Every finding on record at Regency Heights-Detroit

Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 06/30/2026 at 8:56 AM observed a yellow stain under the food storage rack in the dry storage room and black smear marks along the floor. In an interview with Dietary Manger (DM) T at this time, when asked about cleaning of floors, DM T indicated the floors are cleaned daily. On 06/30/2026 at 9:01 AM observed a plastic cutting board with frayed strands of plastic attached to the surface in one area. In an interview at this time, DM T acknowledged the affected area and indicated it looks like it was burnt.On 06/30/2026 at 9:09 AM observed four rolling containers lined with plastic bags containing flour, sugar, oats and rice. In an interview at this time, when asked about the bags used to store food, DM T indicated they use regular trash bags. On 06/30/2026 at 9:11 AM observed several floor tiles cracked and partially missing around the floor drain leaving uneven holes next to the three compartment sink. Further observation found two floor tiles missing and standing water pooled in the hole next to the dishwasher. In an interview at this time, DM T indicated the tiles are on a work order, and they are not sure when it was submitted. On 06/30/2026 at 9:19 AM observed brown buildup accumulated on the floor tiles and in the grout lines beneath the tray line service table. On 06/30/2026 at 9:20 AM in an interview, DM T indicated there is no cleaning schedule for the floors and they are cleaned every day three times a day. When asked if the area under equipment is cleaned, DM T indicated the staff go under equipment when cleaning. On 06/30/2026 at 9:22 AM observation of the clean utensil drawers found a spoon strainer with a piece of brown food debris on the back of the utensil. The top drawer was observed with sticky spots and crumbs present inside the drawer. A small spoon strainer was observed to have food debris on the surface. DM T confirmed the observation of the utensils. In an interview at this time, DM T indicated the drawers are cleaned out daily. On 06/30/2026 at 9:39 AM observed black spots scattered across the surface of the metal ceiling in the produce walk in cooler and along some areas on the wall. Further observation found black and green buildup on the cooler racks surface in the produce cooler. The cooler fans were observed with black spots on the fan cover and on the blades.On 06/30/2026 at 9:46 AM an interview with DM T was conducted regarding cleaning of the ice machine. DM T indicated maintenance cleans the ice machine, and they believe it is cleaned quarterly. When asked if dietary wipes down the surface, DM T indicated they will wipe down the surfaces. Observation of the ice machine found a brown streak on the drip tray on the inside of the ice machine.On 06/30/2026 at 9:48 AM observed brown and black soil accumulated on the floor tiles adjacent to the dish machine in the first floor ice machine room. In an interview with DM T at this time, DM T indicated staff sweep and mop the room. Further observation found bright green buildup on the surface of the drain line from the ice machine. On 06/30/2026 at 10:00 AM observed dried food debris accumulated on the upper surface of the microwave in the rehabilitation center pantry. DM T indicated it needs to be cleaned. On 06/30/2026 at 10:04 AM observed an opened box of cereal with a best day date of February 2024, an opened chip bag with a use by date of March 2026 in a cabinet of the rehabilitation center pantry. In an interview at this time, DM T indicated it is resident food. On 06/30/2026 at 10:08 AM observed the clear liner peeling along the inside edges of the ice machine in the second floor pantry. Further observation found brown debris caked on the upper surface of the microwave. DM T acknowledged and indicated they would have someone clean it. On 06/30/2026 at 10:12 AM observed the drain line from the ice machine lead into a pump and discharged into the drain line under the sink in the second floor pantry. The line terminated below the flood level rim creating an improper air gap. Further observation of the drain line found black buildup accumulated on the surface at the end of the drain line.On 06/30/2026 at 10:19 AM observed a nutrition drink with a best by date of April 2, 2026, in the third floor pantry refrigerator. On 06/30/2026 at 10:24 AM observed brown discoloration consistent with corrosion on the upper surface of the microwave and along the upper edges in the third floor pantry. On 06/30/2026 at 10:30 AM in an interview with DM T regarding the microwaves on the units, DM T indicated the microwaves on the floors are used for residents. On 06/30/2026 at 10:31 AM observed three outdoor waste receptacles with a side door open. In an interview at this time, DM T indicated the doors are not usually open. When asked who is responsible for cleaning the area, DM T indicated everyone is. Further observation found debris around the outside of the waste receptacles including carboard, plastic cups, straws, gloves, and a can.According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.According to the 2022 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment, (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened.According to the 2022 FDA Food Code section 4-101.11 Characteristics, Materials that are used in the construction of UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT may not allow the migration of deleterious substances or impart colors, odors, or tastes to FOOD and under normal use conditions shall be: P (A) Safe; P (B) Durable, CORROSION-RESISTANT, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated WAREWASHING; (D) Finished to have a SMOOTH, EASILY CLEANABLE surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.According to the 2022 FDA Food Code section 6-201.11 Floors, Walls, and Ceilings, Except as specified under S 6-201.14 and except for antislip floor coverings or applications that may be used for safety reasons, floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.According to the 2022 FDA Food Code section 5-202.13 Backflow Prevention, Air Gap, An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).According to the 2022 FDA Food Code section 5-501.15 Outside Receptacles, (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers.According to the 2022 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions, (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing.

Based on observation, interview, and record review, the facility failed to ensure appropriate personal protective equipment (PPE) was worn while providing care for one (R124) out of eight residents reviewed for infection control and prevention, and failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for spread of infection, and increased risk of waterborne pathogens to exist and spread among residents in the facility.Findings include: On 7/1/2026 at approximately 1:50 PM, R124's room door was observed open. R124 was seen from the hallway to be in their bed. A mechanical lift was observed in the room. A sign hung on R124's room door indicated that enhanced barrier precautions (the use of gloves and gown) were needed when assisting with transfers and providing direct care. Certified Nursing Assistant (CNA) E then enters the room and closes the door. At approximately 1:57 PM, CNA E opens the door and requests assistance from another staff member. The CNA is observed wearing only gloves. At approximately 2:00 PM, Licensed Practical Nurse (LPN) D is observed entering the room. LPN D does not don personal protective equipment (PPE) prior to entering the room. On 7/1/2026 approximately 2:12 PM, an interview with R124 was conducted. When queried about the care they had just received, R124 said the staff members assisted them out of bed and placed them in their wheelchair and changed their urinary catheter bag because it was full. When asked if the staff members wore gloves and gowns, R124 said they only wore gloves and no gowns. A review of R124's electronic health record was completed and revealed they originally admitted to the facility on [DATE] with diagnoses that included paraplegia, post-traumatic stress disorder, heart disease with heart failure, adjustment disorder, anxiety disorder, bipolar disorder, insomnia, colostomy status, type II diabetes, chronic pain syndrome, and neuromuscular dysfunction of the bladder. Section C of the Minimum Data Set (MDS) with an Assessment Reference Date of 5/3/2025 indicated R124 scored 15/15 on the Brief Interview for Mental Status questionnaire – indicative of no cognitive impairment. Section GG of the same MDS indicated R124 needed substantial to maximum assistance with bed mobility and was dependent on staff for most Activities of Daily Living. R124 had a physician order dated 5/25/2026 which read, Enhanced Barrier Precautions r/t (related to) wounds and s/p (suprapubic) catheter. R124's care plan revealed the following focus/problem created on 8/17/2022: (R124) is at risk for urinary tract infection and catheter-related trauma: has suprapubic Catheter (20Fr 10 ml balloon) r/t Neuromuscular dysfunction of bladder, hx (history) of recurrent UTIs (urinary tract infection) several instances/claims of S/P catheter leakage and demands S/P catheter replacement often. An intervention dated 10/10/2022 revealed the following: Enhanced Barrier Precautions in place. On 7/1/2026 at approximately 2:10 PM, LPN D was interviewed regarding the care provided to R124. LPN D said R124 was on enhanced barrier precautions related to their wounds, catheter, and colostomy and that the use of PPE (personal protective equipment) would be needed when providing direct care to the resident. LPN D said they were assisting the resident out of bed and changing their foley catheter bag. LPN D also said they only wore gloves and not a gown. When asked why it would be important to follow the precautions, LPN D said, to protect the patient and ourselves and help stop the spread of infection. On 7/1/2026 at approximately 2:20 PM, CNA E was interviewed regarding the care they had provided to R124. CNA E confirmed they did not wear a gown while providing direct care to R124 and said, I should have had a gown on. When asked how they know what type of precautions to use when providing care, CNA E said they would look at the room door signage. When asked why it would be important to follow the signage, CNA E stated, So I don't transfer anything from him to me and vice versa. On 7/2/2026 at approximately 8:30 AM, an interview with the facility Infection Preventionist (IP) B was conducted. IP B said it was their expectation that all staff follow the signage and physician orders for precautions and added that re-education was completed in June 2026 related to hand hygiene, enhanced barrier precautions, and personal protective equipment. On 7/2/2026 at approximately 10:15 AM, an interview with the Director of Nursing was conducted. The DON said it was their expectation that staff use proper PPE when providing care so to reduce the risk of infection among residents or infections spreading throughout the facility. A policy titled Enhanced Barrier Precautions dated 3/5/2025 was provided by the facility and revealed the following: Enhanced Barrier Precautions are indicated for residents with any of the following: .2) a wound or indwelling medical device. Further, the document revealed, Health care personnel caring for residents on Enhanced Barrier Precautions should wear gloves and gowns during high-contact resident care. Examples of high contact resident care activities requiring gown and glove use: Transferring; Device care or use; urinary catheter; Wound care. On 06/30/2026 at 2:42 PM observed a hopper with a shallow pool of light yellow, murky water in the basin in the first floor soiled utility room. In an interview at this time, when asked if the hopper is functional, Housekeeping and Laundry Supervisor (HLS) S indicated it is not working and has not worked since they had been here. Further observation found brown water coming from the hopper hot and cold water faucets when turned on. On 06/30/2026 at 2:44 PM observed the hand sink nonfunctional in the first floor soiled utility room. Further observation found brown discolored water coming from the eye wash station for several seconds before running clear. HLS S acknowledged the discolored water. On 06/30/2026 at 2:50 PM observed two wheelchairs in the walkway to a shower head and a box of foot pedals under the shower head in the first floor east shower room. The shower control handle was absent, and the shower could not be turned on. HLS S indicated that the shower does not work. On 06/30/2026 at 3:00 PM observed brown water coming from the hot and cold sink faucet in the first floor south shower room bathroom. HLS S acknowledged the discolored water. On 06/30/2026 at 3:08 PM observed a shallow pool of cloudy black grease filmed water in the hand sink basin in the second floor soiled utility room. A razer was observed near the drain, and the other compartment was observed with a brown wet substance coating the exit drain on the sink. The faucet was observed nonfunctional, indicating possible stagnant water in the line. On 06/30/2026 at 3:10 PM observed a hopper with a nonfunctional hose attachment in the second floor soiled utility room. [NAME] discolored water came from the hot and cold water fixture of the hopper when turned on. On 06/30/2026 at 3:16 PM observed the shower control handle absent and the shower unable to be turned on in the second floor east shower room. On 06/30/2026 at 3:33 PM observed a hopper with a plastic bag covering the bowl in the third floor soiled utility room. HLS S indicated the hopper was not working, and they covered it up. A very shallow pool of dark brown water was observed in the hopper basin and the spray hose was submerged. The hot cold and flush apparatus were nonfunctional. On 06/30/2026 at 3:34 PM observed a nonfunctional water fixture in the third floor soiled utility room indicating possible stagnant water in the line. On 06/30/2026 at 3:37 PM observed two wheelchairs in the walkway to the shower head in the third floor east shower room. The shower control handle was absent, and the shower could not be turned on. On 06/30/2026 at 3:58 PM observed the sink water faucet off in the rehabilitation center soiled utility room. Further observation found the hopper spray hose off. HLS S indicated the hopper is not used. On 06/30/2026 at 4:02 PM observed a therapy tub connected to the water lines in the first floor rehabilitation center shower room. The tub was observed nonfunctional. HLS S indicated the therapy tub is not used and has not been used. On 07/01/2026 at 11:09 AM observed a plastic bag covering the basin of a water fixture in the dental office. On 07/01/2026 at 3:37 PM an interview with Maintenance Director (MD) C was conducted regarding water management. When asked about control measures to reduce the risk of legionella, MD C stated they flush low use fixtures and take hot water temperatures. When asked what fixtures are flushed, MD C indicated they flush boilers and the water system on the first floor to move water from the top down. When asked about hot water temperatures, MD C indicated they look for the water to be between 110 and 115 degrees F. MD C indicated they take total chlorine samples, and try to flush eyewash stations monthly. When asked about the hoppers on the units, MD C indicated the second and third floor hoppers are under repair and they press the flush apparatus on the hopper in the rehabilitation center but do not turn on the water. When asked about the water turned off to fixtures in shower and utility rooms, MD C indicated they were not aware of the fixtures. When asked about the therapy tub in the rehabilitation center, MD C stated they do not use it. Record review of the facility provided document titled Water Management Program last revised 2/1/2024, includes activities that are performed in a water management program including, Identify areas where Legionella could grow and spread. The policy continues by listing principles of an effective plan, Preventing water stagnation. Record review of the facility provided document online work order includes steps for flushing low flow fixtures, 1. Run water for a minimum of 3 minutes on all plumbing fixtures that do not get used regularly. Examples of this would be rooms off line, storage areas, mechanical rooms, ect. According to the Centers for Disease Control and Prevention, Controlling Legionella in Potable Water Systems dated January 3rd, 2025, Flush low-flow piping runs and dead legs at least weekly. Flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as needed to maintain water quality parameters within control limits. Eliminate dead legs, which are sections of no- or low-water flow.

