensed 26 times. Documentation revealed the resident was administered their prescribed narcotic medication 19 times. A review of R904's May MAR revealed the resident received a documented 19 doses of the pain medication, and also revealed discrepancies when compared to the Controlled Drug Receipt/Record/Disposition Form: 5/4/25, 5/7/25, 5/8/25, 5/9/25 (3 doses), and 5/28/25. On 5/29/25 at 11:49 AM, the Director of Nursing (DON) was asked to review R901 and R902's May MARs and Narcotic Sheets together. The DON acknowledged the discrepancies and revealed there was a concern for drug diversion for Nurse A, but have also started to see a concern regarding another nurse who they were going to call into the facility. The DON further explained that a Past Non-Compliance (PNC) had been completed with a correction date of 5/27/25. A review of the PNC revealed a compliance date of 5/27/25 however, the surveyor reviewed discrepancies dated for 5/28/25 on narcotic sheets, with additional residents appearing to be affected by Nurse A's drug diversion. R903 A review of R903's medical record revealed they were admitted into the facility on [DATE], and readmitted [DATE] with diagnoses that included Metabolic Encephalopathy, Dementia, Schizophrenia, and adjustment disorder. Further review revealed the resident had a moderate cognitive impairment and required partial/moderate assistance for bathing and bed mobility. Further review of R903's physician order dated 11/4/24, Tramadol (narcotic pain medication) HCl Oral Tablet 50 MG (Tramadol HCl) Give 2 tablet by mouth at bedtime for Pain. A review of a Facility Reported Incident (FRI) reported to the SA revealed the following, Incident Summary: On 5/19/25 it was reported by morning charge nurse Licensed Practical Nurse [LPN] B there were discrepancies in the narcotic count. [Nurse A] was the midnight nurse in question. [Nurse A] stated that she did not know what happened. [Local Police] notified Administrator paged [Nurse A] and [Nurse A] saw the police and left the facility . On 5/29/25 at 12:52 PM, an interview was completed with the DON who acknowledged there were discrepancies with the narcotic count for R903. The DON explained midnight shift nurse, Nurse A was finishing the shift, and the oncoming nurse, LPN B was starting their shift, and while completing the narcotic count, noticed a discrepancy. Nurse A's behavior was described as odd, and when questioned about the discrepancy, indicated they would assess the resident. Nurse A was suspended per policy and sent to go get a urine and hair drug screen. Nurse A appeared for drug testing a day late and refused the drug screen of their hair. Regarding the PNC the DON acknowledged more work needed to be completed regarding misappropriation. On 5/29/25 at 2:13 PM, an interview was completed with Unit Manager C regarding the missing medication. Unit Manager C explained they had received a call from the morning shift nurse (LPN B) advising the narcotic count was off. Upon arriving to the facility, Unit Manager C observed Nurse A behaving oddly and was located laying in a resident's bed appearing sleep. When Nurse A was woken up, and questioned about the documentation of the narcotic count, which indicated there were 82 pills, and written underneath were the words, actual 80. Unit Manager C explained they questioned Nurse A further about the documentation and stated they abruptly left and indicated they would go assess the resident. Nurse A was called down to the Administrator's office, but instead left the building. On 5/29/25 at 2:36 PM, an attempted phone call was made to Nurse A to no avail, and the surveyor was unable to leave a message. A review of R903's Controlled Drug Receipt/Record/Disposition form dated 5/7/25 revealed that Nurse A crossed out and documented confusing information on the form. A review of the facility's Pain Management policy revealed the following, 14. The staff will implement the care plan, monitor the residents, and administer therapeutic interventions for pain, if ordered. 15. The licensed nurse, when administering routine pain medications, will record the drug administration on the medication administration record. 16. The licensed nurse, when administering PRN pain medications, will record the drug administration on the PRN medication administration record. 17. Document the date, time, and effectiveness of PRN pain medication on the PRN Administration Record . A review of the facility's Abuse Prohibition policy revealed the following, Each guest/resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property .Misappropriation of guest/resident property means that deliberate misplacement, exploitation, or wrongful, temporary or permanent use of guest's/resident's belongings or money without the guest's/resident's consent .

This citation is pertaining to Intake MI00151818. Based on interview and record review, the facility failed to schedule and coordinate follow up appointments as recommended for one resident (R700) of one resident reviewed for coordination of care. Findings include: A record review on 4/15/25 revealed R700 was admitted into the facility on [DATE] with diagnoses that included Malignant Otitis Externa (unspecified ear), Acute Osteomyelitis, Cholesteatoma of External Ear, Chronic Obstrctive Pulmonary Disease and Heart Failure. Per the clinical discharge summary from the hospital, it was recommended R700 followup with physician for Otolaryngology (ear specialist) Surgery within 3-7 days and Urology (for urinary retention) within one week. Further review with nursing staff about the process of following up with appointments revealed the scheduler/central supply person (Staff A) is responsbile for making the appointments. Further record review revealed on 4/1/25, R700 was discharged to hospital per family request due to bleeding from nose and ears. On 4/15/25 at 12:15 PM, an interview occured with Staff A regarding the process of scheduling hospital recommended follow up appointments for R700. Staff A said, I make the residents' appointments based on the information sent on admission. I dont' remember any ear appointments. Sometimes there is no (appointment times) availability. When asked if making the appointment attempt was documentation, Staff A stated there is no documentation. On 4/15/25 at 1:30 PM, an interview was held with the Director of Nursing (DON) regarding follow up appointments. She stated that the scheduler handles appointments based on information recieved fom admissions department. When asked about documentation of the appointments or follow up for R701, DON stated that there was no documentation. On 4/15/25 at 1:37 PM a facility policy for coordintion of appointments was requested and it was not not recieved by the end of the survey.

This citation pertains to Intake MI00146820. Based on observation, interview and record review, the facility failed to ensure resident safety for one (R800) of one resident resulting in a fall with bruising. Findings include: R800 was admitted [DATE] with medical diagnoses of hypertension, cerebral vascular accident (stroke) with left hemiparesis, cerebral edema, falls, seizure disorder, hyperlipidemia, left auricular hematoma, obesity, osteoarthritis, and coronary artery disease. R800's Basic Interview for Mental Status is a 12/15 indicating moderate cognitive impairment. On 9/11/24 at 10:23 AM, a phone call to the (Patient Representative) PR, revealed R800 sustained bruising of head, ribs, and elbow without any permanent injuries. The PR further revealed R800 was also found to have pneumonia and a urinary tract infection. The PR revealed R800 had fluid removed from lungs and was on antibiotics for the urinary tract infection. The PR further revealed R800 was now residing in an alternative facility. A record review on 9/11/24, revealed on 9/1/24 at 5:49 AM, Certified Nursing Assistant (CNA) A was performing the last bed check of her shift. While turning R800, R800 fell from the bed to the floor opposite where CNA A was standing. R800 was assessed by Registered Nurse (RN) F after the fall . R800 was found to have an elevated blood pressure of 176/82, Pulse 72, Respirations 20, Temperature 97.8 degrees Fahrenheit and a Pulse Oximetry of 96% while on oxygen via Nasal Cannula. R800 was found stable enough to be transferred back to her bed with the use of a mechanical lift and two persons to assist. R800 reported she hit her head and a hematoma (bruise) was noted on her right lower leg. The Nurse Practitioner, Director of Nursing (DON), and R800's Patient Representative were notified. The facility record documented R800 said, When I was turning in the bed, the bed moved and I rolled off the side of bed hitting my head. The care plan for functional ability deficit for Bed Mobility and Transfers, initiated on 2/14/24, R800 requires substantial/maximal assistance with two helper(s) and mechanical lift. This is including rolling side to side, lying to sitting on the side of bed. A review of R800's Kardex (a guide the CNA's use to guide resident care) revealed resident was to have 2 persons for bed mobility, personal hygiene, transfers, and toileting. On 9/11/24 at 11:00 AM, an interview with the DON confirmed the expectation is for CNA's to follow the Kardex and facility policies. A review of the policy Routine Resident Care contains the following, Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene. Steps are taken to ensure that a resident's capacity for self-performance of these activities does not diminish Care is taken to ensure resident safety at all times. A review of the Fall Management Policy, Last Approved 8/18/22 revealed the General Policy Statement The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included: 1. The identification of like residents who require 2 person assist for bed mobility 2. Audit like residents to ensure number of personal assists is accurate 3. Audit like residents to ensure staff are following the bed mobility plan of care Measures systemic changes made to ensure that deficient practice will not occur and affect others 1. Nursing staff re-educated on following the Kardex. 2. Nurse staff re-educated on assisting CNA's with residents who require 2 person assist. How facility monitors its corrective actions to ensure same deficient practice is corrected and will not recur. 1. The Director of Nursing or the Nursing Home Administrator will review 10 residents who require 2 person assist, to ensure that mobility is completed properly weekly for 4 weeks, then monthly for 3 months. Findings will be reported to the QA&A committee monthly for 3 months. Date of compliance 9/5/24. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan for an abdominal drainage tube was initiated within 48 hours of admission for one (R340) of one residents reviewed for care plans. Findings include: On 6/25/2024 at 9:20 AM, observed R340 sitting bedside in a wheelchair in a private room. R340 was noted with an ostomy bag showing from the bottom of the resident's shirt. R340 also had a drainage tube from the mid lower abdomen connected to a drain (a collection device that provides continuous suction to remove excess fluid). The collection device was hanging on R340's walker. On 6/25/2024 a record review revealed there was not a physician order or comprehensive care plan that included care of the drainage tube. On 6/26/2024 at 12:11 PM, R340 revealed the ostomy bag was changed last night but the drainage bag was not emptied. On 6/27/1014 at 11:35 AM, R340 related their drain had not been emptied until they emptied it at 4 PM last evening. On 6/27/2024 at 12:00 PM an interview with the DON revealed the expectation that the drain would have a care plan to meet its specific needs. A review of the policy titled Care Planning, last revised on 6/24/2021 revealed every resident will have a person-centered Plan of Care developed and implemented that is consistent wit the resident rights, based on the comprehensive assessment . The policy further reveals a Baseline Care Plan will be developed within 48 hours identifying any immediate needs .

Based on observation, interview, and record review, the facility failed to ensure a resident was involved in they're plan of care and care conference meetings for one (R20) out of one residents reviewed for care planning meetings. Finding include: On 06/25/24 at 10:14 AM, R20 stated, they have a guardian they have never met, and they don't know how long they've been in the facility or what their plan of care is. R20 was asked if they had ever attended their care conferences. R20 explained they don't know anything about care conferences and they have never attended. On 06/26/24 at 1:15 PM, during the resident council meeting R20 indicated again they are not sure who their guardian is and they don't know what happened to their apartment and belongings before coming to the facility. R20 also indicated they don't have access to their money or able to purchase things they may need. On 06/27/24 at 7:57 AM, R20 was observed in bed. R20 was observed indicated they had a new piece of paper on their overbed table that noted, the name and contact information for their legal guardian. The letter also indicated . If you are interested in a gift card to purchase items, his office can send you one . R20 stated, they are not sure who left the letter there and that this was the first time they have been told who their guardian was. On 06/27/24 at 8:32 AM, during an interview Social Worker (SW M) explained, R20 has asked repeatedly about their property and belongings and they have called R20's guardian. SW M stated, they have left voicemails for the guardian and they have not responded. SW M was asked if R20 was part of their care conferences and SW M stated, No. On 06/27/24 at 11:07 AM, call placed, voicemail left, and email sent to guardian. The guardian did not return a call back by the end of this survey. On 06/27/24 at 12:44 PM, during an interview SW M was asked what is the next step when they cannot get in touch with R20's guardian. SW M stated They always respond to us. Sometimes it takes a couple days SW M then explained another social worker sent an email to R20's guardian yesterday regarding R20's questions about their property and belongings and the guardian has not responded. A review of R20 medical record revealed, R20 was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia; polyosteoarthritis; muscle wasting and atrophy; foot drop. A review of the Minimum Data Set assessment revealed a BIMS score of 15/15 indicating no cognitive deficit. Further record review reveals a Letter of Full Guardianship for R20 was signed 7/1/2021. A review of R20's care conference sign in sheets revealed, R20 and guardian attendance as follows: -7/28/23, R20 was not in attendance and guardian was attempted to be contacted via phone with a voicemail left. -1/26/24 R20 was not in attendance and guardian was not in attendance nor contacted via phone. -4/26/24 revealed that R20 was not in attendance and guardian was attempted to be contacted via phone with voicemail left. A review of the facility policy titled Care Planning Conference indicates the following: On Admission, Quarterly, Annually, with a Significant Change and as needed, the interdisciplinary team will hold a care planning conference with the resident, family or representative in participation. The Care Conference will be used to identify the resident's potential or actual problems, needs, goals and discharge. 2. A written invitation will be sent to the resident and/or family at least a week prior to care conference or as much in advance as possible. 3. Efforts will be made to increase family/resident participation such as telephone conference calls, in room conferences etc. Ensure privacy and HIPAA regulations are adhered to. 4. In addition to the advance invitation, the resident will be notified and invited to attend the care conference on the care conference date. A staff member will assist the resident to the care conference room as needed. 7. The recommended members of the interdisciplinary team care conference may include: Nursing Representative, Social Services, Activities, Dietary, Nurse Assistant, Resident, Family and/or responsible party, Therapy as needed. 17. A summary of the residents plan of care will be provided to the resident &/or resident representative.