Based on observation, and interview, the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 06/30/2026 at 2:39 PM observed drywall cracked with a visible hole in the wall in the laundry room storage room. In an interview at this time, Housekeeping and Laundry Supervisor (HLS) S indicated someone probably ran into the wall, and it had been in that condition for a while. On 06/30/2026 at 2:45 PM observed a janitor sink with a chemical pre-dispensing system in place and the water on in the first floor janitor closet. This set up puts undue back pressure on the faucet's Atmospheric Vacuum Breaker (AVB), which can compromise the integrity of the mechanism. In an interview at this time, when asked if the water is always on, HLS S indicated at the end of the day, the last person turns off the water. On 06/30/2026 at 2:48 PM observed a vertical support beam attached to the supply shelf broken halfway with splintered wood on the surface of the beam in the first floor clean linen room. On 06/30/2026 at 2:53 PM an interview with HLS S was conducted regarding cleaning of the shower room. HLS S indicated housekeeping staff clean the shower rooms twice a day or as needed, and Certified Nursing Assistant (CNAs) are responsible for cleaning equipment. On 06/30/2026 at 2:58 PM observed an approximate one by one foot hole in the wall with a cover board partially covering the damaged area in the first floor south shower room. On 06/30/2026 at 3:02 PM observed a large toilet seat with chipped paint marks on the exterior surface, paint peeling on the interior surface and a brown rust colored ring around the water level. HLS S indicated they would have someone come clean it like it is being used. On 06/30/2026 at 3:07 PM observed a janitor sink with a chemical pre-dispensing system in place and the water on in the second floor janitors closet putting undo backpressure on the faucet's AVB. Further observation found a large portion of the bottom of the wall in the janitor sink with cement cracked and the surface uneven and no longer smooth. On 06/30/2026 at 3:08 PM observed a shallow pool of black water with grease residue in the hand sink basin in the second floor soiled utility room. A razer was observed near the drain with brown debris scattered in the basins, and the second sink compartment was observed with a brown wet substance coating the exit drain on the sink.On 06/30/2026 at 3:15 PM observed areas of laminate chipped and peeling at the hand sink table in the second floor east shower room. Further observation of the adjacent supply closet found sections of missing and cracked paint along with a large brown rust colored area on the shelf where equipment was stored. Additional brown discoloration was observed throughout the metal shelving. On 06/30/2026 at 3:18 PM observed a wall tile missing at the lower shower entry frame in the second floor east shower room. The shower drain in the rear stall was observed to be loose and not connected, and only two out of four lights functional making the stall dimly lit. Further observation found the shower bed mat with creases and tears exposing the foam material. HLS S indicated they would get it changed out for a newer one. An unpleasant odor was present when lifting the mat and debris was observed collected in the shower bed netting. On 06/30/2026 at 3:22 PM observed the ceiling paint peeling and flaking in one of the shower stalls and adjacent ceiling in the second floor south shower room. [NAME] paint flakes were observed on the ground beneath the affected area. Further observation of the room found a section of uneven plaster on the ceiling and circular black spots of buildup on the surface. The lower wall tiles near the entrance next to the shower room were observed to have multiple broken tiles leaving sharp exposed edges and a connecting metal piece broken off leaving a jagged edge. The floor drain in one shower stall was uneven with cement around the edges and matted debris accumulated in the drain.On 06/30/2026 at 3:31 PM observed a janitor sink with a chemical pre-dispensing system in place and the water on in the third floor janitors closet putting undo backpressure on the faucet's AVB.On 06/30/2026 at 3:34 PM observed the hand sink off with white residue coating the surface of the two basins and green mineral buildup at the drain in the third floor soiled utility room.On 06/30/2026 at 3:35 PM observed the double doors to the utility rooms on the third floor chipped along the inside edge with paint and laminate peeling. On 06/30/2026 at 3:38 PM observed the bathroom hand sink release only a trickle of water from the hot and cold faucets when turned on, and the faucet loose to mount and able to move around in the third floor east shower room. Further observation found yellow residue build up on the lower portion of the shower room tiles caulking. HLS S indicated they saw it and would have it cleaned. On 06/30/2026 at 3:40 PM observed areas of laminate chipped and peeling at the hand sink table exposing underlying wood in the third floor south shower room. On 06/30/2026 at 3:45 PM observed the wall adjacent to the ceiling with an approximate two by two foot area of white plaster present on the brown, orange wall in the third floor south shower room. Black buildup was observed accumulated on the wall surface and ceiling around the plastered area.On 06/30/2026 at 3:49 PM observed a dried brown streak originating from the wall opening where the shower head exits in the third floor east shower room. HLS S acknowledged the brown streak. A gap was also observed between the wall and the water fixture at the point where it exits the wall. Further observation found multiple cracked tiles upon entry of the room leaving sharp edges.On 06/30/2026 at 3:57 PM observed a janitor sink with a chemical pre-dispensing system in place and the water on in the first floor rehabilitation center creating undo backpressure on the faucet's AVB.On 07/01/2026 at 10:22 AM observed a wooden bench worn with the finish faded in multiple areas leaving a rough and uneven texture in the second floor east shower room. On 07/01/2026 at 10:38 AM observed the third floor community room with the wall plaster peeling from the surface and the baseboard separating from the wall along the corner of the entrance. On 07/01/2026 at 10:56 AM observed peeling wallpaper along the edge of the wall in the communal third floor south room.On 07/01/2026 at 11:06 AM observed white mineral buildup on the inside spray hose nozzle at the sink in the beauty shop.On 07/01/2026 at 12:46 PM observed two ceiling air vents and the surrounding ceiling tiles soiled with black particulate buildup in the second floor east hall.On 07/01/2026 at 12:48 PM observed several wall tiles with missing supportive adhesive under the sink in resident room [ROOM NUMBER]. The tiles appeared loose and unstable, one tile was observed missing near the sink drain line exposing a section of internal wall structure.On 07/01/2026 at 1:14 PM observed multiple ceiling air vents and the surrounding tiles with black particulate buildup in the first floor north hall.On 07/01/2026 at 1:16 PM observed an approximate one foot of the baseboard torn and missing next to resident room [ROOM NUMBER] in the second floor east hall.On 07/01/2026 at 1:24 PM an interview was conducted with HLS S. When asked about facility repairs, HLS S indicated maintenance requests can be submitted on an online request and housekeeping staff can be assisted by other staff. When asked about cleaning of air vents, HLS S indicated maintenance is responsible for cleaning air vents.On 07/01/2026 at 4:05 PM an interview was conducted with Maintenance Director (MD) C. When asked who is responsible for cleaning air vents, MD C indicated maintenance dusts off the air vents and that they are due. When asked if they do a daily walk through of the facility, MD C indicated they do a walk through daily.