Based on observation, interview, and record review, the facility failed to provide timely incontinence care for dependent residents resulting in moisture associated skin damage (MASD) for one (R110) out of one resident reviewed for incontinence care. Findings include: R110 On 06/25/24 at 1:13 PM, R110 was observed lying in bed on their back. An interview was conducted with R110 at that time. R110 explains they previously had a left leg amputation and cannot walk. R110 states the staff will only occasionally get them up into a chair but even when they do get them out of bed they leave them sitting up for a long period of time. R110 explains they developed a fungal rash on their buttocks from being left wet. R110 explained that wound care sees them once per week and ordered a powder and a cream for the rash but explained the staff cannot find the powder or the cream so they have not been using it. R110 explained they had to buy their own cream and keep it in their drawer. R110 explained the midnight shift does not check on them until 5:30 in the morning. On 06/26/24 at 08:36 AM and at 9:30AM, R110 was observed sleeping in bed on their back. On 06/26/24 at 10:46 AM, an unidentified staff member was observed changing R110s brief which was observed to be wet. An interview with R110 was conducted at that time. R110 was asked when they were last changed. R110 stated they were last changed at 4:45 AM. R110 was asked if the staff used the barrier cream and antifungal powder. R110 explained that staff used cream and power just now but not at 4:45AM. R110 further explained the powder is a prescription so it had to be administered by the nurse. On 06/26/24 at 3:21 PM, R110 was observed lying in bed on their back. R110 was interviewed and asked if they were wearing a brief and if it was wet. R110 stated their brief is wet and needed to be changed. On 06/26/24 at 03:32 PM, R110 was observed being changed by two unidentified staff members. No cream or powder was observed to be on R110's skin when their brief was removed. When staff members rolled R110 to the side R110 stated that feels nice being in a different position for a change. R110 was observed to have MASD with multiple open sores extending from their bilateral upper buttocks down to the top of their thighs and extending throughout their groin and perineal area with satellite lesions noted to upper back and down inner thighs. On 06/26/24 at 03:37 PM, wound care nurse (LPN F) entered the room. LPN F was observed applying cream and powder to R110s MASD from upper buttocks to upper thighs. R110 states it burns and itches. LPN F was asked how often R110 should be getting the cream and powder applied. LPN F explained the cream and miconazole powder is to be used daily and as needed with pericare. LPN F explained that the treatment items are kept in the treatment cart. LPN F was asked how the aides would be able to use the cream and powder with each episode of pericare with incontinence if they are locked in the treatment cart. LPN F stated that R110 bought their own zinc cream they keep in their drawer but we don't rely on using that. On 06/27/24 at 08:16 AM R110 was observed sitting up in bed. R110 was interviewed and asked if their brief was wet. R110 stated that it was wet and pulled their sheet back. R110s brief was observed to be wet. R110 was asked when the last time they were changed was. R110 stated Im not sure. I don't think they changed me at all last night. I don't remember being woken up. R110 was asked if they prefer to wear a brief in bed. R110 explained that they do not prefer to wear a brief in bed and stated they won't let me go without one in bed because I'm on a water pill. On 06/27/24 at 08:26 AM, certified nurse assistant (CNA L) was interviewed and asked what a typical morning routine is for a CNA. CNA L explains they get to work at 6:53 AM, they pass ice water, do a resident's shower, start getting residents up, pass breakfast, pull residents up in bed, pick up breakfast trays, then continue getting residents up and out of bed. CNA L was asked when they check on incontinent residents. CNA L stated they check on them first to see if midnights changed them or not. CNA L confirmed, sometimes midnights is short and people are gonna be wet. It's a 24 hour facility and I just do my job. On 06/27/24 at 09:49 AM, R110 was observed lying in bed on their back. R110's brief was observed to still be wet. R110 was interviewed and asked if they had been changed since the last interview. R110 confirmed their brief still has not been changed. Urine soaked top sheet and pad was observed to be on the floor next to the dresser. R110 was asked why the sheet was on the floor. R110 explained the occupational therapist was just in the room and changed the sheet and pad so it wasn't soaked anymore. R110 stated they never changed me last night. CNA P was asked if the resident's are wet when day shift starts to whcih she said, Yes! We come in and everyone is soaked. CNA P offered to change R110 who stated I hope so because that's why I have this rash and I want to get better. On 06/27/24 at 10:20 AM, the Director of Nursing (DON) was interviewed and asked if all residents wear briefs all the time. The DON stated not everyone wears briefs. We also have pull ups. It depends on the resident. The DON was asked if incontinent residents should be wearing briefs in bed. The DON stated yes, so it stays in one area and so they can be provided incontinence care. The DON was asked if R110 should wear a brief in bed considering their MASD. The DON explained that it is R110's preference to wear a brief and if they don't want to they don't have to. A review of R110's record revealed the following: active order dated 6/20/2024 Antifungal External Powder 2 % (Miconazole Nitrate (Topical) Apply to Groin, sacrum topically one time a day for MASD, fungal infection. Active order dated 6/20/2024 Cleanse sacral wound with NS. Apply chamosyn ointment to wound, then antifungal powder over that and leave open to air with no dressing. every day shift AND as needed for brief changes. Further record review revealed wound care progress notes as follows: wound care progress note dated 6/19/24: MASD, fungal infection noted to bottom and groin. Upon assessment, area with moderate to severe excoriation. Patient does endorse pain at site. Area is highly moist due to episodes of incontinence. New treatment orders placed in PCC (point click care documentation program). Discussed discontinuation of personal zinc cream purchased. Reviewed wound progress and treatment options. wound care progress note dated 6/12: MASD and fungal infection to bottom. Area slightly worse from previous week. Discussed treatment of chamosyn and antifungal powder x 7 days. wound care progress note dated 6/5:MASD and fungal infection to bottom. Area slightly worse from previous week. Discussed treatment of chamosyn and antifungal powder x 7 days. Patient requesting to try own zinc cream before initiating provider treatment orders. Wound care progress note dated 5/29: Per staff increased redness on bottom and groin area. On call provider ordered nystatin, will add zinc paste in addition to orders for MASD. Wound care progress note dated 5/22: no mention of fungal rash or MASD Review of R110s care plan revealed the following: Provide incontinence care with each incontinent episode and apply moisture barrier cream/ointment per facility policy/orders. (R110) is incontinent of bladder & bowel. Will have minimized risk for complications r/t incontinence through next review date Date Initiated: 04/20/2023 Target Date: 07/24/2024 BRIEF USAGE: Resident uses disposable briefs. Change frequently/prn. Further record review revealed no progress notes about refusal of incontinence care for the last 30 days.

This citation has two Deficient Practices. Deficient Practice Statement #1. Based on observation, interview and record review, the facility failed to initiate care orders and monitor an accordion drainage device (a collection device connected to a drain that allows for continuous suction) for one of one (R340) residents reviewed for care. Findings include: On 6/25/2024 at 9:20 AM, R340 was observed in room sitting at bedside in chair. R340 was observed to have an ostomy bag hanging below the shirt hem and with a drain, also visible below shirt hem connected to an accordion drainage system. R340 revealed they and a fissure between the bowel and bladder, that caused an abscess that is being drained. R340 revealed they were admitted after having had surgery and receiving a temporary ostomy. R340 also revealed there was an abdominal abscess that was being drained into an attached bag, R340 revealed no one had emptied the drain since leaving the hospital. It currently contained 40 ml (milliters) of medium brown, nectar thick liquid. A review of R340's medical record revealed, R340 was admitted to facility on 6/21/2024 with relevant diagnoses of vesicointestinal fistula, gastro-esophageal reflux disease, diverticulitis of large intestine, rheumatoid arthritis, abdominal abscess with drain, diverting colostomy. R340 is alert and oriented to person, place, time, and situation. On 6/25/2024 a record review of hospital transfer records, physician admission note, and nursing comprehensive evaluation identified the presence of a drain. On 6/27/2024 an interview with the Director of Nursing (DON) revealed her expectation would be any medical devices need to have a physician's order to initiate care of that device. 50223 Deficient Practice Statement #2 Based on observation, and record review, the facility failed to apply compression stockings and ace wraps to two residents (R20 and R64) out of two reviewed for edema. Findings include: R20 On 06/25/24 at 10:14 AM, R20 was observed lying in bed. R20 was interviewed and explained their legs swell by the end of the day and are painful. R20 explains they are supposed to wear compression stockings but nobody puts them on. No compression stockings were observed in their room. On 06/26/24 at 08:40 AM, R20 was observed lying in bed eating breakfast with bilateral lower extremity edema observed and without compression stockings. On 6/26/24 at 1:05 PM, R20 was observed sitting in their wheelchair at the resident council meeting with bilateral lower extremity edema noted without compression stockings on. On 06/27/24 at 07:57 AM R20 was observed in bed with edema and foot drop to their bilateral lower extremities without compression stockings. R20 was interviewed and explained their compression stockings are too small, and no one can put them on. On 06/27/24 at 09:58 AM R20 was observed still in bed without compression stockings on. A review of R20s record revealed R20 was admitted to the facility on [DATE] with the following diagnosis: unspecified dementia; polyosteoarthritis; muscle wasting and atrophy; foot drop; congestive heart failure; personal history of venous thrombosis and embolism. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating no cognitive deficit. R20 also required assistance with bed mobility and transfers. A review of R20s orders revealed the following: Active order dated 3/22/2024 Compression Stockings: ON in AM, OFF in PM A review of R20's care plan revealed the following: (R20) is at risk for cardiac complications r/t (related to) multiple cardiovascular diseases: CHF (congestive heart failure), CAD (coronary artery disease), HTN (hypertension (high blood pressure) and a fib (atrial fibrillation-irregular heart rhythm) (R20) will have minimized risk factors for cardiovascular distress through the review date. Observe/document/report to MD (medical doctor) PRN (as needed) any s/sx of cardiac distress: chest pain or pressure, heartburn, nausea and vomiting, shortness of breath, excessive sweating, dependent edema (swelling), changes in capillary refill, color/warmth of extremities. Further record review revealed nursing progress note dated 05/29/24 documented Lower legs elevated for swelling due to edema. A Physician progress note dated 06/25/24 noted bilateral lower extremity edema. R64 On 06/25/24 at 01:23 PM, R64 was observed sitting in their wheelchair without footrests or ace wraps. Bilateral lower extremity edema observed. R64 was interviewed and was asked if they had any concerns. R64 stated their legs are swollen and painful and the swelling is not being treated. R64 states they elevate their own legs on pillows when they're in bed. On 06/26/24 at 08:45 AM, R64 was observed lying in bed without ace wraps with bilateral lower extremity edema observed. R64 was interviewed and stated their legs are hurting, and they can't get the edema under control. When asked if they elevate their legs when they are out of bed R64 says they do not have leg rests for their wheelchair to keep them elevated when they're out of bed. On 06/26/24 at 10:53 AM R64 was observed sitting in their wheelchair without ace wraps with bilateral lower extremity edema noted. On 06/27/24 at 0934 AM, R64 was observed sitting in their wheelchair with their legs propped up on a chair without ace wraps. Bilateral lower extremity edema observed to remain unchanged. A review of R64's record revealed they were admitted to the facility on [DATE] with the following diagnosis: parkinsons; osteoarthritis; generalized muscle weakness. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 15/15 indicating intact cognitive function. R64 also required assistance with bed mobility and transfers. Further record review of R64's orders revealed the following: active physician's order dated 6/10/24 Please apply ace wraps to bilateral feet, ankle, and lower legs one time per day for edema Further review of R64's record revealed physician progress notes as follows: physician progress note dated 06/10/24 stating the patient reports (they) do not like wearing compression stockings. The patient reports (they) would rather have (their) feet and legs wrapped with ace wraps. Physician progress note dated 06/25/24 notes a diagnosis of R60.0- localized edema: bilateral lower leg swelling. assessment and plan: wrap lower extremities with ace wraps.

Based on observation, interview, and record review, the facility failed to change a pressure ulcer dressing for one resident (R44) out of eight reviewed for pressure ulcers. Findings include: On 6/25/24 at 9:22 AM, R44 was observed in bed asleep with their breakfasts tray on the bedside table. On 6/26/24 at 8:33 AM, R44 was observed in their wheelchair with their meal. R44 reported no issues. On 6/57/24 at 8:11 AM, a Concern Party (CP) revealed, they were concern about the care that R44 has received at the facility. The CP explained, R44 has developed a pressure ulcer and they are not doing the wound care treatments as ordered. On 6/27/24 at 8:28 AM, R44 was observed in the bed. A skin observation was made. R44's right hip was observed with a skin wound area of approximately 1.5 inches x 1 inch oval. The wound was uncovered and had no trace of any cream/treatment. The CP reported they notified R44's assigned nurse the wound was not covered. The assigned nurse was observed to enter the room with a wound treatment for R44's wound. The nurse was asked if R44's wound should be covered and stated, Yes. A review of R44's medical record revealed, R44 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dementia, Alzheimer's Disease, and Syncope and Collapse. A review of R44's Minimum Data Set assessment dated , 5/8/24 noted R44 with a severely impaired cognition and the requirement of staff to complete activities of daily living. R44's skin was noted at risk for the development of a pressure ulcers and to be without any unhealed pressure ulcers/skin injuries. A review of R44's care plan noted, Focus: [R44] is at risk for impaired skin integrity R/T (related to): impaired bed mobility, incontinence, Anemia, Renal Failure, PVD, Failure to Thrive. Date Initiated: 04/27/2024. Goal: Will have minimized risk for skin breakdown through next review date. Date Initiated: 05/14/2024. Interventions: Follow facility policies/protocols for the prevention/treatment of impaired skin integrity. Date Initiated: 04/27/2024. Provide assistance to reposition frequently and as needed. Date Initiated: 05/01/2024. Provide incontinence care with each incontinent episode and apply moisture barrier cream/ointment per facility policy/orders. Date Initiated: 05/10/2024 . [R44] has Actual impairment to skin integrity R/T impaired bed mobility, diagnosis of failure to thrive. Returned from hospital on 6/14/2024 with an Allevyn dressing to her right hip. Date Initiated: 05/14/2024. Goal: Will have no complications r/t open wound to right hip area through the review date. Date Initiated: 05/14/2024. Interventions: Provide incontinent care and use moisture barrier treatment as needed after incontinent episodes. Date Initiated: 06/16/2024. Treatment to skin impairment per order . A review of R44's Braden Scale for Predicating Pressure Sore Risk dated, 6/18/24 noted, R44 as a low risk. A review of R44's Skin and Wound Evaluation dated, 6/24/24 noted, Describe: Pressure, Stage 2: Partial-thickness skin loss with exposed [NAME], Location Front Right trochanter (hip), lateral. Acquired (blank, not completed). Wound measurements: Area: 3.5 cm, Length: 2.8 cm, Width 1.8 cm, Depth, Undermining, Tunneling: not applicable. Wound Bed: Epithelial 100% of wound covered, surface intact . A review of R44's Treatment Administration Record (TAR) for the month of June 2024 noted, Cleanse area on right hip with NS, pat dry, apply thin layer of zinc oxide cream and leave open air. Start date: 6/16/24 and discontinued 6/24/24. Celanese right hip with SS; pat dry. Apply silvasorb gel and island dressing. Change QOD and PRN. every day shift every other day. Start dated: 6/24/24. Cleanse right hip with SS; pat dry. Apply silvasorb gel and island dressing. Change QOD and PRN (as needed). Start date: 6/27/24. A review of the facility's policy titled, Skin Management dated, 5/14/2024, noted Policy: It is the policy that the facility should identify and implement interventions to prevent development of Clinically unavoidable pressure injuries. Overview: Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes .

Based on observation, interview, and record review, the facility failed to apply prafo boots (custom-fitted device that can help manage ankle/foot anomalies) to two residents (R77 and R20) out of two residents reviewed for range of motion. Findings include: R77 On 06/25/24 at 10:36 AM, R77 was observed in bed. Prafo boots were observed on the floor next to the dresser. On 06/26/24 at 08:49 AM, R77 was observed in bed eating breakfast with the prafo boots noted on the floor. R77 was asked if they wear the boots, R77 explained, they wear the boots when the staff put them on. R77 said the staff put the boots on several times per month. R77 was observed to reference their phone and then stated the last time therapy worked with them was May 6, 2024 and they put the boots on at that time. On 06/27/24 at 09:35 AM, R77 was observed in bed with their prafo boots observed on the floor next to the dresser. On 06/26/24 at 02:20 PM, during an interview, Physical therapist (PT H) was asked about R77's therapy. PT H explained, R77 was discharged from therapy in March and put on the restorative program which is done by two restorative aides usually three days per week and is managed by nursing. PT H explained restorative reports to therapy if there are any changes in the resident's care and they could be picked up during the quarterly screens if needed. On 06/26/24 at 02:30 PM, during an interview, PT I was asked about R77's therapy, PT I stated that R77 started physical therapy in April 2021 during which R77 walked 5 feet with max assist. PT I confirmed that R77 was discharged from PT in March 2024. PT I stated I was just notified this morning that R77's prafo boots were broken. On 06/27/24 at 10:06 AM, during an interview, Restorative Coordinator (RC J) was asked about R77's restorative care. RC J explained R77 started the restorative program on March 7, 2024. RC J said R77 is supposed to wear the prafo boots up to 5 hours per day as tolerated and sometimes R77 refuses. RC J said the restorative aides have told them R77 has been wearing them and is getting better at wearing them. RC J was asked about documentation regarding the refusals for R77. RC J was observed to reviewed some documentation and said R77 refused to wear the prafo boots on June 17th and explained they did not have any other documentation about prafo boots for the current week. A review of R77's task list for the prafo boots noted documentation of application of only five times in last 30 days, and a total of three days that were documented as resident refusal. A review of R77's medical record revealed, that R77 was admitted into the facility in 04/16/2021 with a diagnosis of spinal stenosis; need for assistance with personal care; and myasthenia gravis with acute exacerbation. A review of the Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating an impaired cognitive function. Record review of R77's orders reveal active orders as follows: active order dated 12/13/2023 by PT K patient to wear bilateral PRAFO boots per splint schedule to manage bilateral foot drop contracture deformity signed by physician 12/20/23. Active order dated 5/2/24 by RCJ restorative program coordinator stated prafo bilateral ankle 4-5 hours daily or as tolerated signed by physician 5/2/24. Further record review of R77's last physical therapy evaluation and also R77's physical therapy discharge summary both indicate a recommendation for prafo boots 5 hours per day 5 days per week to facilitate patient maintaining current level of performance and in order to prevent decline. A review of R77's care plan indicated the following: (R77) has potential decline in mobility/physical functioning R/T (related to) muscle weakness. (R77) will maintain maximum level of mobility/physical functioning through next review date. Monitor for, document, and report any adverse effects of brace/splint wearing. Record review also reveals a task list for the prafo boots which shows documentation of application of five times in last 30 days and a total of three days that were documented as resident refusal. R20 On 06/25/24 at 10:14 AM, R20 was observed lying in bed. R20 was interviewed and indicated they can't walk because of the pain in their legs. During the interview prafo boots observed on top of pile of belongings next to dresser. On 06/26/24 at 08:40 AM, R20 was observed in bed eating breakfast the prafo boots were observed on top of a pile of belongings next to the dresser. On 06/27/24 at 07:57 AM, R20 was observed in bed and the prafo boots were observed on the floor by the dresser. R20 was asked how often they wear the boots. R20 said they (staff) used to put the boots on them for 5-6 hours at a time and now they don't put them on anymore. R20 was observed with edema and foot drop to their bilateral lower extremities. When R20 was asked if they were able to flex their ankle, R20 was observed to try to flex their ankle but was unable to and stated I think that's what the boots are supposed to be for. On 06/27/24 at 09:58, R20 was observed in bed. The prafo boots remained on floor in the same place next to the dresser. A review of R20s record revealed that R20 was admitted to the facility on [DATE] with the following diagnosis: unspecified dementia; polyosteoarthritis; muscle wasting and atrophy; foot drop. A review of the Minimum Data Set assessment revealed a BIMS score of 15/15 indicating no cognitive deficit. Record review of R20's orders revealed the following: active order dated 5/28/2024 by Licensed Practical Nurse (LPN) J documents, Wear Bilateral PRAFO's up to 6 hours daily or as tolerated. Further record review of R20's last physical therapy evaluation and also R20's physical therapy discharge summary both indicate a recommendation for prafo boots 6 hours per day 5 days per week to manage foot drop and to reduce the risk of further contracture deformity. A record review of R20's care plan revealed the following: (R20) has potential for decline in mobility/physical functioning related to weakness. (R20) will maintain maximum level of mobility/physical functioning through next review date. Monitor for, document, and report any adverse effects of brace/splint wearing. Monitor for, document, and report any changes in (R20) mobility/physical function. Further review revealed a task list for the prafo boots which shows documentation of application of only seven times in last 30 days and a total of one day that was documented as resident refusal. On 06/27/24 at 10:06 AM during an interview, LPN J explained that R20 is supposed to be wearing prafo boots saying, the nursing aides can put them on. On 06/27/24 at 10:15 AM was observed in bed with the prafo boots were observed on floor in same place next to dresser. An interview was conducted in R20's room with certified nurse assistant (CNA L at this time. When CNA L was asked if R20 was supposed to be wearing the boots when they are in bed and who is supposed to put them on and take them off CNA L explained the restorative aides do that and said they were never told to or trained how to put the boots on. On 06/27/24 at 10:20 AM, during an interview, the Director of Nursing (DON) was asked which staff was responsible to put the boots on the residents. The DON explained, that anyone that has the resident can put on prafo boots and the duty is not assigned to a specific person. The DON stated, I would expect that someone would put them on the resident. On 06/27/24 at 02:05 PM, during an interview, Physical Therapist K (PT K), stated while a resident is in physical therapy they do stretching, check for improvement, check how they tolerate the boots and for skin breakdown et cetera. PT K confirmed if a resident was not wearing the prafo boots to maintain the neutral position of their ankle that they would have increased tightness, pain, and contractures of the joint. Review of the facility's policy titled Contracture prevention and management program states the following: Purpose: Assisting a resident to attain and/or maintain joint mobility promotes independence, prevents or reduces contractures, preserves range of motion for use of prosthesis, stimulates circulation and enhances muscle strengthening. A resident requiring passive range of motion, active range of motion and/or splint/brace application and removal are considered for this restorative program. Restorative programs including range of motion and splint/brace assistance are provided by trained nursing assistants or licensed nurses.

Based on observation, interview and record review, facility failed to properly label medications with resident identifier or open date in two of four medicaiton carts. Findings include: On 06/26/24 at 9:37 AM, the Superior Wing medication cart was reviewed with Licensed Practical Nurse (LPN) G. Two Trelegy Ellipta inhalers were observed not labeled with a resident identifier. LPN G reported they label the inhaler they open with the name of the resident and the date opened. On 06/26/2024 at 12:30 PM, the medication cart for the C200 wing was reviewed with LPN B. There was a Breo inhaler labeled with a resident name on the box, but not a date when opened. There was also a bottle of Humalog Insulin that did not have an open date on vial or on box. On 6/27/2024 at 12:00 PM, a interview with the Director of Nursing (DON) revealed their expectation is medication open dates should be on the medication container. Review of the Medication Storage Guidance revealed Multiple-Dose Vials for Injection should be Date when opened and discard unused portion after 28 days. Review of the Medication Storage Guidance for Inhaled Medications for Breo Ellipta Inhalation Powder should have date when opening the foil tray and discard after 6 weeks A review of the prescribing information at BREO ELLIPTA (fluticasone furoate and vilanterol) (mybreo.com) revealed, .How do I store BREO? Safely throw away BREO in the trash 6 weeks after you open the tray or when the counter reads 0, whichever coes first. Write the date you pen the tray on the label on the inhaler. Review of the Medication Storage Guidance for Inhaled Medications for Trelegy Ellipta should have date when the foil tray is opened and discard after 6 weeks.

This intake pertains to Intake MI00138670. Based on interview and record review, the facility failed to timely implement interventions or properly treat an existing pressure injury for one resident (R700) out of three reviewed for wounds, resulting in the hospitalization for debridement of the wound. Findings Include: A review of an Intake called into the State Agency noted the following, .Complainant states that facility neglected to properly treat the bedsore .complainant states the bedsore got progressively worse and the size of a grapefruit. Complainant states on [date] the resident was sent to the hospital for debridement . A review of the medical record revealed that R700 admitted into the facility on [DATE] with the following diagnoses, Multiple Sclerosis and Dysphagia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 12/15 indicating a slightly impaired cognition. R700 also required extensive two-person assist with bed mobility and transfers. Further review of the admission skin assessment noted the following, Site: Sacrum Description: Open Area. A review of the admission progress note noted the following, Date: 5/12/2023 at 6:51 PM .Resident has an open area to coccyx. A review of the physician orders revealed that an order to treat the wound was not entered until 5/16/2023 (4 days later). Further review of the progress notes revealed that R700 was seen by the wound care team on 5/23/2023 (11 days later). The progress note revealed the following, .Sacral unstageable (Slough or eschar-dead skin- obscures the wound bed)-this area measures 3.5 x 2.1 cm (centimeters) with no determinable depth. Edges are attached and there is no eschar (necrotic tissue), tunneling, or undermining, or odor. This area can be cleaned with normal saline, and santyl applied to the area. Wound should be covered with a dry dressing. A review of the physician orders revealed the following order, Start Date: 5/17/2023 .Iodsorb External Gel 0.9% .Apply to Sacrum topically every 48 hours for Sacral Ulcer. Start Date:6/5/2023 .Santyl External Ointment 250 Unit/GM .Apply to sacrum topically everyday shift for sacral ulcer. Review of the Treatment Administration Record (TAR) revealed blank spaces that indicate the treatment was not documented and/ or completed on the following days, 6/7 and 6/13. Further review of the progress notes revealed the following, Date:6/5/2023 .On exam today patient is alert. Family and nursing report concerns for worsening wound to buttocks. Date:6/6/2023 .Sacral Unstageable-this area measures 5.6 x 3.2 cm with no determinable depth .This area can be cleaned with normal saline, and Dakins wet to dry applied to the area. Wound should be covered with a dry dressing. Review of the physician orders did not reveal an Dakins wet to dry wound care order. Date: 6/12/2023 .Nursing reports significant purulent, malodorous drainage of dressings-they are currently fully saturated and due to be changed per schedule. Wound appears to have significant tunneling depth significantly increased since last assessment by wound care . Additional review of the physician orders revealed the following, Revision Date:6/13/2023 .Transfer to hospital for surgical debridement of buttocks wound. On 1/3/2024 at 12:34 PM, an interview was conducted with Wound Care Nurse (WCN) C. WCN C stated that when a resident is admitted into the facility with a wound, then a treatment order should be entered immediately. WCN C stated that they created a template for the nurses to use or they can call the physician and obtain an order. WCN C was queried as to why the orders were not changed to the recommendations provided by the wound care provider. WCN C stated that they spoke about the orders at bedside with the provider and decided to go with other treatments. A review of a facility policy titled, Skin Management revealed the following, .4. Guests/residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing, A physician's order for treatment, and Wound location, measurements and characteristics documented.

This citation pertains to intake MI00140941 Based on interview and record review, the facility failed to provide two-person assistance during care for one resident (R712) out of one reviewed for falls, resulting in a fall from bed and death. Findings Include: A review of an incident and accident report dated [DATE] revealed the following, Nursing Description: CENA (Certified Nursing Assistant) was in Resident's room to provide care. While CENA was at the sink [they] heard a loud thump. CENA went back to Resident's bed and saw that [R712] was lying on the floor. CENA informed Writer that Resident was on the floor. Writer observed Resident lying on the floor on [their] right side on the left side of [their] bed with [their] head slightly under the bed frame. Writer asked Resident did [they] roll out of bed on [their] own, Resident stated yes with a head shake. Prior to fall, Resident was last seen at approximately at 2:00 am lying in [their] bed sleeping with call light within reach. Resident Description: Writer asked Resident did [they] roll out of bed on [their] own, [R712] stated yes with a head shake. CENA and roommate heard the thump. Writer asked Resident if [they] had hit [their] head, [R712] stated no. A review of the medical record revealed that R712 admitted into the facility with the following diagnoses, Dementia and Hemiplegia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of ,d+[DATE] indicating an intact cognition. R712 also required extensive two person assist with bed mobility and transfers per the most recent functional mobility Minimum Data Set Assessment set. Further review of the care plan revealed the following intervention, Bed Mobility: Resident requires 2-person assistance to reposition and turn in bed. Date Initiated: [DATE]. A review of the progress notes revealed the following, Date [DATE] at 2:00 PM .At 8:57AM upon assessment resident was observed unresponsive to voice, touch, and pain. Writer initiated a code blue 911 was called. EMS (Emergency Medical Services) on scene and policemen responsible party was notified. Resident was pronounced deceased at 9:14 AM picked up at 1:35 PM by medical examiner. A review of Autopsy Report revealed the following notes from the Medical Examiner, .it is my opinion that [R712] dies secondary to multiple pulmonary fat emboli, with contributory blunt force injuries of the head, neck, chest, and upper back. It is unclear how these injuries were sustained. On [DATE] at 1:50 PM, an interview was conducted with the Director of Nursing (DON). The DON was queried as to if R712 was supposed to be a two person assist during care. The DON stated that R712 was supposed to be a two person assist during care. The DON stated that the certified nursing assistant had been wrote up and education had been given to all staff, as well as more. A review of a facility policy titled, Fall Management, noted the following, Policy: The facility will identify hazards and resident risk factors and implement interventions to minimize falls and risk of injury related to falls. During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included, Description of deficient practice, In-depth analysis how the defiency practice occured: Certified Nursing Assistant failed to provide care including bed mobility for a resident that requires a 2 person assist. How facility identified resident affected and residents having potential to be affected by the same deficient practice:Like residents are those who require 2 person assist for bed mobility. Corrective action taken for residents affected: Like residents plan of care has been audited to ensure number of personal assists is accurate. Like residents have been audited to ensure staff are following the bed mobility plan of care. Measures of systemic changes made to ensure that deficient practice will not occur and affect others: NUrsing staff educated on assist cena's with residents who require 2 person assist. Nursing stadd educated on following kardex. How facility monitors its corrective actions to ensure same decifient practice is corrected and will not recur: The Director fo Nursing and the Nursing Home Administrator wll review 10 residents who require 2 person assist including bed mobility are completed properly for 4 weeks then monthly for 2 months. The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

This citation pertains to intake number MI00132609 Based on interview and record review the facility failed to provide adequate supervision and secure all facility doors for one resident at risk for elopement (R905) of three residents reviewed for elopement, resulting in the resident exiting out of an unlocked unalarmed kitchen door and ambulating to an adjacent neighborhood and sustaining lacerations to the left side of their face and body. Findings include: On 11/30/22 at 9:35 AM, unidentified family member I was contacted regarding an alleged incident which occurred involving R905 on 10/30/22. Family member I stated, I was told by the facility that [Resident] got out an unlocked side door of the facility and was found by [police], they had fallen and cut their face. I just don't want this to happen to anyone else. On 11/30/22 at 9:59 AM, an incident and accident report (I/A) involving R905 dated 10/30/22 7:00 AM, was reviewed and revealed the following, During morning rounds [Nurse I] noticed that [Resident] was not in their room. Code search initiated. At approximately 7:30 AM, [police] called and notified that resident was being taken to [hospital] for evaluation. On 11/30/22 at 10:05 AM, the Accuweather.com website revealed that the temperature on 10/30/22 reached a high of 65 degrees Fahrenheit and a low of 39 degrees Fahrenheit. On 11/30/22 at 10:32 AM, a review of a police report dated 10/30/22 indicated that R905 was located in a neighborhood close to the facility and was observed to have Injuries to the left side of their body. The police report further indicated that R905 was taken to the hospital via EMS (emergency medical services) for further evaluation. On 11/30/22 at 11:45 AM, a review of R905's most recent, Risk for Elopement assessment dated [DATE] revealed that R905 was, At Risk for elopement. On 11/30/22 at 11:49 AM, a review of R905's elopement risk care plan revealed the following, Focus: [R905] is at risk for exit seeking behavior R/T (related to) history of attempts to leave facility .Date Initiated: 10/13/2022 Revision on: 10/25/2022. Goal: [R905] will not leave facility unattended through the review date. Date Initiated: 10/13/2022 Revision on: 10/25/2022 Target Date: 11/2/2022. Interventions: Approach [R905] in a slow calm manner and redirect away from exit doors as needed. Date Initiated: 10/13/2022 Revision on: 10/25/2022. Distract [R905] when wandering in to inappropriate areas by offering pleasant diversion, structured activities, food, conversation, etc., Date Initiated: 10/13/2022 Revision on: 10/25/2022. On 11/30/22 at 12:34 PM, a review of R905's electronic medical record (EMR) revealed that R905 was originally admitted to the facility on [DATE] with diagnoses that included, Unspecified displaced fracture of surgical neck of left humorous (upper left arm), BiPolar disorder, and Unspecified psychosis. R905's most recent minimum data set assessment (MDS) dated [DATE], indicated that R905 had a moderately impaired cognition and required extensive assistance with all activities of daily living (ADLs) other than eating. R905 was discharged from the facility on 10/30/22. On 11/30/22 at 2:15 PM, Nurse I was interviewed by phone and asked about the incident involving R905 which occurred on 10/30/22. Nurse I stated, It was right around shift change. [R905] wasn't in their room. I had been redirecting [R905] back to their room a few times that night. Nurse I indicated that they had been told that [R905] exited out a door through the kitchen. Nurse I stated, When I was on the phone talking to the Director of Nursing (DON) regarding the incident, the [police] called and stated they had found the resident. Nurse I was asked where the resident was found and indicated that they were unsure. Nurse I was asked at what time on 10/30/22 they last saw the resident in the facility. Nurse I indicated that they were unsure when they last saw R905. On 11/30/22 at 3:10 PM, certified nursing assistant (CNA) D was interviewed and asked about the incident involving R905 which occurred on 10/30/22. CNA D stated, I was in my assigned hallway and not too far away from [R905's] room. Around 3:30 AM, [R905] exited their room and I assisted them back to their room and into bed. I began my rounds/changes around 4:00 AM, and the resident was out of my sight. I didn't see [R905] after that. CNA D was asked if they knew where R905 was found. CNA D stated, No. On 12/1/22 at 9:30 AM, unit nurse manager (UNM) H was interviewed regarding the incident involving R905 which occurred on 10/30/22. UNM H indicated that they were the on call manager on the night of the incident. UNM H stated, I came into the facility along with the DON and Administrator (NHA), by the time I got in, the police had called and indicated that they had found the resident and the resident was being transported to [Hospital] for an evaluation. We completed an elopement code drill and have done inservice training since the incident occurred. On 12/1/22 at 10:00 AM, food services director (FSD) K was interviewed regarding the elopement incident involving R905. FSD K verified that the kitchen door was left unlocked on 10/30/22. FSD K indicated that although they were not exactly sure what exact door [R905] exited through, FSD K acknowledged that there had been a door in the kitchen that was unalarmed that could have been exited through. FSD K stated, All doors are locked now, the door in the kitchen has a screamer alarm (alarm that makes a loud noise) on it now, and the door leading into the kitchen has a log sheet now which staff sign to verify that the door was locked and sign in the morning to verify that the door was locked when they arrive for their shift. On 12/1/22 at 12:15 PM, the NHA was interviewed and asked what their expectations were for staff to prevent resident elopement. The NHA stated, Expectation for staff are to be aware of your residents and to engage them in activities and keep them occupied as much as possible. On 12/1/22 at 12:47 PM, a facility policy titled Elopement Policy Last Revised 4/26/2022 stated the following, Policy: It is the policy of this facility to prevent to the extent reasonably possible, the elopement of guests/residents from the facility .8. Rounds of all residents are made at the beginning of the shift, at mealtimes, and at the end of the shift at a minimum by direct care staff and licensed nurses. CNA or nurse can achieve this through medication administration pass, mealtime passes, and during care rounds Upon return of the resident to the facility, the Director of Nursing or charge nurse should: f. Investigate how the resident exited and make recommendations on safety measures to the Safety Team Committee; and g. Update the resident's care plan and care guide with preventive interventions for elopement. On 11/30/22 at 9:00 AM, the facility provided documentation to address the incident which occurred on 10/30/22. A summary of this plan indicated the following, October 30, 2022: Past Non-Compliance (PNC). Date: 10/30/22: Description of deficient practice: Facility failed to prevent a resident, who requires supervision, from going outside the facility doors independently. The resident was able to enter the Dietary Kitchen and exited the facility through a door in the kitchen that did not have an alarming system in place. A QAPI/RCA meeting was held to review the Elopement on 10/30/22. How facility identified resident affected and residents having potential to be affected by the same deficient practice. The Administrative Nurses reviewed the residents in the facility last Elopement Risk Assessment to identify the residents who at risk for elopement. Corrective action taken for the resident affected: Resident was assessed at the hospital The Resident Chart was reviewed Upon readmission the resident will be re-assessed for Elopement Risk The Elopement care plan was reviewed and revised as needed Wander Guard device was device checked and was functioning properly Resident room placement was reviewed Measures of systemic changes made to ensure the deficient practice will not occur and affect others. A QAPI Meeting was held to review the elopement, staffing and door alarms on 10/30/22. Rounds were made on all doors in the facility that exit to the outside to validate alarms are functioning, if the door is not alarmed a screamer door alarm was placed on that door. The entrance door to the Dietary Department will be checked by 2 staff members to validate the door is locked at the end of the day. Administrative Nurses and or the Social Worker reviewed the residents identified at risk for elopement to validate the last risk for elopement evaluation was accurate, the orders for the wander guard are in PCC, the care plans for elopement are up to date and the wander guard is in place and functioning. The Elopement policy was reviewed and deemed appropriate. Re-education on the elopement policy began on 10/30/22. How facility monitors its corrective actions to ensure same deficient practice is corrected and will not recur. The Maintenance Staff or designee will complete rounds on all doors in the facility that exit to the outside to validate alarms are functioning 7 days a week for 4 weeks and then monthly for 2 months, any concerns will be addressed. Findings will be reported to the QAPI committee monthly for 3 months for recommendations. Maintenance Staff or designee will make rounds to validate the entrance door the Dietary Kitchen is locked on off shits weekly x 4 weeks and then monthly for 2 months, any concerns will be addressed. Findings will be reported to the QAPI committee monthly for 3 months for recommendations. The Licensed Nurses or designee will make frequent random rounds on the residents identified at Risk for Elopement on the Midnight weekly x 4 weeks and then monthly for 2 months, any concerns will be addressed. Findings will be reported to the QAPI committee monthly for 3 months for recommendations.

This citation pertains to Intake: MI 823 Based on interview and record review, the facility failed to prevent staff to resident abuse for one resident (R704), following R704's refusal to release their bed remote causing a facility staff member to forcibly twist and bend the resident's right hand, resulting in an abrasion and pain to their right fifth finger. Findings include: A review of Intake MI 823 revealed the following, [R704] resides in Regency nursing home . [Certified Nursing Assistant A] is a staff member at the facility. Yesterday (12/27/2020), [CNA A] was in R704's room. [CNA A] asked [R704] to drop the TV remote. When [they] would not, she grabbed [their] right hand, squeezing and twisting it causing [their] pinky nail to lift and bleed . [CNA A] denied the incident occurred, however [R704] has bruising and dried-up blood on [their] right pinky finger. A review of R704's medical record revealed that they were admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status score of 12/15 indicating a moderately impaired cognition, and required extensive assistance for Activities of Daily Living. On 2/8/21 at 11:50 AM, an interview was completed with R704 about the incident with CNA A. R704 explained that they already had weakness in their right wrist as it has not been strong since their stroke. R704 explained that they were talking with facility staff, who asked what happened to their pinky on their right hand because it was bleeding. R704 explained that a band aid was provided to them at that time. R704 further explained that they didn't want to tell anyone about the incident, but once asked, they disclosed that while holding the bed remote in their hand, she, CNA A squeezed R704's hand to take it out, twisting their wrist until R704 dropped the remote. R704 explained that they did not want the police involved, but they were called in to interview them. R704 explained that they have not had CNA A working with them since the incident. A review of R704's medical record revealed the following progress notes: 12/28/2020 14:04 (2:04 PM). Nurses Note. Note text. Reported to writer that resident stated, that 'last night a staff member squeezed [their] hand causing it to bleed. Resident stated [they] had the bed controller in [their] hand and the staff member tried to take the control out of [their] hand, Dried blood noted on finger, no open areas or cuts noted on finger, Area cleansed, Physician notified. Message left for RP (responsible party) for call back. DON (Director of Nursing) and Administrator notified. 12/29/2020 11:15 (11:15 AM). Social Services Note. SS (Social Services) interviewed resident in [their] room. When res (resident) was asked does [R704] feel safe here at the facility? Res answered 'Yes'. When asked does [R704] feel afraid? Res answered .,'No.' Res voiced no concerns at this time. Res is calm and pleasant at this time. SS offered to vent [their] feelings and concerns. Res stated, 'I'm ok'. Encouraged res to inform staff if [R704] has any concerns. Date of Service: 12/30/2020. Visit Type: Acute .Chief Complaint/Nature of Presenting Problem: Right 5th finger abrasion. History of Present Illness. [Identifying information] being seen and evaluated today for follow up on nursing notification, patient was found to have a small abrasion on [their] right 5th finger, [R704] states [R704] was holding the bed control and a staff member tried to take it from [them]. [R704] admits mild pain associated at site of abrasion, ROM (range of motion) intact with mild [CONDITION(S)] noted on exam, no drainage noted, Pt. (patient) states pain is improving and controlled with Tylenol . A review of R704's Behavioral Progress note dated: 12/29/20. Complaint: Follow up evaluation-Accusations .12/28/20 .Resident seen up in bed. [R704] recalls some lady squeezed [their] finger when taking [their] remote to [their] bed. Reports yesterday was hurting but has passed since. No complaints at this time. [R704] stated the staff member was mean and [R704] wasn't sure why . On 2/8/21 at 2:17 PM, Social Worker B was asked what she knew about the abuse allegations made by R704. Social Worker B stated, [R704] said that [they] had the remote control in [their] hand, and the CNA was trying to get it from [their] hand. Social Worker B was asked if she observed R704's hand after the incident and stated, There was a little blood on [R704's] pinky finger. It was checked by the PCP (Primary Care Physician) and the unit manager. Social Worker B was asked if they remembered anything else and stated, [R704] has been pretty consistent with [their] story, and what [they] told other disciplines. On 2/8/21 at 2:22 PM, an interview was completed with CNA A who was asked about the incident between she and R704, and she explained that she was suspended for 3 days while they investigated the allegation. She also reported being interviewed by police. CNA A stated that the date of the alleged incident, [R704] cut [their] light on and said that they wanted to get into bed. [R704's] brief was changed, and [R704] was straightened in bed. CNA A was asked if she had squeezed R704's hand and stated, I didn't do anything. CNA A was asked if they knew where the abrasion came from and stated, No. CNA A was asked about her return to work, and whether she was provided with any training, and she explained that she was, but did not remember what it was about. On 2/8/21 at 2:58 PM, an interview was completed with the DON about the incident with R704, and they stated, I talked to [R704] and asked what happened. [R704] said that, the young lady wanted to take the bed control from [them], and [they] wanted to keep it. The DON explained that she asked R704 why [they] did not want to give the remote to her, and they stated, 'I just wanted to keep it and I didn't want to give it to her, and she grabbed it from me.' The DON further explained that she spoke to CNA A who explained that the incident that R704 described did not happen, and that if anything occurred, it was not intentional. The DON explained that R704, does not have a very good working relationship with the CNAs and if you look into R704's progress notes there is documentation that R704 feels the CNAs are prejudiced against [them]. The DON continued, CNA A seems truthful, and the abrasion was a tiny little crack in the cuticle area. You could barely see it. A review of CNA A's personnel file revealed the following Inservice form: Inservice 1:1 Topic: Abuse Date: 12/31/20 Presenter: [name of Administrator], Title: Admin Goal: Abuse, Neglect, Mistreatment Awareness Description: Alleged Abuse of a resident by squeezing residents hand very hard causing R (right) pinky to bleed. If a resident refused anything report to nurse ASAP (as soon as possible) & come back later to offer assistance again. On 2/8/21 at 3:46 PM, an interview was completed with the Administrator who was asked what was told to them by R704, and he stated, [R704] told me that the girl squeezed [their] hand and caused it to bleed. The Administrator was asked what R704's finger looked like after the incident, and he explained that it looked like where you may have caught it (cuticle) on something, with minimal bleeding, and indicated that, You couldn't notice anything. The Administrator was asked about the outcome of the investigation and stated, I couldn't substantiate that it occurred. The Administrator was asked why CNA A was provided with education upon returning to work and explained that, It's protocol. The Administrator also stated, We don't condone any form of abuse. A review of the facility's Abuse Prohibition policy outlines the following, Each resident shall be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property. Abuse shall include freedom from verbal, mental, sexual, physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or convenience that are not required to treat the resident's medical symptoms. Definitions: Abuse means the willful infliction of injury, unreasonable confinement intimidation or punishment with resulting physical harm, pain or mental anguish .