Based on observation, interview, and record review, the facility failed to provide an appropriately sized mattress for one (R124) of one resident reviewed for accommodation of needs resulting in resident dissatisfaction. Findings include:On 6/30/2026 at approximately 10:00 AM, R124 was interviewed in their room. R124 said they had concerns with the gap between the top of their mattress and the headboard of their bed. R124 then placed the bed in a flat position. An observation of the bed and mattress revealed an approximate 10-inch gap between the top edge of the mattress and the headboard when measured with a tape measure. R124 said they had communicated the concern to the facility but there had been no resolution. On 7/1/2026 at approximately 2:50 PM, a second observation of the mattress was made. A pillow was observed in between the gap lying flat. A review of R124's electronic health record was completed and revealed they originally admitted to the facility on [DATE] with diagnoses that included paraplegia, post-traumatic stress disorder, heart disease with heart failure, adjustment disorder, anxiety disorder, bipolar disorder, insomnia, colostomy status, type II diabetes, chronic pain syndrome, and neuromuscular dysfunction of the bladder. Section C of the Minimum Data Set (MDS) with an Assessment Reference Date of 5/3/2025 indicated R124 scored 15/15 on the Brief Interview for Mental Status questionnaire - indicative of no cognitive impairment. Section GG of the same MDS indicated R124 needed substantial to maximum assistance with bed mobility and was dependent on staff for most Activities of Daily Living. R124's care plan revealed they needed two-person assistance with turning and repositioning in bed, and that a trapeze and bilateral assist bars were installed to the bed frame to assist with increased mobility. Further record review revealed R124s current weight was 251 pounds and 5 feet 10 inches tall l as of 6/12/2026. On 7/2/2026 at approximately 8:10 AM, an interview was conducted with Licensed Practical Nurse (LPN) H. When asked who they would report bed or mattress safety concerns to, LPN H said they would report them to the maintenance department and unit manager. LPN H confirmed they were not aware of any resident bed or mattress concerns currently. On 7/2/2026 at approximately 8:55 AM, an interview was conducted with Unit Manager (UM) I. When asked what they would do if they were made aware of a bed or mattress concern, UM I said they would ensure the residents safety and notify the maintenance department. UM I confirmed they were not aware of any current bed or mattress concerns on their unit. When asked what type of safety concerns there would be for a mattress that does not fit a bed frame properly, UM I said that if the mattress is not the correct size it could lead to fall concerns or safe bed mobility. UM I then observed the gap between the mattress and headboard for R124 and said, That is a concern - I will contact maintenance.On 7/2/2026 at approximately 9:30 AM, Maintenance Director (MD) C was interviewed and asked about the facility's process for inspecting and monitoring mattresses and bed frames. MD C said they complete an audit every month. MD C further said that the nursing staff also notify their department of any concerns and they will respond. MD C then observed R124's bed frame and mattress and confirmed the gap was a concern and said, nursing should have gotten a wedge to fill the gap. When asked when R124's bed and mattress were last audited, MD C said they were not sure but would provide the audit sheets. On 7/2/2026 at approximately 10:00 AM, MD C provided an audit titled, Mattress Assessment. The document revealed it was marked complete by MD C on September 26, 2025, and revealed R124's mattress was marked green - indicative of no mattress concerns. MD C said the audit includes making observations of the mattress for wear and tear and spacing. On 7/2/2026 at approximately 1:00 PM, the Nursing Home Administrator (NHA) was interviewed regarding the bed and mattress concern. When asked what type of safety concerns there would be for the gap, the NHA said, Potential injury could occur because of the gap. A policy titled Side Rail/Bed/Mattress Spacing and Mechanical Requirements dated 3/7/2023 was provided by the facility and revealed the following: A properly fitting mattress allows no greater gap than 4.3/4 inches between the footboard or headboard and the mattress when the mattress is pushed to either end of the bed. In addition, the document revealed, A representative of housekeeping/maintenance or designee will measure and record each of the following bed dimensions upon the initiation of the use of bed for 3 days, change in mattress or side rails, and every sixty days in conjunction with a check of the mechanical soundness of the bed, rails, and mattress. All measurements should be taken with the bed in the flat position, with any side rails in the up position, and with the resident in bed: .the distance from the headboard to the mattress.

Based on observation, interview, and record review, the facility failed to ensure an adequate supply of emergency food was available. Findings include: On 5/29/25 at 11:16 AM, an observation and interview regarding the facility's emergency food supply was conducted with Dietary Manager (DM) H. DM H provided a document titled, Emergency Planning Recommendations for your Facility which indicated in part the following: We suggest storing a minimum of a 3-day supply of non-perishable food on site. DM H agreed that non-perishable foods were shelf-stable (food stored at room temperature and able to last long periods without spoiling). This document included a disaster menu for Day 1, Day 2, and Day 3. The disaster menus for Day 1, Day 2, and Day 3 were compared to the shelf-stable food on hand. The following items were not available and not substitutable with other foods on hand: assorted 100% juices, high protein breakfast bars, shelf-stable milk, and canned potatoes. The following shelf-stable food items listed on the disaster menus were also not available but may, in an emergency, be substituted with other items that were on hand: green beans, chicken and dumplings, carrots, apricots, ham, green peas, pulled chicken, mixed vegetables, assorted sodas, and stewed tomatoes. On 5/30/25 at 1:56 PM, the Nursing Home Administrator (NHA) stated, We should have the correct amount of food for three days. In the future we will make sure we have what is exactly on the menu. On 5/30/25 at 3:00 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information pertaining to this citation when asked.

Based on observation, interview, and record review, the facility failed to ensure consistent proper working order of the facility's walk-in freezer which had the potential to affect all residents that eat from the kitchen. Findings include: During the initial tour of the kitchen on 5/27/25 at 8:36 AM with Dietary Manager (DM) H, the internal temperature of the walk-in freezer was observed to be 9 F (Fahrenheit). A four-ounce cup of ice cream stored in the freezer was observed soft, not frozen solid. During a return visit to the kitchen on 5/29/25 at 11:16 AM with DM H present, the internal temperature of the walk-in freezer was 9 F. A four-ounce cup of ice cream stored in the freezer was soft, not frozen solid. The walk-in freezer door did not seal properly when closed. A noticeable gap was visible when the freezer door was closed which allowed cold air to escape. DM H stated, I never considered it (the freezer door not closing properly) being a concern because the meat was always frozen. We need to shop for a new freezer. On 5/30/25 at 1:56 PM during an interview, the Nursing Home Administrator (NHA) said they knew the freezer door needed to be replaced but had not started the process prior to this survey. A review of the 2013 FDA Food Code revealed the following: - Section 3-501.11. Stored frozen foods shall be maintained frozen. - Section 4-501.11. Food repair and proper adjustment. (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. On 5/30/25 at 3:00 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information pertaining to this citation when asked.

Based on observation, interview, and record review, the facility failed to: 1. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, meatballs, corned beef, baked beans, and diced potatoes; 2. Ensure the caulking of the hand washing sink was in good repair; 3. Store an ice scoop in a clean and sanitary manner; and 4. Properly date-label food stored in a resident refrigerator. These deficient practices resulted in the potential for food-borne illness for the residents that eat from the kitchen and residents that reside on the first-floor unit. Findings include: On 5/27/25 at 8:36 AM, the initial tour of the kitchen began with Dietary Manager (DM) H. The following was observed inside of the walk-in cooler: a pan of previously cooked meatballs dated 5/24, a pan of previously cooked corned beef dated 5/26, a pan of previously cooked baked beans dated 5/26, and a pan of previously cook diced potatoes dated 5/26. DM H said staff did not complete a cooling log for these previously cooked food items. On 5/28/25 at 12:39 PM, Certified Nurse Aide (CNA) J was observed passing ice water to residents on the first floor. CNA J was observed reaching into a portable ice chest, pulling out a scoop full of ice, putting the ice in a cup, and placing the ice scoop back in the chest with the ice. CNA J was not wearing gloves. When queried if the ice scoop should be stored inside the ice chest, CNA J said, I should have stuck it in the bin (located outside of the ice chest) to avoid contamination (of the ice). On 5/29/25 at 11:16 AM during a return visit to the kitchen, DM H said the cooks were responsible for storing previously cooked food in the cooler and were unaware of the correct procedures to cool cooked food. The caulking around the handwashing sink was observed to be missing. DM H stated, If water gets behind (the sink) bacteria could grow. When asked about the proper storage of an ice scoop, DM H said cross contamination could occur when you place the ice scoop handle on the ice. On 5/29/25 at 11:30 AM, the contents of the 1st floor resident's refrigerator were observed with DM H. The following items stored in the refrigerator were not identified with a resident's name: a disposable container of partially eaten stir fry, a 16.9 oz. bottle of carbonated beverage, an opened loaf of bread, an opened pack of sliced salami, an opened pack of sliced American cheese, and a disposable container of salad. A review of the policy titled, Food from Outside Sources, dated 11/12/21, documented in part the following: All food brought in is to be checked by the Nurse, Dietary Manager, or Dietitian. It must be placed in a sealed container and labeled for the content, the guest's/resident's name and date the food was received, and an expiration date of 3 days after food was brought in. It is recommended that only enough food be brought in for that visit. According to the 2013 FDA Food Code: Section 3-101.11, Safe, Unadulterated, and Honestly Presented, was reviewed and revealed, Food shall be safe, unadulterated, and, as specified under S 3-601.12, honestly presented. Section 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored: (E) In a clean, protected location if the utensils, such as ice scoops, are used only with a food that is not time/temperature control for safety food. Section 3-501.14, Cooling. (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 F to 70 F; and (2) Within a total of 6 hours from 135 F to 41 F or less. Section 4-501.11, Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. On 5/30/25 at 3:00 PM during the exit conference, the Nursing Home Administrator and Director of Nursing did not offer additional documentation or information pertaining to this citation when asked.

Based on interview and record review the facility failed to accurately document one resident's (R93) code status in the electronic medical record (EMR) out of six residents reviewed for advanced medical directives (AMD), resulting in the potential for R93's choices not being followed. Findings include: Record review of R93's information page in the EMR documented in the code status area that resident was a Full Code (resuscitation would be performed in the event resident had no heartbeat or breathing had stopped). Record review of R93's Do-Not-Resuscitate Order revealed, I have discussed my health status with my physician named above. I request that in the event my heart and breathing should stop, no person shall attempt to resuscitate me. This order will remain in effect until it is revoked as provided by law. Being of sound mind, I voluntarily execute this order, and I understand its full import. Further review of form revealed resident had signed the document on 7/8/24, as well as R93's attending physician. An interview was conducted on 5/27/25 at 11:10 PM with R93, it was confirmed that the resident was a DNR (Do not resuscitate). Review of R93's EMR revealed admission into the facility on [DATE] with a pertinent diagnosis of a history of myocardial infarction (heart attack). Review of R93's Brief Interview for Mental Status (BIMS) dated 4/11/25, R93 scored 15 out of 15 (intact cognition). Review of Physician Orders dated 2/19/25 documented resident was a full code. Review of Physician Progress Notes dated 5/20/25, 4/22/25, 2/4/25, 12/24/24 documented CODE STATUS-DNR. An interview was conducted on 5/29/25 at 10:04 AM with Licensed Practical Nurse (LPN) K, it was reported in the event a resident had no heartbeat and breathing had stopped, LPN K would refer to the resident's information page under code status to confirm if resuscitation should be performed before proceeding forward with care. An interview was conducted on 5/29/25 at 10:20 AM with LPN C, it was reported in the event a resident had no heartbeat and breathing had stopped, LPN C would refer to the resident's information page under code status to confirm if resuscitation should be performed before proceeding forward with care. An interview was conducted on 5/29/25 at 10:22 AM with Unit Manager (UM) L, It was reported in the event a resident had no heartbeat and breathing had stopped the nursing staff should refer to the resident's information page and under code status before proceeding with care. It was further reported that R93's code status was changed when the resident had returned from a hospital stay on 2/19/25 in error, and the resident should have not been changed to a full code and remained a DNR per the resident's wishes. An interview was conducted on 5/29/25 at 12:12 PM with the Director of Nursing (DON), it was reported that nursing should consult the special instructions (information page) before proceeding with care. It was further reported that R93's EMR was marked inaccurately and R93 should have remained a DNR after returning to the facility on [DATE]. The facility's policy Advance Directive-Michigan dated 7/6/23 documented, . A. Recognition of Resident Self-Determination. The Facility is committed to the promotion of the well-being of all our Residents. We recognize each Resident's right to refuse treatment, to live a dignified life, and to self-determination, which includes the right to refuse care and to formulate advance directives regarding future care.