This citation pertains to intake MI 551. Based on observation, interview, and record review, the facility failed to assess for risk of consumption of hot liquids, and ensure adequate monitoring and supervision of hot beverages for one sampled resident (R#901) of six reviewed, resulting in hot coffee (per facility, obtained from R#904) spilling on R#901's lap. R#901 was known to be a 1:1 assist for meals and severely cognitively impaired, and sustained 2nd [MEDICAL CONDITION] severe pain to both inner thighs requiring a transfer to the emergency room , resulting in an Immediate Jeopardy (IJ). The Immediate Jeopardy started on 2/24/20 and was identified on 3/11/20. The Administrator was notified of the Immediate Jeopardy on 3/11/20 at 3:25 PM and was asked to submit a plan to remove the immediacy. The IJ was removed on 3/12/20, based on the facility's implementation of the removal plan as verified onsite on 3/12/20. Although the immediacy was removed, the facility's deficient practice was not corrected and remained isolated with actual harm that is not Immediate Jeopardy. Findings Include: On 3/6/20 at 4:09 PM, Confidential Witness A was interviewed regarding R#901's care at the facility. Witness A indicated their family member was burned with hot coffee. When queried further, Witness A stated, It was during lunch, I was told in the main dining room (2nd floor). When the nurse called me, she told me that (R#901) was drinking coffee and got burned. Then the DON (Director of Nursing) called me later on that evening stating that another resident (R#904) had given (R#901) coffee. (R#901) was sent to the ER (emergency room ). The doctor there told me with those types [MEDICAL CONDITION]'s best to have them seen by a burn specialist. When I went to go see (R#901), it looked pretty bad (location of the burn). It was between (R#901's) legs and close to their privates. On 3/11/20 at 8:23 AM, during the initial tour of the facility, an unidentified resident was observed eating breakfast in the first floor dining room. The coffee on their tray was visibly steaming. At this time, Dietary Aide B was asked to provide a cup of coffee from the kitchen, and it was requested that the temperature be taken. Aide B obtained the cup of coffee and used their thermometer to take the temperature, which read 170 degrees Fahrenheit (F). Aide B stated, When it goes out onto the floor, it won't be that hot. On 3/11/20 at 8:47 AM, R#904 was observed lying in bed eating breakfast. The resident was able to answer questions and respond to their name, however they appeared confused as they stated their brother was in the corner of the room and did not know the correct month or year. On 3/11/20 at 8:49 AM, R#901 was observed in the hallway, sitting in their wheelchair. R#901 appeared thin and was unable to appropriately answer interview questions except for their name. A review of R#901's medical record revealed: Note 2/24/20 12:45 (PM) (written by Licensed Practical Nurse (LPN) C) Resident was in the dining room getting ready for lunch sitting at the table, resident received a cup of coffee with a white lid on it. Resident removed lid and threw it on the floor and picked up coffee cup and spilled it on (their) lap. Writer and Aide assisted resident to room, removed (their) clothes and observed area. Redness observed on inner left thigh, forming a blister, resident groaning, facial pain. Dr. (doctor) notified and ordered Silverdine (sic) cream, ABD pad, tylenol 650 mg (milligrams) PRN (as needed), send resident to hospital for further evaluation. Residents (family member) aware. Note 2/24/20 12:50 (PM) (written by Wound Care Nurse (WCN) G) Upon assessment left medial thigh with redness and a small area with an intact serous fluid filled blister. Right medial thigh with redness noted. No blistering observed. Skin intact to both areas. [MEDICATION NAME] cream applied and covered with ABD pads. Ice applied intermittently while ABD pads covering area until resident discharged to hospital. R#901's pain assessments were reviewed and their pain assessment dated [DATE] at 12:37 PM utilizing the PAINAD scale (Pain Assessment in Advanced Dementia Scale) was 10/10, indicating severe pain. Further review of R#901's medical record at this time revealed multiple Nutrition/Dietary assessments dated 10/16/19, 11/18/19, 12/13/19, and 1/13/20 that indicated R#901 was to be 1:1 (one to one) assist for feeding/meals. The resident's nutritional assessment dated [DATE] revealed, Regular level 3 Advanced Mech (mechanical) Soft Nectar Thick liquids. Oral diet for pleasure feeding per SLP (Speech Language Pathologist). Thickened liquids per SLP 2/13/20 r/t (related to) resident was having difficulty with thin liquids .Eating ability: 1:1 feeder .Physical/mental limitations: Confused, disoriented, alert, ambulation difficulties .Clinical observation: vision impairment. R#901's hospital discharge records included directions for Hot Water Burn: Hot water on the skin can cause a first- or second-degree burn. A first-degree burn causes only redness and heals in a few days. A second-degree burn is deeper. It causes a blister to form. The blister may break and leak clear fluid. It may become infected. Second-[MEDICAL CONDITION] 1 to 2 weeks to heal. A review of R#901's wound care note dated 2/27/20 revealed: (R#901) being seen by wound care in consultation .has second-[MEDICAL CONDITION] hot liquid to right medial thigh and left medial thigh .Wound #1 Location: Right medial thigh, Type: Second-degree burn/hot liquid, Description: There is pink granulation tissue appreciated at the wound base with attached edges there is a small area of ruptured blister without signs of infection or discharge .Size: (length by width by depth) 7.68 cm (centimeters) x 3.51 cm x 0.0. No tunneling or undermining. Wound #2 Location: Left medial thigh, Type: Secondary burn/hot liquids, Description: Pink granulation tissue with small area of ruptured blister with no signs of infection .Size: 6.34 cm x 2.94 cm x 0.0. On 3/11/20 at 10:05 AM, LPN C was interviewed and queried regarding coffee spilling on R#901 on 2/24/20. LPN C stated she was the resident's assigned nurse that day, and Certified Nursing Assistant (CNA) D was the resident's assigned aide. LPN C indicated she did not know who took R#901 to the dining room for lunch. LPN C stated, I saw (CNA D) push (R#901) out of the dining room very quickly saying their pants were wet and it looked like coffee may have been dropped on them. We brought (the resident) to their room and assessed them. (The resident's skin) was red and started getting worse, it was not blistering at first but the skin was looking real thin. When asked if anyone in the dining room witnessed what happened, LPN C stated they did not witness the incident or remember anyone else who did. LPN C continued, I saw the floor was wet with the cup and lid on the floor. When asked where the coffee came from, LPN C stated, I'm not sure. When asked if R#901 was supposed to be a 1:1 assist at meals, LPN C stated, Yes. (The resident) had just gotten pushed to the table and I'm not sure how they got the coffee. When asked what happened after she assessed the resident, LPN C stated, We ended up talking to the doctor and sending (the resident) out. When asked if the resident was having pain, LPN C stated, You could tell something was going on, they were making facial grimacing. When queried regarding her note indicating the resident was groaning and indicators of pain were observed on the resident's face, LPN C stated her documentation was accurate based on what she saw. On 3/11/20 at 10:31 AM, CNA D was interviewed via phone and queried regarding the incident involving R#901 on 2/24/20. When asked what happened, CNA D stated, What happened is that I was pushing another resident into the dining room for lunch. When I came in, I saw (R#901) over there making a sound. I saw some smoke (steam) and I was like 'Oh my god!' I called out to the nurse (LPN C) and said I think (R#901) spilled coffee! So we rolled (R#901) into the room and put them in bed and took their clothing off immediately. When asked if she saw how R#901 obtained the cup of coffee, CNA D stated, No, I just happened to be walking in there and saw it. When asked who was in the dining room with the resident, if there were any other staff present, CNA D stated, I really don't recall. Let me think. I saw some people at the nurse's station (located outside of the dining room) but it happened so fast I couldn't really see. I was just thinking about the resident. I just know I saw (R#901) go, 'Ah ah ah!' and saw coffee on the floor. I saw the lid on the floor. When asked about feeding assistance for R#901, CNA D stated, I did find out that (R#901) is a 1:1 assist. I'm still new to the building. When asked if she had set anything up for R#901 at the table, CNA D stated, No, I was pushing residents into the dining room. I wouldn't have given (R#901) a cup of coffee anyway because (R#901) seemed kind of shaky. When asked if they had anything to add, CNA D stated, I'm just thankful I came in and the nurse was close by, too. I saw the smoke and called her over to get the resident. They (facility) asked me what happened but everyone was saying they didn't see anything. But somebody gave (R#901) that coffee. When asked if anyone admitted to giving the resident coffee, CNA D stated, No, nobody. Someone should've said something. Even if they didn't know not to give it to the resident, they should say something so they could do an inservice on not giving someone something they're not supposed to have. I just feel like it was very lucky that I just happened to walk in because if I hadn't, I don't know how long (R#901) would've been there. CNA D was then asked if she hadn't seen R#901 with the spilled coffee on their lap, if any other staff in the dining room would have seen it. CNA D replied, I really can't recall if anyone else was in there. On 3/11/20 at 11:08 AM, Dietary Aide B was observed to be filling coffee carafes with coffee and water from a coffee machine in the 2nd floor dining room. Chef F was present and was asked to obtain the temperature of the liquids in each carafe with his thermometer. The first carafe temperature was 153 degrees F, the second carafe was 152.6 degrees F, and the hot water from the machine that was poured into a carafe was 166 degrees F. Chef F stated, We should put a little ice in there. When queried regarding coffee and hot water temperatures, Dietary Aide B stated, We normally look for temps to be about 160 degrees F. According to the CMS State Operations Manual Appendix PP, revised 2017 under F-tag 689, a third-degree burn (which penetrates the entire thickness of the skin and permanently destroys tissue) can occur if skin is exposed to liquids at a temperature of 155 degrees F for 1 second. On 3/11/20 at 11:12 AM, Wound Care Nurse (WCN) G was interviewed regarding R#901's burn. WCN G stated she had already completed the day's treatment, but had taken photos and measurements of the wound. When queried regarding the wound, WCN G stated, There are 2nd degree burns, I believe from a coffee spill. The treatment just changed. The resident followed-up with a burn center. We will now be putting triple antibiotic cream on, then xeroform (a sterile wound dressing that is occlusive and non-adherent), then a dry dressing on top, every day and as needed. WCN G provided photos of the wounds. The left inner thigh was observed to have pink granulation (healing) tissue in a long strip and, according to WCN G measured approximately 3.4 x 0.6 (centimeters/cm). The right inner thigh was observed with yellow tissue in the center of a round area of pink granulation tissue. WCN G indicated the measurement of the right wound was 2.3 x 0.8 (cm). On 3/11/20 at 11:15 AM, Activity Aide I was observed at the front of the 2nd floor dining room with a coffee cart containing the carafes of coffee that were checked for temperature at 11:08 AM. Aide I went from table to table and poured residents coffee into cups with white plastic lids on top. No meal tickets were observed on the tables with the residents as the coffee was being passed by Activity Aide I. On 3/11/20 at 11:25 AM, an unidentified resident obtained coffee with a lid and straw. The resident began removing the lid. Activity Aide I stated, Leave the top on. The resident continued to remove the lid and straw and began drinking the coffee out of the cup. Activity Aide I did not address the resident further. On 3/11/20 at 11:35 AM, Confidential Witness H was interviewed and indicated they visited the facility almost daily. When asked if how Activity Aide I was serving coffee was how the coffee was normally served in the dining room, Witness H stated, Yes, this is how they normally pass coffee. Normally, there are one or two people in here passing out coffees usually with lids. I don't feel there are enough people in here to watch everyone. More staff come when the food actually gets served. On 3/11/20 at 11:38 AM, Activity Aide I was interviewed and asked if she was present in the dining room, or was the one passing out coffees to residents on 2/24/20. Activity Aide I stated, I was here that day but wasn't in the dining room when it happened. I left