Based on observation, interview, and record review, the facility failed to properly maintain residents' wheelchairs for two residents (R34 and R86), out of six residents reviewed for a safe and comfortable environment, resulting in resident discomfort and potential for the spread of harmful pathogens. Findings include: On 5/27/25 at 10:19 AM, R34 was observed asleep in bed. Both armrests of the wheelchair observed in R34's room were in disrepair. The covering on one armrest was severely frayed and only partially covered the foam underneath. There was no padding or covering on the other armrest which would result in the resident's arm positioned on bare metal. The covering on the back section of R34's wheelchair was partially missing exposing the foam underneath. On 5/27/25 at 12:51 PM, R86 was observed awake in her room sitting in a wheelchair. The covering on both armrests on R86's wheelchair were split and frayed, and the padding underneath was exposed. R86 said sometimes the armrests hurt her arms. On 5/30/25 at 10:41 AM, Therapy Manager (TM) F said managers do rounds on the residents and were to contact maintenance if a resident's wheelchair required repair. TM F stated, We have (wheelchair arm) replacement pads available. TM F added damaged wheelchair armrest pads should be replaced because it's more comfortable for the patient and the look is more appropriate. After observing R34 sitting in his wheelchair, TM F said one armrest was missing a cushion, the other armrest was worn out and needed to be replaced, and the back support was torn and needed to be replaced. After observing R86's wheelchair, TM F said both armrests were torn and did not have a smooth, solid surface. A review of the clinical record for R34 documented an initial admitted [DATE] and readmitted [DATE]. R34's diagnoses included osteoarthritis, muscle wasting, difficulty in walking, and dementia. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment and the use of a wheelchair for mobility. A review of the clinical record for R86 documented an initial admitted [DATE] and readmitted [DATE]. R86's diagnoses included atrial fibrillation, hemiplegia and hemiparesis affecting right dominant side, and difficulty in walking. A MDS assessment dated [DATE] documented intact cognition and the use of a wheelchair for mobility. On 5/30/25 at 1:31 PM, the Director of Nursing (DON) said the condition of R34's and R86's wheelchairs should have been seen by nursing and reported to maintenance for replacement. The cracked surface of the wheelchair armrest could cause bruising of the resident's skin. The DON added that it was an infection control issue because the cracked surface of the armrest could not be truly cleaned if exposed to bodily fluid. On 5/30/25 at 3:00 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information pertaining to this citation when asked.

Based on observation, interview, and record review, the facility failed to ensure that medications were administered in accordance to professional standards of practice for two (R12 and R17) of five residents reviewed for medication administration resulting in the potential for medication errors to occur. Findings include: On 5/28/25 at 8:28 AM Licensed Practical Nurse (LPN) C was observed to have two medications cups with pills inside stacked on top of each other on the medication cart. During inquiry LPN C said the medications were for two different residents, R12 and R17. R12's medication cup was on the top and R12's medication cup was underneath. LPN C said they were going to administer the medications to the residents and then sign them out because, It saves time to pull two resident's medications at the same time. Upon inspection of the medication cups it was determined that neither R12 or R17 had their entire 9:00 AM prescribed medications in the medication cups. LPN C said, I only put the packaged medications in the cups. Not the floor stock medications. LPN C acknowledged that this was not the standards of practice for medication administration and did not align with the facility's medications administration policy. At this time nurse manager, LPN B was present and asked about medication administration. LPN B replied, We should only pull one resident's medications at a time, administer the medication to that resident, and then sign the medications out. I don't know what is going on here. Observation of the medication cup identified to be for R12 revealed the following 8 pills in the cup: 1- folic acid 5 milligrams (mg) 5 tablets of 1 mg each 2- carbamazepine 200 mg 2 tablets 3- norco 5-325 mg 1 tablet According to the physician's orders and Medication Administration Record (MAR) the following medications were also prescribed for the 9:00 AM and not in R12's medication cup or prepared for administration: - aspirin 81 mg - calcium carbonate 600 mg - lactulose 30 milliliters (ml) - magnesium hydroxide 30 ml - artificial tears 1- 0.3% 1 drop each eye Observation of the medication cup identified to be for R17 revealed the following 7 pills in the cup: 1- tamsulosin 0.4 milligrams (mg) 1 capsule 2- chlorthalidone 25 mg 1 tablet 3- farxiga 5 mg 1 tab 4- hydralazine 50 mg 2 tabs 5- metformin 1000 mg 1 caplet 6- xanax .5 mg 1 tablet According to the physician's orders and Medication Administration Record (MAR) the following medication was also prescribed for the 9:00 AM and not in R17's medication cup; - aspirin chewable 81 mg 1 tablet On 5/27/25 at approximately 11:00 AM during an interview the Director of Nursing (DON) said, The nurse should prepare one resident's medication at a time. After administering those medications to that resident then sign them out. I don't know why someone would pull multiple resident's medications at the same time. It's not safe and doesn't follow the standards of practice. According to the facility's Medication Administration policy last revised on 10/17/2023 in part read: Residents medications are administered in an accurate, safe, timely, and sanitary manner. 4. Follow safe preparation practices. a- prepare medications immediately prior to administration.

Based on observation, interview, and record review the facility failed to ensure that nail care was provided for one dependent resident (R107) of three reviewed for activities of daily living care (ADLs). Findings include: On 5/27/25 at 10:51 AM, 5/28/25 at 1:40 PM, and 5/29/25 at 12:14 PM, observations were made of R107's nails being one forth to one third of an inch above the tip of their thumb and multiple fingers. R107's nails were observed to be discolored with a light brownish appearance. R107 was interviewed multiple times about the length and appearance of their nails and did not respond to the surveyor's questions. On 5/29/25 at 12:16 PM, certified nurse assistant (CNA) A was interviewd and shown R107's nails. CNA A indicated that they needed to be trimmed and cleaned. On 5/29/25 at 12:31 PM, unit nurse manager/licensed practical nurse (UNM/LPN) B was interviewed about their expectations regarding nail care involving R107. UNM B indicated that they had noticed the condition of R107's nails yesterday and that the nurse working yesterday should have taken care of them. A review of R107's electronic medical record (EMR) under the Task section for the past thirty days of R107's ADL care revealed documentation which indicated that routine care was provided for the resident on a daily basis, including .Nail care. A review of R107's behavior for the past thirty days involving, Behavior Monitoring: resistant to care combative, grabbing revealed, twenty six out of thirty days which were documented as, None of the above observed and three days documented as, Not applicable. A further review of R107's EMR revealed that R107 was most recently admitted to the facility on [DATE] with diagnoses that included Dementia and Protein-calorie malnutrition. R107's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R107 had a severely impaired cognition and required maximum assistance to being totally dependent for their ADLs. On 5/29/25 at 1:29 PM, the Administrator (NHA) was interviewed regarding their expectations for nail care involving dependent residents. The NHA indicated that residents' nails should be cleaned and trimmed as needed. Refusals and/or resistance to care should be documented. A facility policy titled, Activities of Daily Living (ADL) Program Last Revised: 4/5/2024 stated the following, Purpose: ADL[s] may include, but are not limited to .grooming .Procedure: .A resident may benefit from [an] .ADL Program if .g. Residents who require extensive assistance with grooming .3. Determine specific tasks and areas of ADLs .Grooming may include x. Trimming nails.

Based on interview and record review the facility failed to ensure a physician ordered lab draw (Keppra level) was completed for one resident (R84) reviewed for lab results, resulting in R84's physician being unaware that the ordered Keppra level was not completed along with the potential for an abnormal Keppra blood level go undetected and untreated. Findings include: Review of R84's Electronic Health Record (EHR) revealed the resident readmitted to the facility on [DATE] with multiple diagnoses that included Chronic Kidney disease and Epilepsy (seizures). According to the physician's orders on 4/11/25, R84 was prescribed Keppra 750 milligrams (mg) twice a day. On 4/24/25, R84 was ordered to have a Keppra blood level drawn. As of 5/27/25 there was no Keppra level results available and no progress notes to indicate a Keppra level had been drawn. Further review of R84's EHR revealed the resident had no seizure activity in the facility. On 5/27/25 at approximately 1:00 PM the Director of Nursing (DON) reviewed R84's EHR and said, It looks like the Keppra level was not drawn. I will reach out to the lab to determine where the Keppra level is. On 5/29/25 at 10:27 AM the DON said the Keppra level was not drawn by lab because the nurse did not put the order in correctly. The DON added the Medical Director will be notified and the Keppra level would be drawn immediately. The DON was asked for a policy for labs and said, We don't have a policy for labs or blood draws, but we do have one for following physician's orders. The Keppra level should have been done and followed up with by now. According to Drugs.com; Keppra (levetiracetam) is an anticonvulsant/antiseizure drug. Optimal response (therapeutic range) for levetiracetam is achieved with blood serum levels of 10.0 - 40.0 micrograms/milliliter (mcg/ml). According to Labtestsonline.org; Keppra (levetiracetam) does not require routine periodic monitoring, but levetiracetam test may be requested and reviewed to adjust the dosage as necessary. Review of the facility's Physician's Order policy last revised on 10/20/2023 in part reads; Physician orders are obtained to provide clear direction in the care of the resident. Treatment rendered to a resident must be in accordance with the specific standing, written, verbal, or telephone order of the a physician .

This citation pertains to intake MI00149633. Based on interview and record review, the facility failed to notify the Resident Representative (RR) of a diagnosis of pneumonia and physician's order for an antibiotic for one resident (R101) out of three residents reviewed for change in condition Findings include: It was reported to the State Agency that the facility did not notify the RR about the resident's medical condition. A review of the clinical record revealed R101 was initially admitted to the facility on [DATE] and discharged from the facility on 1/16/25. R101's diagnoses included Alzheimer's disease, dysphagia, and adult failure to thrive. A Minimum Data Set assessment dated [DATE] documented severe cognitive impairment. Additional review of R101's clinical record documented in part the following: 1. Change in Condition Evaluation of 1/15/25 at 12:21 PM: Resident feels hot to touch, resident temperature documented. Physician recommended chest x-ray. R101's RR notified on 1/15/25 at 12:33 PM. 2. Nursing progress note of 1/15/25 at 9:55 PM: Patient received resting in bed. No signs/symptoms of shortness of breath or any distress noted. No complaints of pain. Patient's chest x-ray and abdominal x-ray completed. Results reviewed with on-call medical doctor. Order for Doxycyline 100 mg (an antibiotic) twice a day for seven days. Diagnosis: pneumonia, related to chest x-ray results. 3. Physician order on 1/15/25 for Doxycyline hyclate, give one tablet by mouth two times a day for pneumonia During an interview on 2/3/25 at 12:37 PM, the Director of Nursing (DON) said she was aware that R101 had been diagnosed with pneumonia and had been prescribed an antibiotic. The DON explained R101's RR should have been notified about the new diagnosis and antibiotic order but had not been. A facility policy titled, Notification of Change, dated 2/14/24, was reviewed and revealed in part the following: -The facility must inform the resident, consult with the resident's practitioner; and notify consistent with his or her authority, the resident representative(s) when there is a change in status. Even when a resident is competent, his or her designated resident representative or family, as appropriate, should be notified of significant changes in the resident's health status unless the resident does not want the notification. - A change in status would include the following: -- A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). --A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). - The licensed nurse will document in the resident electronic medical record the notification and information that was provided, including any additional orders from the practitioner. On 2/3/25 at 2:05 PM during the exit conference, the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey, and they reported there was not.

Based on observations, interviews, and record review the facility failed to implement interventions to prevent pressure ulcers for one (R153) of 10 residents reviewed for pressure ulcers resulting in R153 developing an Unstageable Pressure Ulcer to her left hip. Findings include: According to the National Pressure Ulcer/Injury Advisory Panel (NPUAP); Unstageable Pressure Ulcer/Injury is full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (necrotic dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. On 04/03/24 at 11:48 AM, R153 was observed seated in her wheelchair in the hallway with bilateral hip protector pads in place. R153 was unable to be meaningfully interviewed due to impaired cognition. Upon inquiry, Registered Nurse (RN) G said the resident had developed a pressure ulcer on her left hip and the hip pads were ordered to reduce pressure while the resident was seated in the wheelchair. At 2:14 PM, R153 was observed laying in bed on her left side. The hip protectors were resting on the wheelchair. R153's mattress was observed to be a standard mattress and not a specific pressure relieving mattress. There was no foam wedge or pillows observed in the resident's room. RN G was asked about R153's turning schedule and if the resident had a specialty mattress for pressure ulcers. RN G replied, She (R153) is up for most of the day in her wheelchair . I don't know if this is a specialty mattress for pressure ulcers. RN G acknowledged there was no visible foam wedge/pillow to assist with repositioning the resident. On 04/04/24 at 11:35 AM R153 was observed in her wheelchair in the hallway with her hip protectors in place. The resident's mattress was removed from the bed and resting on it's edge, leaning against the wall on the floor in R153's room. Observation of the mattress indicated it was a standard mattress and not identified as a specialty pressure-relieving mattress. There were no positioning devices visible in the resident's room. At 1:23 PM both R153 and her bed were in the same condition. At this time LPN I was asked about R153's bed and mattress. LPN I said the resident was getting a new mattress but could not say what type of mattress. At 2:33 PM both R153 and her bed/mattress were in the same condition. At this time the Director of Nursing (DON) was asked about R153's bed and mattress. The DON said R153 was getting a new pressure relieving mattress. At 2:52 PM (over 3 hours later) R153's received a new mattress. The mattress was identified at LTC 105 mattress. R153 was placed back in bed on her right side without the use of any foam wedge or pillow. According to R153's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with multiple diagnoses that included dementia. The nurse's admission note documented the resident had 'no open areas to skin'. The Minimum Data Set (MDS) dated [DATE] indicated R153 had severe cognition impairment and required substantial/maximum assistance from staff to roll from left to right. Section M indicated the resident had no open areas on skin' and Yes to having pressure reducing devices on both chair and bed. A Braden Skin Assessment (used to determine if a resident is 'at risk' to develop pressure ulcers) dated 3/10/24 identified R153 as being at 'moderate risk' (score of 14) to develop pressure ulcers. A Care Plan for 'At risk for Impaired Skin' was initiated on 3/10/24 and included the following interventions; follow facility policies/protocols for the prevention/treatment of impaired skin integrity. A progress note on 3/26/24 at 3:40 PM documented the resident had a dark circle on her left hip. There was no additional description or measurements. On 3/26/24 a Care Plan for 'Actual Impaired Skin Integrity' for a Left Hip Unstageable Pressure Ulcer was initiated and included the following interventions; pressure reduction mattress and turn and reposition as tolerated. On 3/27/24 a wound care note documented the following; facility acquired left hip unstageable 4.1 cm (centimeter) x 3.0 cm x less than 0.1 cm. Full thickness wound. The following was prescribed; clean left hip with normal saline, apply santyl cover with border dressing every day shift and as needed. On 4/4/24 a wound care note documented the following; left hip unstageable this area measure 5.7 cm x 3.8 cm with a depth of 0.1 cm. Full thickness wound. 20% granulations tissue and 80% slough, edges are attached. no tunneling. The following was prescribed; left hip wound cleansed with normal saline, treated with santyl and dressed with a dry border gauze dressing every day shift and as needed. On 4/05/24 at 12:55 PM the wound care nurse, LPN M said when he became aware of R153's left hip pressure ulcer an eschar cap was already covering it and therefore the area was identified as an 'unstageable pressure ulcer' LPN M could not explain why R153's did not have an appropriate pressure relieving mattress on her bed, or a foam wedge/pillow at the time an unstageable pressure ulcer was identified. LPN M said, I don't even know how to order a specialty mattress for pressure ulcers. You would have to talk to the maintenance person. On 4/05/24 at 2:22 PM during an interview with the DON, she acknowledged that she had the maintenance staff replace R153's standard mattress with the LTC 105 mattress. The LTC 105 mattress is used with residents who have stage 3 or 4 pressure ulcers because it distributes the pressure more evenly throughout the body. The DON reviewed the facility's skin management policy and referred to the Mattress Grid. The Mattress Grid identified that a 'LTC 105' mattress should be used for residents with stage 3 or 4 pressure ulcers. The DON could not explain why R153 did not have the recommended mattress applied to her bed at the time the pressure ulcer was identified. According to the facility's 'Skin Management' policy last revised 7/14/21, in part: The facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries. 3. Appropriate preventative measures will be implemented on residents identified at risk and the interventions will be documented on the care plan. Appendix A revised 10/2019;Residents who are identified at Moderate Risk (score 13-14) will received increase frequency of turning . pressure redistribution support surface, use foam wedges or pillows for 30 degree lateral positioning. Mattress Grid (undated) identified the following mattress for stage 3/4 pressure ulcers; LTC 105.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 142 residents who receive meal services (oral foods) out of the facility's total census of 153 residents. Findings include: In an observation on 4/3/24 at 11:23 a.m., Dietary Cook B touched a piece of cooked pork loin with bare hands while getting a temperature. Dietary Cook B picked up part of the pork loin and put it back in the pan without wearing gloves. CDM (Certified Dietary Manager) D instructed Dietary Cook B to put on gloves. In an observation on 4/3/24 at 11:24 a.m., Assistant Cook C removed gloves and did not perform hand hygiene before writing down temps in a book. In an observation on 4/3/24 11:50 a.m., Dietary Cook B removed gloves then walked to a drawer, opened it, and touched serving utensils. Dietary Cook B did not perform hand hygiene after glove removal. In an observation on 4/3/24 11:54 a.m., Dietary Cook B had gloved hands. Dietary Cook B removed gloves and walked to front of the kitchen and reported she was looking for buns. Dietary B did not immediately perform hand hygiene after removal of the gloves. In an observation on 4/3/24 at 11:56 a.m., Dietary Aide E removed gloves, walked in the walk-in cooler, and exited the walk-in cooler with ranch in hand. CDM D instructed Dietary Aide E to wash her hands. In an interview on 4/3/24 at 11:58 a.m., CDM D reported staff should wash their hands after removing gloves and gloves should be changed between tasks. CDM D reported staff should wear gloves when handling food. Review of the U.S. Public Health Service 2017 Food Code, Chapter 2-301.14 When to Wash directs that: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLEUSE ARTICLES and: and contamination and to prevent cross contamination when changing tasks; (H) Before donning gloves for working with FOOD; and (I) After engaging in other activities that contaminate the hands. Review of a Food Handling and Production policy revised 11/12/21 documented, It is the policy of this facility to comply with strict time and temperature requirements and use proper food handling techniques to prevent foodborne illness. Procedure . wash hands regularly . 9. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable utensils to avoid manual contact with prepared foods . Review of a Hand Hygiene policy revised 10/11/23 documented, hand washing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections. Hand hygiene should be performed after removing personal protective equipment (e.g. gloves, gown, facemask).