at 12 for my break. I came back and saw the ambulance and they told me (R#901) got burnt. I know not to give (R#901) coffee, they aren't steady, so I was wondering who did. I never found out who. I normally pass coffee between 11:15 AM and 11:40 AM. (R#901) wasn't in the room at the time I was passing out coffees. People can go get it for themselves as they come in the room though. On 3/11/20 at 12:10 PM, Therapy Manager J was interviewed and queried regarding therapy's role in hot beverage screenings. Manager J stated, It's not therapy per se, just an overall thing. If we note it in the initial assessment it would be reported to nursing that the resident would be at risk for [MEDICAL CONDITION] what not. When asked if there were any screenings specific to hot beverages/liquids, Manager J stated, No. When queried regarding the last time R#901 had therapy before 2/28/20, Manager J stated, The end of November 2019. Manager J then read from the resident's therapy notes and stated, The reason for referral then was a recent fall with new onset decreased strength and neuromotor control. Decreased coordination. Increased need for assistance from others. When asked about eating/drinking on the November 2019 notes, Manager J stated, The goal there was to increase upper strength to improve self feeding skills. The resident was discharged in December 2019. When asked how residents are being monitored for safety with hot liquids, Manager J stated, It's a joint effort between nursing and therapy. I would say it would be more up to nursing. If they noticed something during lunch meal, they can contact us and we can make recommendations. Or if therapy notices something upon admission, they can make recommendations or notify (nursing) if the resident is at risk for burning themselves. But there isn't a direct therapy screening evaluation for hot liquids. A review of the Incident/Accident (I/A) report involving spilled coffee and R#901 on 2/24/20 revealed a statement from R#904 which read, Resident interview(ed) and stated that (they were) in the dining room for lunch and gave (R#901) (their) coffee. A review of R#904's electronic medical record revealed no progress notes regarding the coffee and R#901. The I/A also included 13 staff interviews (including LPN C, CNA D, and Activity Aide I), all of which indicated none of the interviewed staff were present in the dining room when the event occurred. No interviews on the I/A indicated there was someone present who witnessed the event. On 3/11/20 at 12:40 PM, R#904 was observed in bed eating lunch. When queried regarding an incident involving R#901 on 2/24/20 in the dining room at lunchtime, R#904 responded, I ain't never go down to the lunch room or dining room I always eat in my room. I'm eating lunch right now. Don't you see me eating now? When queried if they gave R#901 any coffee, R#904 stated, No I ain't give anyone anything but a blessing. I didn't even know it happened. When asked if they ever eat lunch with R#901, the resident responded, Who is (R#901?) When asked if they ever go to the dining room with R#901, R#904 stated, No, I don't like that. I never eat over in that dining room. I don't even know the first step to make it there if someone asked me to go. When asked if they could remember being in the dining room with R#901, the resident stated, I know I haven't, I ain't never been with (R#901) over there. When asked if they ever brought R#901 coffee, the resident stated, No. I'm a friendly person but when it comes to doing big things I don't go for that. On 3/11/20 at 1:43 PM, Therapy Manager J approached and stated that the interdisciplinary team (IDT) therapy screens in the electronic medical records do have a question about handling hot liquids. A review of R#901's most recent IDT therapy screen, dated 11/26/19 revealed, .5. Change in ADL (activities of daily living) function - Yes .9. Resident is observed to be safe handling hot liquids - N/A not applicable) .10. Change in assist or adaptive equipment recommended for hot liquids - N/A. A review of R#904's most recent IDT therapy screen, dated 1/13/20 revealed, 9. Resident is observed to be safe handling hot liquids - No .10. Change in assist or adaptive equipment recommended for hot liquids - No. On 3/11/20 at 2:40 PM, the Director of Nursing (DON) was interviewed regarding the incident involving R#901 on 2/24/20. The DON stated, We did interviews, also treated the resident and sent them out. The CNA (D) had just taken (R#901) to the dining room. When the CNA came back she observed that (R#901) had spilled in their lap. We interviewed staff to see if they gave the resident any beverages. The DON indicated that upon interview, R#904 stated they had given their coffee to R#901. When asked what staff were in the dining room when this occurred, the DON stated, There were staff in there but no one actually saw it happen. They were pushing people in and out. When asked if there were cameras in the dining room, the DON stated, No. When asked how staff knows which residents can have coffee and which cannot, or who should be monitored with it, the DON stated, It's on the meal ticket, there are likes and dislikes. They print a meal ticket for every person. Dietary does it based on what people want. When asked how staff knows who can safely handle hot liquids, the DON stated, If there is a problem assessed by speech therapy they will notify dietary and will put it on their ticket. The DON was queried regarding R#901's evaluation for handling hot beverages and asked about it stating N/A. The DON stated, I think maybe the resident was NPO (nothing by mouth) at the time. The DON was queried regarding R#901's chart that indicated the resident had a diet order at the time for both food and liquids and provided no further information. When queried regarding R#904 being assessed for unsafe handling of hot liquids but having coffee on 2/24/20, the DON stated, Well it says no adaptive equipment. What we do is we put on a lid and (R#904) had a lid on the coffee. When asked if staff should have been monitoring R#904 with the coffee since they were assessed to not be safe handling hot liquids, the DON stated, I can't say. It's whatever recommendations come from speech therapy or give cooler liquids. On 3/11/20 at 3:11 PM, the Nursing Home Administrator (NHA) was interviewed regarding the incident involving R#901 and spilled coffee on 2/24/20. The NHA stated, We were immediately informed that (R#901) had a hot beverage spilled on them. Staff assessed the resident right away and we started an investigation to find out how it happened. (The DON) was asking the CNAs what they observed. How did the resident get the hot liquid? And that's where we asked everyone (residents) sitting at the table. That's where (R#904) had it and gave it to (R#901). Staff noticed that coffee was in (R#901's) lap and the lid was on the floor. When queried regarding assessing and monitoring residents with hot liquids, and how that is determined, the NHA stated, That's a good question. Dietary can do that. Then staff can see if residents are able to hold a cup for one or if they are shaky. When queried regarding R#904's assessment for unsafe handling of hot liquids, the NHA stated, Yes, I just saw that today. I believe the resident's dexterity is good for hot beverages. When queried regarding N/A as R#901's assessment for handling of hot beverages, the NHA provided no further information. When queried regarding R#901 being ordered as a 1:1 assist for feeding and set-up, the NHA stated, I became aware of it that day. When queried regarding expectation of staff during resident mealtime, the NHA stated, Ultimately it's supervision and making sure the residents are getting the right things served to them. We educated staff about serving hot liquids and not providing food or drink to a resident who has been assessed for 1:1 assist until the assistance is available. When queried regarding cameras in the dining room or witnesses to the event of R#901 obtaining the coffee, the NHA stated, There are no cameras. No other staff saw anything when it happened. A review of R#901's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was initially admitted into the facility 6/6/19 and most recently re-admitted on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was severely cognitively impaired and required extensive assistance from staff for mobility, transfers, dressing, eating, and hygiene. A review of R#904's MDS assessment dated [DATE] revealed the resident was initially admitted into the facility on [DATE] and most recently re-admitted on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident was moderately cognitively impaired and required set-up to limited assistance from staff for eating, hygiene, transfers and mobility. A review of the facility policy titled, Hot Liquids and Foods, dated 4/2015, revealed, .The facility will provide supervision to residents who receive hot food and beverages in an attempt to prevent hot liquid/food spills which may result in burns. The following are suggestions for ways to prevent accidental spills: Supervise the area .prepour beverages whenever possible, into drinking cups with lids; Remember insulated mugs and foam cups keep beverages hotter longer .Explain to the resident a hot liquid is being served and place the beverage in the resident's field of vision; Beverages served directly from the coffee urn will be hotter than when served from a carafe and beverages cool faster when uncovered .When serving hot liquids or foods to residents with dementia and behaviors or medical conditions that put them at risk for spills the following will be observed: Evaluate the resident's ability to manage beverages; this includes nursing staff understanding the resident's limitations mentally and physically before leaving the resident in charge of the hot liquid/food .If heating and brewing equipment are located in areas accessible to residents, the following will be observed: Supervise the area, Place protective heat shield around equipment or lock equipment when not in use .Skin on the arms and legs, being less sensitive than the mouth, can suffer a burn before the danger is realized. Clothing may hold a hot spill against the skin which increases the risk for injury. The elderly are more susceptible [MEDICAL CONDITION] younger residents, particularly those who are immobilized in a wheelchair. Removal Plan: Element #1: Resident identified to be affected by the alleged deficient practice. Resident #901 remains a resident of the facility. Resident was initially admitted on [DATE]. Resident was admitted on a po diet. In July of 2019, she had a PEG inserted and was on tube feedings along with a po diet. She was a 1:1 assist with feeding. On 2/24, Resident #901 was taken to the dining room for lunch and was seated at the table with no tray or beverages in front of her. Her table mate gave her a cup of coffee with the lid on it. Resident #901 removed the lid, spilled the coffee and received a burn to her thigh. Resident #901 was assessed and sent to Hospital for evaluation and returned to the facility on the same day. A Hot Liquid assessment for resident #901 has been completed on 3/11/20. Element #2: Residents with the potential to be affected by the alleged deficient practice. On 3/11/20, 137 residents received a hot liquid assessment. 47 residents were identified to be at risk for hot liquids. Care Plans and Kardex's were updated with feeding assistance requirements and hot liquid requirements after the assessments were completed. New admissions will be assessed for hot liquids on an ongoing basis. Element #3: Systemic Measures. 15/47 Licensed nurses were reeducated on 3/11/20 on the importance of following feeding assistance requirements and hot liquid requirements. 32 Licensed nurses will be reeducated prior to their next shift of duty. 24/ 66 CNA's were re-educated on 3/11/20 on the importance of following feeding assistance requirements and hot liquid requirements. 42/66 will be reeducated before they return to work for their next shift of duty. 12/21 Dietary staff members were re-educated that coffee must be served at the proper temperature and cannot go out of the kitchen higher than 150 degrees. 9 Dietary staff members will be reeducated prior to the start of their next shift of duty. Resident tray tickets now reflect feeding assistance required and hot liquid precautions. At risk residents will be supervised by licensed staff during meal time. Element #4: Quality Assurance. An Ad Hoc QA Committee meeting was held on 3/11/20 with the Medical Director and IDT to discuss the deficient practice and plan to ensure compliance. The DON/Designee will conduct audits to ensure that hot liquid assessments are completed as required; care plans and kardexes are updated with feeding assistance requirements and hot liquid requirements; coffee is being served at the appropriate temperature and tray tickets reflect proper feeding assistance requirements and hot liquid requirements weekly x4, monthly x3. Results of the audits will be taken to the QA committee for review and recommendation. Any areas of non-compliance will be addressed immediately. Element #5: The Administrator is responsible for sustained compliance.