Based on observation, interview, and record review, the facility failed to immediately notify the family of a change in condition and subsequent transfer to the hospital for one (R55) of three residents reviewed for notification of change. Findings include: On 04/04/24 at 10:00 AM an observation of R55's room revealed an empty bed and recliner chair. Upon inquiry, Licensed Practical Nurse (LPN) J reported that R55 was sent out to the hospital prior to the start of her shift. On 04/04/24 at approximately 11:29 AM R55's Family Member (FM) #1 was observed at the nurse's station asking where R55 was. LPN I told FM #1 the resident (R55) was transferred to the hospital and another family member (FM#2) was aware. At this time FM#1 said, No, you never told us. This has happened 2 or 3 times now. They do not tell us. FM #1 then called FM #2 on his cell phone to verify if FM#2 had been notified of R55's change in condition and subsequent transfer to the hospital. FM #2 over the phone said, No, they didn't tell us. We found out because we went up there to visit and she (R55) wasn't there. Then they told us she went to the hospital. On 04/04/24 at 11:30 AM, R55's Electronic Health Record (EHR) was reviewed. There were no progress notes for 04/04/24. There was no documentation to support R55's family members had been notified of the resident's change in condition or transfer to the hospital. On 04/04/24 at 11:42 AM, during an interview with Nurse Practitioner (NP) K said she ordered R55 to be transferred to the hospital for abnormal labs that required treatment in a hospital. NP K reviewed R55's EHR and confirmed there were no progress notes at this time. NP K could not say if R55's family member had been notified of the change in condition or transfer. During an interview with the Director of Nursing (DON) at 12:07 PM she said the facility's staff should have notified the family member immediately of the resident's transfer to the hospital. The DON reviewed R55's EHR and confirmed there was no documentation to support when R55 had been transferred to the hospital or that R55's family had been contacted. According to the facility's 'Transfer and Discharge' policy last revised 3/26/24, in part: Procedure: Emergency Transfer to Acute Care 1. When a resident is transferred on an emergency basis to an acute care facility, notice of the transfer is provided to the resident and the resident representative as soon as practicable.

Based on observation, interview and record review, the facility failed to apply splinting devices for two (R23 and R62) of eight residents reviewed for limited range of motion, resulting in the potential for increased joint contracture, loss of range of motion and increased pain. R23 On 4/03/24 at 10:39 AM R23's was observed in bed with left hand clenched into a fist. On 4/04/24 at 11:34 AM R23 was observed in bed with left hand clenched into a fist no carrot, or towel roll in hand. On 4/04/24 at 3:15 PM R23 was observed in bed with left hand clenched into a fist with no carrot or towel roll in left hand. Review of R23's Electronic Health Record (EHR) revealed the most recent admission to facility on 4/19/2022 with diagnosis that included Alzheimer's disease, diffuse traumatic brain injury, and hemiplegia and hemiparesis left side. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment and dependent for activities of daily living (ADLs). Review of R23's April Medication Administration Record (MAR) revealed hand roll to left hand in the day and off at night was applied on dates 4/1/2024 through 4/4/2024 by Licensed Practical Nurse (LPN) F. R62 On 04/03/24 at 10:15 AM R62 was observed in bed with both elbows bent, elbow braces on side table not worn by resident. On 4/04/24 at 10:25 AM R62 was observed in bed elbows bent, elbow braces not worn lying on side table in room. On 4/04/24 at 11:22 AM R62 was observed in bed elbows bent not wearing elbow splints. Review of R62's Electronic Health Record (EHR) revealed admitted to facility on 5/5/2023 with diagnosis that included chronic respiratory failure, contractures to right and left elbows, and traumatic brain injury. A Minimum Data Set (MDS) assessment dated [DATE] documented severe cognitive impairment and dependent for activities of daily living (ADL). Review of R62's April MAR revealed elbow braces bilateral on 4 to 6 hrs daily on at 10 AM one time a day on at 10 AM off between 2 PM and 4 PM daily were applied on dates 4/1/2024 through 4/4/2024 by LPN F. On 4/4/2024 at 3:17 PM LPN F was interviewed regarding the application and removal of R62's elbow splints and R23's hand splint. LPN F said she did not apply R62's elbow splints or R23's hand splint this week but documented that she did apply them on the MAR for April 2024. LPN F agreed that R23 and R62's April MAR for splint application were not correct and that R23 and R62 did not have restorative splinting services this week. On 4/5/2024 at 1:52 PM the Director of Nursing (DON) was interviewed and said that there is not a restorative nurse or aide and that the floor staff apply splints to the residents. The DON agreed that R23 and R62 should have the restorative splinting program as ordered by the physician in order to prevent worsening of contractures. Review of the facility policy titled Restorative Nursing effective date 4/26/2022 revealed in part . The facility strives to enable the resident to attain and maintain the highest practicable level of physical, mental, and psychosocial well-being. Nursing Restorative is available up to 6-7 times per week and is provided for residents meeting restorative program criteria.

Based on interview and record review the facility failed to ensure accurate information for transfer was communicated to the receiving hospital for one (R55) of two residents reviewed for discharges and transfers. Findings include: On 04/04/24 at approximately 10:00 AM Licensed Practical Nurse (LPN) J reported that R55 was sent out to the hospital prior to the start of her shift and was unaware of the circumstances that required R55 to be transferred to the hospital. On 04/04/24 at 11:30 AM, R55's Electronic Health Record (EHR) was reviewed. An order dated 4/4/24 at 7:27 AM indicated R55 was to be sent to the hospital for abnormal labs. A 'Transfer Form' dated 4/4/24 at 7:37 AM documented 'transfer details' that were dated 3/12/24 and indicated that R55 was sent out to the hospital for 'shortness of breath'. There was no corresponding progress note for 04/04/24 to indicate any additional medical information was provided to the receiving hospital. On 04/04/24 at 11:42 AM upon inquiry, Nurse Practitioner (NP) K said she ordered R55 to be transferred to the hospital for abnormal labs that required treatment in a hospital. NP K said the resident did not have shortness of breath. NP K reviewed R55's EHR and confirmed the 'Transfer Form' was inaccurate and there was no corresponding progress note to indicate the receiving hospital had the accurate reason for R55's transfer. NP K said she was in the process of documenting a progress note for R55 at this time. During an interview with the Director of Nursing (DON) at 2:43 PM she reviewed R55's EHR and confirmed the 'Transfer Form' dated 4/4/24 was inaccurate. The DON said the nurse who completed the transfer form dated 4/4/24 had just copied the information from a previous transfer form and could not explain why. The DON said, one-to-one education has been given to the nurse. According to the facility's 'Transfer and Discharge' policy last revised 3/26/24, in part: Procedure: Emergency Transfer to Acute Care: 4. A transfer form is completed, a list of medications and a copy of the care plan goals is sent to the receiving hospital. 5. Nursing documents the hospital transfer in the medical record.

This citation pertains to intake MI00141524. Based on interview and record review, the facility failed to thoroughly investigate an injury of unknown origin and unexpected death for one (R162) of two resident reviewed for abuse. Findings include: The State agency received a complaint that R162 was found expired in her room on the floor with an injury of unknown origin to the back of her head. A review of R162's closed Electronic Health Record (EHR) revealed that on [DATE] at approximately 7:45 AM the resident was observed laying on her left side on the floor in front of her bed and determined to be expired. There was no additional progress note or total body assessment that documented the condition of the resident's head or body. R162 was receiving palliative care (medical care focusing on pain relief) and had a 'Do Not Resuscitate' order. There was no Accident and Incident (A&I) report for [DATE] in the resident's EHR. On [DATE] at 11:22 AM the facility's 'Safety Coordinator' Licensed Practical Nurse (LPN) H was asked about R162's incident on [DATE]. LPN H said there was no A&I report or further documentation because the resident had expired. LPN H acknowledged that R162 was found on the floor and said, There was no A&I report to indicate that a fall occurred. So we don't know what happened. LPN H could not say with certainty if R162 had an injury to the back of her head. On [DATE] at 11:33 AM the Director of Nursing (DON) was asked about R162 being found deceased on the floor on [DATE]. The DON acknowledged that no investigation or A&I report had been documented. The DON said she had interviewed both the nurse and the CNA (certified nursing assistant) that day and started an investigation regarding R162' death, but there was no documentation to support that. The DON said, An investigation should have been completed for the resident (R162). It is in the facility policy. The DON could not say with certainty if R162 had an injury to the back of her head. At 2:15 PM the DON said she conducted a late investigation and made a late entry in R162's closed EHR. According to the facility's Abuse Prohibition Policy last revised on [DATE], in part: Allegations of guest/resident abuse, exploitation, neglect, misappropriation of property, adverse event, or mistreatment shall be thoroughly investigated and documented by the Administrator, and reported to the appropriate state agencies, physician, families, and/or representative. Definition: Adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Injuries of unknown source - An injury should be classified as an injury of unknown source when all of the following criteria are met: The source of the injury was not observed by any person; and the source of the injury could not be explained by the guest/resident; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the extent of the injury, or the injury is located in an area not generally vulnerable to trauma), or the number of injuries observed at one particular point in time or the incidence of injuries over time.

Based on interview and record review, the facility failed to respond to concerns from residents about staff call light response times, resulting in dissatisfaction and unmet needs among 13 residents of 20 residents with the quality of care. Findings Include: On 4/4/24 at 1:55 PM a meeting was held with the members of the council. Residents presented concerns and dissatisfaction with call light response times. An anonymous resident commented about being told by staff to put a call light on before shift change because staff is busy. An anonymous resident gave an example of call light wait time explaining one day it took three and a half hours before a call light was answered. During the meeting of 20 residents, 13 residents raised their hands in response to the question of problems with call light response times. On 4/4/24 at 4:30 PM, record review of the Council Meeting Notes revealed on 3/19/24 a note was made stating in part, . (residents) discussed answering call lights not being answered in a timely manner. On 4/5/24 at 9:30 AM the Activities Director L was interviewed and the concerns about call light response time were discussed. Activities Director L indicated the process for resident council concerns voiced by council is for a pink form titled Resident, Family, Employee, and Visitor Assistance Form to be filled out by the Activities Director L after a meeting and then a follow-up is done with a department manager about the specific concern. Once the problem is resolved the person who made the complaint is informed of the outcome and asked to sign indicating if they are or are not satisfied with the response. Activities Director L showed five pink forms kept in a binder that had been completed within the last few months. None of the concerns listed on the forms addressed call light response times and the Activities Director L said the concerns mentioned in the 4/4/24 Resident Council Meeting had not been made known. Activities Director L said We address concerns immediately. On 4/5/24 at 3:23 pm, during quality assurance review, the Administrator reported being unaware or resident concerns with all light response times.

Based on interview and record review, the facility failed to implement interventions to prevent the development of a pressure ulcer and properly treat a pressure ulcer for one resident (R96) of five residents reviewed for pressure ulcer/injuries resulting in the development of a facility acquired Stage III pressure ulcer (Full-thickness loss of skin, in which adipose [fat] is visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present. Slough and/or eschar [dead skin tissue] may be visible.). Findings include: A review of the Admission Record for Resident #96 (R96) revealed an initial admitted [DATE], readmitted [DATE], and discharge date of [DATE]. R96's diagnoses included congestive heart failure, cerebral infarction, gastrostomy status, ulcer of esophagus with bleeding, and Alzheimer's Disease. Review of R96's Minimum Data Set (MDS) assessments revealed the following: A Quarterly MDS assessment dated [DATE] revealed R96 had no pressure ulcers or injuries and noted R96 was at risk for the development of pressure ulcers. On 10/26/22 R96 was discharged without any unhealed pressure ulcers. On 11/3/22 R96 was readmitted to the facility without any skin concerns/pressure ulcers/pressure injuries noted. On 11/21/22 R96 was discharged from the facility with a documented Stage III pressure ulcer. A Significant Change MDS dated [DATE], documented R96 had one unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.) In addition, R96 was assessed to have severe cognitive impairment and required extensive two or more persons assist for bed mobility. A review of R96's clinical record revealed the following: 1. Skin & Wound - Total Body Skin assessment dated [DATE]. Skin assessment: Turgor: good elasticity; Skin Color: normal for ethnic group; Temperature: Warm (normal); Moisture: Normal; Condition: Normal; New Wounds: 0. 2. Skin & Wound - Total Body Skin assessment dated [DATE]: Skin assessment: Turgor: good elasticity; Skin Color: normal for ethnic group; Temperature: Warm (normal); Moisture: Normal; Condition: Normal; New Wounds: 0. 3. Physician Assistant (PA) wound care note dated 1/25/2023 documented in part: Physical exam included: - sacral wound - This wound measures 5.9 x 2.5 cm with no appreciable depth. Wound bed consists of 70% dark non blanching tissue/eschar and 30% granular tissue.There is no slough, no eschar, no tunneling, and no undermining. There is no odor present. Surrounding area (periwound) is fragile but without warmth, swelling, pain on exam, redness, induration or sign of infection. This wound is to be cleaned every other day with normal saline solution and medihoney applied to the wound bed. Wound should be dressed with a border gauze. Assessments and Plans: Pressure ulcer of sacral region, stage 3: Medihoney 4. PA progress note of 1/26/2023 documented in part: Chief complaint: New wound. History of present illness: Patient seen today for evaluation following report by wound team that patient has new sacral wound. 5. PA wound care note dated 2/1/2023 documented in part: History of present illnesses: Patient is being followed up on today by the wound team for multiple wounds. Physical exam: sacral 3 - This wound measures 6.2 x 6.0 cm with no appreciable depth. Wound bed consists of 70% dark non blanching tissue/eschar and 30% granular tissue. There is a scant amount of serosangeous discharge from this wound. Edges are attached. Patient denies pain with examination. There is no slough, no eschar, no tunneling, and no undermining. There is no odor present. Surrounding area (periwound) is fragile but without warmth, swelling, pain on exam, redness, induration or sign of infection. This wound is to be cleaned every other day with normal saline solution and medihoney applied to the wound bed. Wound should be dressed with a border gauze. Assessment and plans: Pressure ulcer of sacral region, stage 3: Medihoney 6. PA wound care note dated 2/8/2023 documented in part: Physical exam: - sacral 3 - This wound measures 8.3 x 7.2 cm with 2.0 depth. There is undermining of 6.0 cm from 10-2 o clock. Wound bed consists of 30% granulation tissue and and 70% soft eschar. There is a scant amount of serosangeous discharge from this wound with string odor. No bone is palpable at the base of this wound or in the undermined area. Edges partially are attached. Patient denies pain with examination. There is no slough, no tunneling, and no undermining. Surrounding area (periwound) is fragile but without warmth, swelling, pain on exam, redness, induration or sign of infection. This wound is to be cleaned every other day with normal saline solution and medihoney applied to the wound bed. Wound should be dressed with a border gauze. Undermined area is to be packed. Assessments and Plans: Pressure ulcer of sacral region, Stage 3: 4- Medihoney. Pack undermining. 7. Skin & Wound Evaluation with an effective date of 2/8/2023 - signed on 2/13/2023 documented in part: Location: Sacrum. In-House acquired. The exact date wound was present was 1/25/2023. Measurements: 8.3 cm x 7.2 cm. Depth not applicable. Goal of care: Monitor/manage: wound healing not achievable due to untreatable underlying condition. Dressing is intact. Notes: 2.0 cm depth. There is undermining of 6.0 cm from 10-2 o-clock. 8. January 2023 Treatment Administration Record (TAR) revealed no documentation related to providing wound care for R96's sacrum wound. 9. February 2023 TAR documented the following orders: Wound care. Cleanse sacrum with normal saline, apply medihoney. Every day shift. Every Monday, Wednesday, Friday, Sunday. Start date of 2/8/2023; and, Wound care. Cleanse sacrum with normal saline. Apply medihoney every 24 hours as needed. Start date: 2.7.2023. 10. The only TAR documentation related to providing wound care for R96's sacrum wound occurred on 2/8/2023. 11. A review of R96's care plans did not identify an actual impaired skin integrity care plan specific to a stage 3 sacral pressure ulcer. During interviews and review of R96's clinical record on 2/15/2023 at 12:16 PM, 2/15/2023 at 1:18 PM, and 2/16/2023 at 12:13 PM with the Director of Nursing (DON), the following was discussed. In reference to the Skin & Wound - Total Body Skin Assessments completed on 1/24/2023 and 1/31/2023 the DON acknowledged that the completed skin assessments indicated no concerns with R96's skin. The DON stated, The skin assessments should have indicated alterations in the resident's skin whether it was new or old. It's a concern that there is nothing noted. There is always some type of indication that the skin may be starting to breakdown. The DON listed the following indicators that may have been present on 1/24/2023 the day before a stage 3 pressure ulcer was identified on R96's sacrum: nonblanchable redness, dark purple areas, warm skin, redness, mushy area, weeping, edema. The DON acknowledged that the skin and wound evaluation of 2/8/2023 indicated the wound was discovered 1/25/2023 but according to the February 2023 TAR, treatment did not occur until 2/8/2023. The DON expressed concerns that the wound treatment directives as indicated in the PA note of 1/25/2023 were not noted and put on the TAR until 2/7/2023. The DON stated, The orders weren't followed through correctly. During an interview beginning on 2/15/2023 at 1:18 PM, PA L stated I did not put the treatment order in. The wound care nurse would put the order in. During an interview beginning on 2/15/2023 at 1:18 PM, Wound Care Nurse, LPN (Licensed Practical Nurse) K stated, I dropped the ball on the order. I made the error. If it's not documented, it's not done. A review of the facility policy titled, Skin Management, dated 12/15/2022 documented in part the following: - Guest/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. - Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan. - The licensed nurse will initiate documentation in the electronic health record, which includes a description of the skin impairment as follows: In Electronic Health Record (EHR) facilities, the licensed nurse will document on the skin and wound evaluation for pressure injury and vascular ulcers. Document weekly until the area is resolved. - The licensed nurse will document preventative measures on the care plan/Kardex. - A weekly total body skin evaluation is completed for each guest/resident by the licensed nurse. The licensed nurse will document findings of the skin evaluation.