Based on observation, interview and record review the facility failed to consistently implement and/or modify interventions that were consistent with resident's needs and identify risk factors that could prevent the development of an unstageable pressure ulcer (obscured full-thickness skin and tissue loss) for sampled resident (#705); and provide appropriate care to prevent the development of bilateral heels ulcers for sampled resident (#712) from seven residents all observed for pressure ulcers from a total of 14 sampled resident's. This resulted in delayed healing and the worsening of an existing pressure sore for Resident #705 and the potential for the development of pressure sores for Resident 712. Findings include: On 10/04/2016 at 8:50 a.m., The Unit Manager, A was queried if the facility had any facility acquired pressure ulcers. Unit manager A responded, Yes. and identified resident #705. During the initial tour, resident #705 was observed lying on her left side, repetitively yelling out loud as through she was in pain. A pillow was observed positioned away from her torso on the bed and appeared to been placed so as to position resident, however, it was not doing so. Resident #705's feet and knees were directly on the surface of her bed. The resident did not answer when questioned how she was doing, her eyes remained closed. On 10/05/16 at 8:00 a.m., a review of the clinical record revealed that resident #705 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #705's cognition was moderately impaired, required extensive physical assistance from staff for all activities of daily living including turning and repositioning in her bed. The Braden Scale (an assessment tool used to predict the risk of pressure ulcer (PU) development) indicated that Resident #705 was at risk for the development of PU. The physician's documentation, dated September 15, 2016 documented the following concerning resident #705: This is an initial consult .Appears quite frail and has multiple medical comorbidity's with limited cognition with limited mobilities and incontinent with recent weight loss over the past month or so ago. This wound has had a fast decline. The open wound measures 8 centimeters (cm) in length by 4 cm in width with a depth unable to be determined. Wound base has a 100% dark gray necrotic tissue with boggy center with surrounding [DIAGNOSES REDACTED] and mild excoriation with slight malodor. This wound will be treated for [REDACTED]. Resident should be turning and off loading per protocol and avoid positioning to the right hip . The nursing documentation dated from the first Admission Note dated 7/27/16 to 9/14/16, did not have documentation that supported any skin issues or changes until the discovery of an unstageable pressure ulcer to the right hip. Documentation did not identify any changes in the unstageable pressure ulcer, such as whether becoming larger or smaller and or any measurements. Additionally, the Interdisciplinary Team's documentation did not reveal any concerns such as favoring one side or the other, or any non-compliance with care. The following nursing documentation, which included documentation after the wound discovery, dated 9/15/16 revealed the following: 8/30/16, resists care at times, AEB (as evidenced by) swinging at staff, (no change in care plan about non-compliance was documented), 9/14/16, resident prefers to stay in bed, 9/15/16 , resident doesn't want to get out of bed, just wants to sleep all day, resists care, will refuse to have brief changed or eat. Will be repositioned and she will then roll self back to rt (right) side as this is her favorite side, pain to back and hips on scheduled pain med. '3' (pain scale used from 1-10, 10 being the worse type of pain) Identified infection to the right hip, wound reddened with purulent drainage. Further documentation revealed; 9/16/16 open pressure sore on right hip, 9/17/16 open area on right hip, 9/18/16 right hip received [MEDICATION NAME] for pain. The first wound care documentation dated 9/19/16, Wound/skin Healing Record by the facility's wound care nurse, time 2:46 PM documented, right trochanter hip Pressure 8.0 by 4.0 depth UTD (unable to determine) stage unstageable. Date of onset 9/15/16, no tunneling. Wound bed pink/beefy red and black/brown eschar, surrounding skin is normal for skin. Further documentation concerning any measurements completed were done as follows: 9/26/16 Right trochanter hip, type of sore, pressure 5.0 x 4.0 UTD unstageable serosanguineous moderate no odor, wound bed had slough black/brown eschar surrounding skin color bight red, normal skin progress is improved. Treatment changed care plan updated no pain. 9/27/16, Wound Skin Healing Record no measurements, 9/30/16 at 10:18, Right trochanter pressure 6.0 by 6.0 UTD unstageable last note on 10/3/16 head to toe, Right trochanter hip, open wound (no measurements). No information provided as to if physician notified, or staff notified. Wound was starting to become larger. 9/22/16 Pain right hip, appetite poor. Infection: Just finished antibiotics for wound on right hip. On 10/05/16 at 11:02 a.m., at 1:30 p.m., and again at 2:00 p.m., resident #705 was observed lying on her right side hip. The facility's staff/Certified Nursing Assistant (CENA) B who was in resident # 705's room during the second observation, reported that she had just placed the resident in her bed (on her right side). The last observation, with unit manager A observed the resident lying in her bed on her right side. When unit manager A was queried if the resident was supposed to be lying on her right side?, stated, I don't know, I don't think so. When unit manager A was told that CENA B had placed the resident in her bed on her right side could offered no response. On 10/05/16 at 3:53 p.m., an observation of # 705's wound care was completed. Wound care nurse, C was observed providing wound care and was queried concerning the development of the 'unstageable pressure ulcer.' Nurse C explained we observed a pink dressing with no date on her right hip and no one would own up to who put it there. I know, we own the development of that wound. Observation of wound care revealed the following: Resident was compliant with care and was not exhibiting resisting care by swating at staff. Wound is large with surrounding skin red, the center was beige with what appears to be tunneling. Sanguineous drainage was observed with strong malodorous smell and measured 6.2 centimeters (cm) by 5.2 cm with slough (non viable tissue) and a hole that looked like a tunnel. On 10/06/16 at 10:00 a.m., review of resident # 705's care plans revealed the following: Initiated on 9/16/16 and revised on dated 9/19/16 titled, Breakdown/pressure ulcers or further breakdown related to decreased mobility, incontinence, with the following interventions: Turn/reposition resident at least every two hours, more often as needed or requested, Follow facility's protocols for the prevention/treatment of [REDACTED]. The Initial care plan dated 7/26/16 titled, Resident is at risk for skin breakdown/pressure ulcers related to decreased mobility and bowel and bladder incontinence, revealed interventions that included to inform resident/family/caregivers of any new area of skin breakdown. Review of the facility's CENA care guide, not dated, revealed under the 'Resident Care' section, to avoid positioning resident on her right side. The facility provided a Plan of Correction, date of report, 9/20/16, with completion of plan of correction date of, 9/18/16, revealed a description of Deficient Practice (why and how did it happen): Upon performing weekly head to toe skin check, pressure injury was noted on hip. The previous weeks' head to toe skin check revealed that skin was intact. On Friday 9/15/16, resident was noted to have a new pressure injury with an Allevyn dressing on it undated and unsigned. Further documentation: 'Plan of Correction:' Chart reviewed. Care Plan updated. Resident at Risk note documented .In - depth analysis of how the deficiency occurred. Resident was noted to have new pressure injury noted on 9/15/16 with an Allevyn dressing on it with no date and no initials. Investigation did not reveal the source of application of the Allevyn. Resident had a weekly head to toe the week before with no skin issues identified and the following Thursday a new injury was noted. Resident is non-compliant with care. 'Corrective Action taken for resident affected:' Treatment ordered; resident seen by wound NP (nurse practitioner) . On 10/06/16 at 8:47 a.m., Unit manager A was queried what was the facility doing to prevent the development and prevention of the unstageable pressure ulcer if she favored her right side? An answer was not be provided. On 10/06/16 at 10:00 a.m., The Director of Nursing (DON) was queried regarding the nursing and physician documentation. When queried, what did you do to address these concerns or modify the care plan once they were identified: 1. not cooperating with care or resistive with her care and was swatting at staff and 2. she favored her right side. Where in the Past Non-Compliance were those concerns addressed? Additionally, What did she do about these identified areas within the plan of correction (POC), i.e., any observations? An answer could not be provided. Information within the POC had education that included using a Communication Board as a tool to inform staff members of significant events . When queried regarding the observation of positioning resident on her right side, the DON stated, I just heard about that. When queried regarding how do you ensure that staff are following the directives, did they make any observations so as to identify if positioning resident #705 was a concern or if the need to modify care plans regarding these concerns were necessary? An answer was not be provided. As to following the physician's guidelines, documented in the physician's progress note on 9/18/16, that being not to place the resident on her right side, the DON was unaware of the physician's documentation. On 10/06/16 at 4:00 p.m., a review of the facility's policy titled, Skin Management dated, 5/2010 and revised on 8/2016 revealed, It is the policy of the facility that a resident does not develop pressure injury unless clinically unavoidable. Overview: Residents with wounds and or pressure injury and those at risk for skin compromise are identified, assessed and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. Further revealed, 6. The interdisciplinary team considers whether the resident exhibits conditions or is receiving treatments that may place the resident at higher risk of developing pressure injury or complicate their treatment. Such conditions may include: Resident refusal of some aspect of care or treatment. 9. The licensed nurse will monitor, evaluate and document changes regarding skin condition (to include: dressing, surrounding skin, possible complications and pain) in the medical record and 16. A resident at risk meeting will be conducted weekly by the Interdisciplinary Team (IDT). During the meeting, the IDT will evaluate resident skin changes, review treatment modalities, interventions and will make recommendations as needed. Care plans and resident kardex will be updated accordingly. Residents reviewed for skin alterations are as follows: Newly developed .pressure injuries, any pressure areas that has shown no signs of healing within a two to three week time frame, 17. The DON/designee will document any changes in the care plan kardex at the meeting. ( ) Resident #712 On 10/04/16 at 2:03 p.m., 3:22 p.m., 5:28 p.m., and on 10/05/16 at 7:22 a.m., 9:19 a.m., 11:12 a.m., 4:24 p.m., and on 10/06/16 at 10:27 a.m., and 10:43 a.m., resident #712 was observed in bed with a pillow under the lower legs, both heels were resting on the bed surface. On 10/06/16 at 10:43 a.m., resident #712 was observed with nurse 'D'. The sheet that covered the lower extremities was pulled back and revealed both heels of resident #712 were resting on the bed surface. Nurse 'D' was asked to check if the heels were off the bed surface and demonstrated a hand could not pass under the heels. Nurse 'D' was queried if the heels should be floated off the bed and stated, Yes. The heels were observed to be reddened and soft and blanched to white when pressed on by nurse 'D'. On 10/06/16 at 11:00 a.m., the wound care nurse was queried about the need to float the heels of resident #712 and indicated they should be floated. The wound nurse further indicated the spouse comes in and moves the pillows around. The spouse was observed to be in the room only once during the survey on 10/05/16 at 11:15 a.m. On 10/06/16 at 1:30 p.m., a review of the medical record for resident #712 revealed: Resident #712 was admitted into the facility in March of 2013 and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS (minimum data set) assessment dated [DATE] indicated resident #712 had impaired cognition, and required total assist of one to two persons for bed mobility, transfer, walking, dressing, eating, hygiene, bathing and bowel and bladder care. The resident nursing care plan Has multiple high risk factors that put at risk for unavoidable skin breakdown revised 09/27/16, revealed change position every two hours and as needed, float heels while in bed. The Is dependant on staff for activities, cognitive stimulation, social interaction care plan dated 08/24/16 revealed, pillows under B/L (bilateral) heels to float heels, turn and reposition frequently. On 10/06/16 at 3:18 p.m., the DON (Director of Nursing) was queried if the expectation that when the heels are floated on a pillow they should be off the bed and stated, Yes. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO REPOSITION ONE (# 805) SAMPLED RESIDENT OUT OF FOUR RESIDENTS REVIEWED FOR PRESSURE ULCERS, FROM A TOTAL SAMPLE OF 16 RESIDENTS, EVERY TWO HOURS, RESULTING IN THE DEVELOPMENT OF A NEW PRESSURE SORE, PROLONGED HEALING AND THE POTENTIAL FOR INFECTION. FINDINGS INCLUDE: ON 4/26/11 AT 10 A.M., OBSERVATION OF THE " PEACH " UNIT REVEALED THAT RESIDENT # 805 WAS LYING IN BED ON HER BACK WITH A PILLOW UNDER HER LEFT TORSO AND WAS RECEIVING NOURISHMENT VIA TUBE FEEDING. AT 12:45 P.M., RESIDENT #805 WAS STILL LYING ON HER BACK. AT 1:05 P.M. RESIDENT # 805 WAS REPOSITIONED. ON 4/26/11 AT 11 A.M., REVIEW OF RESIDENT #805 ' S MINIMUM DATA SET (MDS) dated , 12/22/10 INDICATED THAT THE RESIDENT HAD ONE STAGE THREE PRESSURE ULCER ON THE COCCYX THAT MEASURED 2.8 CENTIMETERS (CM) LONG BY 2.8 CM WIDE BY 0.5 CM DEPTH. THE QUARTERLY MDS assessment dated [DATE] INDICATED THAT THE RESIDENT HAD TWO STAGE THREE PRESSURE ULCERS. THE LARGEST OF WHICH, ACCORDING TO THE MDS, WAS 5.8 CM LONG BY 4.8 CM WIDE BY 1.0 CM DEPTH. ACCORDING TO THE MDS, RESIDENT #805 WAS COMPLETELY DEPENDENT ON STAFF FOR MOVEMENT AND REPOSITIONING. THE RESIDENT'S FACE SHEET INDICATED [DIAGNOSES REDACTED]. RESIDENT #805'S NURSING COMPREHENSIVE assessment dated , 12/30/11 IDENTIFIED THE RESIDENT AT HIGH RISK FOR PRESSURE ULCERS. ON 4/27/11 AT 11:10 A.M., 1:10 PM, 2:00 PM AND 3:10 PM, RESIDENT #805 WAS OBSERVED LYING IN THE SAME POSITION IN BED WITH A PILLOW UNDER LEFT TORSO. AT 3:10 WOUND CARE NURSE # "I" PERFORMED DRESSING CHANGES ON THE RESIDENT' S PRESSURE ULCERS. AT THIS TIME, RESIDENT # 805 HAD LOOSE LIQUID STOOL IN HER BRIEFS AND THE PRESSURE ULCER DRESSING ON HER COCCYX WAS SOILED WITH FECES. ON 4/2711 AT 2:15 P.M., REVIEW OF THE NURSE PRACTITIONER PRESSURE ULCERS NOTES INDICATED THAT ON 2/8/11 THE RESIDENT HAD ONE STAGE THREE PRESSURE ULCER ON THE COCCYX MEASURING 3.5 CM X 2.5 CM X 0.5 CM. THESE NOTES ALSO INDICATED THAT THE RESIDENT ' S FOLEY CATHETER, " OFTEN LEAKS " AND RESIDENT HAS, " NUMEROUS LIQUID STOOLS ." THE WOUND CARE NOTE DATED, 2/15/11 INDICATED ONE STAGE THREE PRESSURE ULCER TO THE COCCYX MEASURING 3.2 CM X 2.5 CM X 0.5 CM. THIS NOTE ALSO NOTED THAT THE FOLEY CATHETER OCCASIONALLY LEAKS AND RESIDENT IS INCONTINENT OF STOOL WITH CONTAMINATION TO THE WOUND. THE NURSE PRACTITIONER NOTE DATED, 2/25/11 INDICATED THAT THE RESIDENT HAD A STAGE THREE PRESSURE ULCER ON THE COCCYX MEASURING 3.1 CM X 3.5 CM X 0.5 CM AND AN OPEN AREA ON RIGHT BUTTOCKS MEASURING 3.1 CM X 6.5 CM WITH A CENTRAL INDETERMINABLE DEPTH. IT WAS RECOMMENDED BY THE NURSE PRACTITIONER THAT THE RESIDENT BE PLACED IN A LARGER BED WITH A BARIATRIC MATTRESS. THE WOUND CARE NOTE DATED, 3/18/11 INDICATED THAT THE RESIDENT'S COCCYX PRESSURE ULCER MEASURED 4.0 CM X 2.8 CM X 3.2 CM AND THE PRESSURE ULCER ON THE RIGHT BUTTOCKS MEASURED 6.1 CM X 3.9 CM, " WITH BASE THAT RUNS FROM 0.2 CM TO UNDETERMINABLE AT DEEPEST LEVEL." ALL WOUND CARE NOTES PREVIOUSLY MENTIONED INDICATED THAT RESIDENT #805 WAS RECEIVING ADEQUATE NUTRITION FOR WOUNDS HEALING. REVIEW OF THE INITIAL CARE PLAN DATED, 3/12/11 AND THE INTERDISCIPLINARY CARE PLAN DATED, 4/26/11 BOTH INDICATED THAT THE RESIDENT WAS TO BE REPOSITIONED EVERY TWO HOURS AND AS NEEDED DUE TO THE RESIDENT BEING AT HIGH RISK FOR SKIN BREAKDOWN. THERE WERE NO DOCUMENTED EVIDENCE THAT RESIDENT # 805 WAS REPOSITIONED EVERY TWO HOURS. ON 4/28/11 AT 1:15 P.M., THE DIRECTOR OF NURSING (DON) WAS INTERVIEWED REGARDING REPOSITIONING AND FOLEY LEAKAGE OF RESIDENT # 805. NO VERBAL EXPLANATION WAS OFFERED. ( / )

BASED ON OBSERVATIONS, INTERVIEWS AND RECORDS REVIEW, THE FACILITY FAILED TO ENSURE THAT 4 OF 4 SAMPLED RESIDENTS (#101, #102, #103 AND #104), RECEIVED THE SUPERVISION AND ASSISTIVE DEVICES NECESSARY TO PREVENT INJURY, RESULTING IN RESIDENT #101 SUSTAINING FACIAL BRUISING AND SHOULDER PAIN, RESIDENT #102 AND RESIDENT #103 WITH THE POTENTIAL FOR FUTURE FALLS WITH INJURY AND RESIDENT #104 WITH A CLOSED HIP FRACTURE REQUIRING SURGICAL INTERVENTION AND THERAPY. FINDINGS INCLUDE: RESIDENT #101: ACCORDING TO THE FACE SHEET DATED 02/27/2010, RESIDENT #101 WAS AN [AGE] year-OLD-FEMALE LIVING AT THE FACILITY SINCE 05/05/2010. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #101 WAS INDEPENDENT IN HER DECISION MAKING WITH NO MEMORY LOSS. SHE REQUIRED PHYSICAL SUPPORT TO BALANCE WHILE SEATED. RESIDENT #101 COULD NOT WALK AND WAS DEPENDENT ON TWO STAFF MEMBERS FOR ALL TRANSFERS. ACCORDING TO THE FALL ASSESSMENT COMPLETED ON 02/05/2010, STAFF ASSESSED RESIDENT #101 "AT RISK" FOR FALLS. STAFF DEVELOPED A CARE PLAN DATED 02/16/2010 REQUIRING STAFF TO "ASSIST WITH ALL TRANSFERS". ACCORDING TO PHYSICIAN ORDERS [REDACTED]. THE PHYSICAL DEVICE ASSESSMENT SHEET DATED 03/02/2010, ESTABLISHED THAT THE WHEELCHAIR AND LAP TRAY PROVIDED RESIDENT #101 WITH THE NECESSARY PHYSICAL SUPPORT REQUIRED TO ACCOMMODATE HER "LEANING AND/OR RIGIDITY ", UNSTEADINESS, WEAKNESS AND IMMOBILITY, THREATENING HER SAFETY DUE TO HER INABILITY TO BALANCE. ACCORDING TO PHYSICAL THERAPY NOTES DATED 06/28/2010, RESIDENT #101 SUFFERED A STROKE THAT LEFT HER WITH LEFT SIDED FLACCIDITY (LIMPNESS). THERAPIES ASSESSMENT REQUIRED STAFF TO PROVIDE MAXIMUM ASSISTANCE WITH ALL OF HER TRANSFERS. ACCORDING TO FACILITY POLICY AND PROCEDURE FOR "SAFETY-GENERAL GUIDELINES FOR RESIDENT SAFETY" DATED 05/2010, STAFF ARE TO "SUPPORT THE RESIDENT'S BODY WELL DURING ALL ...TRANSFERRING "AND" ENSURE ALL SAFETY DEVICES ARE IN PLACE AT ALL TIMES ... (INCLUDING) TABLE TOPS". ON 10/06/2010 AT 1:50 P.M., EMPLOYEE " F " STATED THAT SHE KNEW ON 09/14/2010 THAT RESIDENT #101 REQUIRED ASSISTANCE WITH ALL OF HER TRANSFERS, BUT STATED SHE LEFT RESIDENT #101 SITTING ALONE ON THE EDGE OF HER BED, WITHOUT ANY ASSISTIVE DEVICES. SHE ESTABLISHED THAT THIS RESULTED IN RESIDENT #101 FALLING FROM THE BED TO THE FLOOR STRIKING HER LEFT ARM AND FACE. ON 10/06/2010 AT 2:15 P.M., RESIDENT #101 VERIFIED THE EVENTS EMPLOYEE "F" REPORTED FROM 09/14/2010 AROUND 6:00 P.M. RESIDENT #101 REPORTED THAT SHE SUFFERED FACIAL BRUISING AND LEFT SHOULDER PAIN FROM THE FALL. RESIDENT #101 REPORTED THAT STAFF IS NOT TO LEAVE HER ALONE ON THE EDGE OF HER BED BECAUSE SHE CANNOT BALANCE. ON 10/07/2010 AT 11:30, THE DIRECTOR OF NURSING REVIEWED THE MEDICAL RECORD AND CONFIRMED THAT EMPLOYEE " F " DID NOT MEET THE CARE NEEDS OR FACILITIES SAFETY POLICY WHEN TRANSFERRING RESIDENT #101 AT 6:00 P.M. ON 09/14/2010. SHE STATED THAT STAFF SHOULD NOT HAVE RESIDENT #101 ALONE ON THE EDGE OF HER BED. RESIDENT #102: ACCORDING TO THE FACE SHEET DATED 09/30/2010, RESIDENT #102 WAS A [AGE] year-OLD-MALE LIVING AT THE FACILITY SINCE 02/17/2010. HIS [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #102 HAD MODERATELY IMPAIRED DECISION MAKING WITH BOTH LONG AND SHORT-TERM MEMORY LOSS. RESIDENT #101 HAD FALLEN IN THE LAST THIRTY DAYS. HE REQUIRED STAFF TO PROVIDE HIM WITH EXTENSIVE ASSISTANCE FOR ALL TRANSFERS AND AMBULATION. ACCORDING TO A FALLS ASSESSMENT TOOL DATED 07/07/2010, STAFF ASSESSED RESIDENT #102 AT RISK FOR FALLS AND DEVELOPED A CARE PLAN. ACCORDING TO THE FALLS CARE PLAN DATED 10/06/2010, RESIDENT #102 ' S FALL RISK REQUIRED STAFF TO " ASSIST WITH ALL TRANSFERS AND AMBULATION " . ACCORDING TO PHYSICAL THERAPY NOTES DATED 07/08/2010, RESIDENT #102 REQUIRED STAFF TO ASSIST WITH ALL TRANSFERS AND AMBULATION. ACCORDING TO FACILITY POLICY AND PROCEDURE FOR " SAFETY-GENERAL GUIDELINES FOR RESIDENT SAFETY " DATED 05/2010, STAFF ARE TO " SUPPORT THE RESIDENT ' S BODY WELL DURING ALL POSITIONING, TRANSFERRING AND AMBULATION " . ACCORDING TO AN INCIDENT REPORT DATED 10/05/2010, RESIDENT #102 TRANSFERRED FROM HIS BED WITHOUT STAFF ASSISTANCE AT 1:00 A.M. AND fell TO THE FLOOR. STAFF DID NOT ASSIST WITH THIS TRANSFER. ON 10/07/2010 AT 11:30, THE DIRECTOR OF NURSING STATED RESIDENT #102 OFTEN TRANSFERS WITHOUT STAFF ASSISTANCE BUT SHE WAS NOT ABLE TO IDENTIFY ANY CARE PLAN MODIFICATIONS MADE BY STAFF, TO PREVENT FUTURE FALLS WITH INJURY. AN OBSERVATION ON 10/06/2010 AT 10:09 A.M. REVEALED THAT RESIDENT #102 fell OUT OF HIS WHEELCHAIR TO THE FLOOR WITH HIS WHEELCHAIR ALARM SOUNDING. THIS ALARM SOUNDED FOR TWO MINUTES WITH NO STAFF RESPONSE. WHEN THE FACILITIES BUSINESS OFFICE MANAGER RESPONDED TO THE ALARM FIRST, SHE STATED, "I WOULD DO SOMETHING BUT I CAN'T". SHE LEFT RESIDENT #102 ON THE FLOOR, WITHOUT ANY SUPERVISION. ON 10/07/2010 AT 11:30, THE DIRECTOR OF NURSING STATED STAFF FAILED TO PROVIDE ASSISTANCE FOR RESIDENT #102 DURING THIS TRANSFER. SHE COULD NOT EXPLAIN WHY STAFF TOOK TWO MINUTES TO RESPOND TO RESIDENT #102'S SAFETY ALARMS. SHE THEN STATED THAT SHE WAS SURPRISED WITH THE NUMBER OF FALLS RESIDENT #102 HAS SUSTAINED WITHOUT SUFFERING ANY SERIOUSLY INJURY "YET". RESIDENT #103: ACCORDING TO THE FACE SHEET DATED 07/12/2010, RESIDENT #103 WAS A [AGE] year-old-FEMALE LIVING AT THE FACILITY SINCE 01/24/2001. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM DATA SHEET DATED 07/17/2010, RESIDENT #103 HAD SOME DIFFICULTY MAKING DECISIONS IN NEW SITUATIONS WITH SOME SHORT-TERM MEMORY LOSS. SHE WAS COMPLETELY DEPENDENT ON STAFF TO PROVIDE HER WITH ALL TRANSFERS. ACCORDING TO A FALLS ASSESSMENT TOOL DATED 7/11/2010, STAFF ASSESSED RESIDENT #103 TO BE AT RISK FOR FALLS AND DEVELOPED A CARE PLAN ON 07/16/2010. TO MINIMIZE RESIDENT #103 ' S RISK FOR FALLS STAFF IS TO "ASSIST WITH ALL TRANSFERS". ACCORDING TO PHYSICAL THERAPY NOTES DATED 08/25/2010, RESIDENT #103 REQUIRED STAFF ASSISTANCE WITH ALL TRANSFERS. ACCORDING TO AN INCIDENT AND ACCIDENT REPORT DATED 09/03/2010, STAFF IDENTIFIED THAT RESIDENT #103 WAS RESTLESS IN BED, REQUIRING SUPERVISION. THE STAFF NURSE DISCONTINUED THE INCREASED LEVEL OF SUPERVISION TO COMPLETE A MEDICATION PASS, AT WHICH TIME THE RESIDENT fell FROM HER BED TO THE FLOOR. THERE WAS NO STAFF PRESENT FOR THIS TRANSFER. ON 10/07/2010 AT 11:30, THE DIRECTOR OF NURSING STATED STAFF WAS NOT PRESENT FOR THIS TRANSFER. RESIDENT #104: ACCORDING TO THE FACE SHEET DATED 03/16/2010, RESIDENT #104 WAS A [AGE] year-old-FEMALE LIVING AT THE FACILITY SINCE 10/29/2008. HER [DIAGNOSES REDACTED]. ACCORDING TO THE MINIMUM (MDS) data set [DATE], RESIDENT #104 HAD SOME DIFFICULTY IN NEW SITUATIONS WITH SOME SHORT-TERM MEMORY LOSS. SHE REQUIRED TWO STAFF MEMBERS TO PROVIDE EXTENSIVE ASSISTANCE WITH ALL TRANSFERS. SHE COULD NOT BALANCE WHILE STANDING, WITHOUT PHYSICAL ASSISTANCE AND SHE HAD A RECENT FALL. ACCORDING TO THE FALL ASSESSMENT TOOL DATED 05/05/2010, STAFF REASSESSED RESIDENT #104 WHO REMAINED AT RISK FOR FALLS. ACCORDING TO THE A CARE PLAN DATED 06/08/2010, STAFF IDENTIFIED THAT RESIDENT #104 SUFFERED DECREASED MOBILITY REQUIRING STAFF TO ASSIST WITH ALL OF HER TRANSFERS. ACCORDING TO AN INCIDENT AND ACCIDENT REPORT DATED 09/05/2010 AT 1:20 A.M., RESIDENT #104 fell IN ANOTHER RESIDENTS ROOM WHILE AMBULATING WITHOUT STAFF ASSISTANCE. ON 10/07/2010 AT 11:30, THE DIRECTOR OF NURSING STATED STAFF WAS NOT PRESENT FOR THIS TRANSFER. ACCORDING TO LOCAL HOSPITAL RECORDS AND READMISSION NOTES, RESIDENT #104 SUFFERED A RIGHT HIP FRACTURE REQUIRING SURGICAL INTERVENTION WHEN SHE fell on [DATE]. AN OBSERVATION ON 10/07/2010 AT 1:40 P.M. REVEALED THAT RESIDENT #104 SELF-TRANSFERRED FROM HER WHEELCHAIR ACTIVATING HER SENSOR ALARM. FOR THE NEXT SEVEN MINUTES, NO STAFF RESPONDED TO THE SOUNDING ALARM. WITHIN THOSE SEVEN MINUTES RESIDENT #104 SELF-TRANSFERRED IN AND OUT OF HER WHEELCHAIR TWO OTHER TIMES, TOILETED HERSELF, COMPLETED SELF-HYGIENE TASK AND RETURNED TO HER BEDROOM TO APPLY HER OWN CLOTHING BEFORE A STAFF MEMBER ARRIVED AT 1:47 P.M. RESIDENT #104 STATED THAT SHE OFTEN TRANSFERS AND AMBULATES WITHOUT STAFF ASSISTANCE BECAUSE THEY DO NOT RESPOND TO HER ALARM. RESIDENT #104'S ROOMMATE VERIFIED THAT RESIDENT #104 OFTEN TRANSFERS AND AMBULATES THROUGHOUT THE DAY AND NIGHT, COMPLETING ACTIVITIES OF DAILY LIVING BEFORE STAFF EVEN RESPOND TO THE SOUNDING ALARM.