This citation pertains to intake MI 1. This citation has two Deficient Practices. Deficient Practice #1 Based on observation, interview, and record review the facility failed to provide proper bed mobility assistance during activity of daily living (brief change) assistance per the plan of care for one resident (R#812) resulting in a fall with injury (hematoma and laceration) to the right facial area. Deficient Practice #2 Based on interview and record review the facility failed to provide proper monitoring and one to one supervision per the plan of care for one resident (R#808), resulting in multiple falls with injury (lacerations) to the right facial area. Findings include:Findings include: Resident #812 On 3/9/21 at 3:47 p.m., the Resident was observed laying in bed watching television. The Resident was also observed to be large framed. The Resident had the right forearm and hand resting on the chest area while the left arm was underneath the blanket. The Resident did not have any bruising however did have right side facial scars. The Resident was asked if able to move the left arm. The Resident shook her head no. The Resident was then asked to extend the right arm as far she can. The Resident was able to extend her right forearm and hand about six inches. The Resident was then asked if she was able to move around in the bed independently (turn from side to side or reposition self). The Resident shook her head no. On 3/9/21 at 11:36 a.m., review of the R812's clinical record documented the Resident was admitted into the facility on [DATE] with diagnoses that included [CONDITION(S)], [CONDITION(S)], and dementia. According to the admission Minimum Data Set (MDS) assessment dated [DATE], the Resident was severely cognitively impaired and required extensive two-person assistance with most activities of daily living (ADLs) particularly with bed mobility (turning and repositioning). The Resident also had upper and lower both side impairment with range of motion. Review of the ADL Self Care Performance care plan dated 1/13/21 documented: Resident requires assistance with ADLs and mobility regarding to impaired mobility, [CONDITION(S)], debility, and dementia. Intervention: Bed Mobility- Resident requires total 2 staff assist with bed mobility. According to the Incident and Accident Report dated 2/19/21 at approximately 3:55 a.m., the CENA was performing incontinent care, turned the Resident on her side, and turned to obtain a washcloth. While laying on her side, the Resident attempted to hold on to the side of the bed, leaned forward and fell out of the bed. The Resident had right eye swelling, a right forehead bump, and left jaw swelling. The nurse assisted the CENA with ADL care for the resident per the plan of care. The CENA was re-educated on having two persons while assisting with bed mobility (turning/changing position in bed). Review of the Physician's orders dated 2/19/21 documented the following: Skull x-ray 4 views, stat for status post fall with facial swelling right eye. Facial x-ray series (3 view), stat for status post fall with facial swelling right eye and right forehead. Further review of the clinical record revealed on the Kardex (electronic care guide) under the Bed Mobility Task, dates after the incident on 2/19/21 documented staff continued to provide one person assistance with bed mobility: 2/20, 2/21, 2/22, 2/23, 2/24, 2/25, 2/26, 2/27, 2/28, 3/1, 3/2, 3/3, 3/4, 3/5, 3/6, 3/7, and 3/8. On 3/10/21 at 12:00 p.m., CENA A confirmed to be the assigned nurse aide for the Resident. CENA A also confirmed she was a floater (not assigned a regular set of residents, floor, or hall) and had not previously cared for the Resident. The CENA was asked how she would know what care needs the Resident required. CENA A stated, I would look in the computer (Kardex) to see what the care needs are. CENA A was asked if a resident requires two-person assistance and no one was available at the time, would the care be performed alone. CENA A stated, I would do what I can by myself until someone becomes available to help me. I usually do not have a problem looking for someone to help me and do not wait long. There is usually three people working that could help. CENA A the proceeded to go into the Resident's room alone, announcing to the Resident, Hi (Resident's name). I'm going to help you get dressed. On 3/10/21 at 12:20 p.m., CENA A exited the Resident's room alone. A soiled brief and bed pad were observed in the trash can by the door. The Resident was in bed and dressed. CENA A was heard asking another CENA with assistance with getting the Resident out of bed and was going to retrieve a sling (used when transferring while using a lifting device, requiring two-person assistance). On 3/10/21 at 2:30 p.m. the Director of Nursing (DON) was interviewed about the incident that occurred on 2/19/21. The DON did acknowledge the incident did occur. The DON was informed the staff continue to provide one person assistance instead two-person assistance per the care plan. The DON stated, This will be taken care of immediately. On 3/10/21 at 2:37 p.m. CENA A was interviewed again and asked what care was provided to the Resident. CENA A stated, I did a bed bath, changed her brief, and got her dressed. CENA A was asked did she have to turn and reposition the Resident when changing her brief and giving the bed bath. CENA A stated, Yes. I turned her to change her. Lastly CENA A was asked did she turn the Resident by herself. CENA A stated, Yes, I did. Review of One on One In-Service: Reviewing the Kardex provided to the CENA involved in the incident documented: It is your responsibility to review transfer information, bed mobility information, and extensive or limited assistance requirements for every resident before providing any type of care to ensure safety. R #808 On 3/9/21, record review revealed R#808 was admitted into facility on 5/21/19 with diagnoses that included End Stage [CONDITION(S)] (ESRD), heart failure, diabetes, and dementia. According to the Minimum Data Set (MDS) dated [DATE], R#808 had impaired cognition and was extensive assist with Activities of Daily Living (ADLS). According to the residents Kardex (care guide) noted on Resident Care- Don't leave resident in room unattended while awake. Review of fall care plan documented Don't leave resident in room attended while awake. This intervention was created on 3/26/20. Review of Incident and Accident Report documented the following: 3/26/20- Resident received back from [CONDITION(S)] was observed by writer in the room on the floor, assisted back to bed with no injury sustained. Interventions implemented- To reeducate staff on leaving the resident in room alone. Signed off on bottom of form by Nurse, Administrator (ADM), Director of Nursing (DON) and Physician. 3/30/20- Resident observed on the floor between window and bed laying on side. No visible bruising Interventions implemented- To reeducate staff on leaving resident alone in room. Signed off on bottom of form by Nurse, Administrator (ADM), Director of Nursing (DON) and Physician. 4/30/20- Resident observed on right side of head, half under bed and no bruises. 5/18/20- Resident was in room in bed when noticed on floor next to bed face down. Laceration noted to right 9/23/20- Resident observed on right side face on floor . 11/28/20- Resident was observed laying on her back on her right side of bed on the floor. Physician Statement: Transfer to hospital. On 3/10/21, review of progress notes revealed resident returned from hospital. Progress notes dated 11/28/20 at 19:40 documented . wound closed with 6 stitches and should be removed in 7 days. On 3/11/21 at 1:00 pm, during interview with DON, when asked the purpose for interventions, DON said, To assist staff with the plan of care for a resident. When asked the purpose of Kardex, DON replied, To notify staff how to care for the patient. When asked if the R#808 had multiple falls and received injuries while at facility, DON stated, Yes. When asked was the care plan consistently updated and the intervention to not leave resident alone in room when awake updated and continued as an intervention until the resident was discharged from the facility, DON stated, Yes. When asked if this intervention was adhered to during the residents stay, DON replied, No, but the intervention was no longer appropriate after first fall. We (facility) did not remove it When I asked who is responsible for changing and removing interventions, DON replied, Clinical staff is responsible. On 3/10/21, during record review of policy Care Planning documented Every resident in the facility will have a person-centered Plan of Care developed and implemented that is consistent with the resident rights, based on the comprehensive assessment that includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs identified in the comprehensive assessments and prepared by an interdisciplinary team who includes but not limited to; attending physician, a registered nurse who is responsible for the resident, a nurse aide, a member of food/nutrition services, the resident or resident representative, therapy staff as required and any other ancillary staff. Additional resources will also be utilized to ensure that any additional needs or risk areas are identified. On 3/10/21, during record review of policy Fall Management documented the following: The facility will identify hazards and guest/resident risk factors and implement interventions to minimize falls and risk of injury related to falls. Overview- Each guest/resident is assisted in attaining/maintaining his or her highest practical level of function by providing the guest/resident adequate supervision, assistive devices, and/or functional programs as appropriate to minimize the risk for falls. Guests/residents will be evaluated by the interdisciplinary team for their risk for falls. A plan of care is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/designee is responsible for coordination of an interdisciplinary approach to managing the process for prediction, risk evaluation, treatment, evaluation, and monitoring of guest/resident falls.

Based on interview, and record review the facility failed to provide proper bed mobility assistance during activity of daily living assistance per the plan of care and report the fall with injury that subsequently occurred after not providing proper assistance for one (R11) reviewed for quality of care, resulting in delay in treatment and hospitalization . Findings include: This citation pertains to Intake/FRI MI 3. On 2/11/20 at 9:30 a.m. review of the facility investigation and other pertinent documentation regarding a facility reported incident (FRI) that occurred 10/28/19 during the day shift (7 am-3:30pm), documented, On 10/29/19 at approximately 8:30 a.m., (Resident's name) in informed that she wanted some pain medicine related to a headache. Upon further inquiry, she informed the nurse that she had a fall the day before (10/28/19) while the CENA (Y) was performing care (changing her), she was rolled out of bed onto the floor. She stated that CENA (Y) and male CENA (BB) helped her back into bed. The nurse assessed her (on 10/29/19 day shift approximately between 8:30 am-9:00am) and discovered a bruise on left upper forehead (pain to touch and minimum swelling per nursing noted dated 10/29/19 at 8:46am) and subsequently a bruise on her left shoulder. The Resident was sent to the hospital for a CT of the head and neck, which were negative of fracture or dislocation. The Resident returned to the facility and currently resides in the facility. CENA (BB) was in serviced on Reporting Incidents on 10/29/19 in relation to the incident, and CENA (Y) was terminated. The facility reported the incident to the state agency on 10/29/19 as an injury of unknown origin, however through further investigation, the Resident was rolled out of bed by an employee whom did not report the incident to the nurse immediately after the incident occurred, placed the Resident back in bed with the assistance from another employee whom also did not report the incident to the nurse, leaving the Resident with potential unassessed injuries until discovered the next day. On 2/11/20 at 9:03 a.m., during the initial pool process, the Resident was observed eating breakfast in bed and watching television. The Resident did not provide verbal answers but shook her head yes or no to questions. The Resident was asked if she was able to recall the incident that occurred on 10/28/19. The Resident shook her head yes and proceeded to continue eating her breakfast. At this time, the Resident's cognitive status is undetermined, and a thorough interview could not be completed. The Resident did not appear in pain or discomfort. On 2/11/20 at 1:36 p.m., the Resident was revisited and appeared to be asleep. The Resident's name was called however there was no response from the Resident. On 2/11/20 at 3:54 p.m., review of the Resident's clinical record documented the Resident was initially admitted into the facility on [DATE] with last readmission on 2/7/19. The Resident's [DIAGNOSES REDACTED]. According to the annual and quarterly Minimum Data Set (MDS) assessments dated 7/29/19, 10/28/19, and 1/20/20 the Resident was moderately cognitively impaired and required extensive two-person assistance with most activities of daily living, particularly two-person assist with bed mobility. Further record review documented on the Incident and Accident Investigation Form dated 10/29/19: Date of incident 10/28/19, in resident's room, at approximately 8:30 a.m., the Resident told the nurse she had been rolled out of the bed the previous day. CENA (Y) did admit to witnessing the resident falling and did not alert the nurse. CENA (Y) did not follow care plan. Staff were re-educated on Reporting Incidents Immediately to the Nurse and Following Care Plans. A second Incident and Accident Report dated 10/29/20 also documented, .Location of Injury: left forehead hematoma and left shoulder bruise . send resident out to hospital for CT of head and neck . Resident is a two person assist when providing incontinence care . Review of the witness statement provided by Nurse (AA) (whom was the nurse for the resident during the shift the incident occurred) stated, I was the nurse for the resident on 10/28/19 from 7am-3:30pm. The CENA (Y) was the CENA caring for the resident on my shift. The CENA (Y) never reported a fall to me. Review of witness statement provided by CENA (BB) (who assisted CENA Y getting resident off the floor) stated, Around 11:00 a.m. on 10/28/19 CENA (Y) asked me to assist her in the resident's room. When I got to the room, the resident was laying on the right side of her bed on the floor. We assisted her back into her bed at this time. I was not aware that the CENA (Y) did not report the incident to the nurse. I am aware that a fall requires reporting and assessing from the nurse, but I assumed that the CENA (Y) had already done that and I was just there to assist with the transfer. Further follow up from the Director of Nursing handwritten and dated for 12/29/19 with CENA (BB) documented there was no Hoyer lift in the room and no other staff members present in the room while he assisted. Review of witness statement provided by CENA (Y) stated, I cared for the resident yesterday on my shift 10/28/19 from 7am-3:30pm. The resident did not have a fall on my shift. There was a moment when I was about to change her around 11:00 am, when I was assisting her, she was above the bed in a Hoyer sling, on the Hoyer lift while I was changing the linens on her bed. no one else was in the room. She (the resident) grabbed onto the sling because she was swaying a bit, that might be why she thought she was going to fall. No one helped me with her, she never touched the floor. There is nothing that happened that could have caused those bruises, she did not bump anything or hit anything on the lift that would have caused bruising. Never once has she fallen in my care. If there was a fall, I would have reported it to the nurse. According to the facility's investigation, CENA (Y) later admitted she was not truthful and the Resident in fact did fall and she had not reported it. Various other witness statements from the both CENAs and nurses on various shifts documented they had not been informed of the resident having a fall. On 2/13/20 at 3:30 p.m., the Director of Nurse's (DON) was interviewed and asked what the expectation of staff was reporting incidents and following the plan of care. The DON stated, I expect my staff to always follow the plan of care and report all unusual occurrences to ensure all residents safety and receive they proper treatment as needed. Because the employee (CENA (Y)) failed to report the incident, she was terminated. The entire facility has been in-serviced and re-educated on reporting and following the plan of care. They are reoccurring educations and the staff are often in-serviced. Review of the Resident's care plan titled ADL Self Care Performance Deficit date initiated on 7/2/16, revision on 2/13/20 documented: Resident requires assistance with ADL's and mobility r/t impaired mobility, limited ROM (range of motion) in the upper/lower extremities. Intervention (date initiated on 7/19/16) Bed Mobility: Resident requires 2-person assistance to reposition and turn every 2 hours and as needed. Review of the facility's policy titled Incidents and Accidents for Residents or Visitors revision date 9/2013 documented: Incident or Accidents involving a resident will be documented and reported so as to meet regulatory requirements. The Administrator and the Director of Nursing will be notified as outlined in policy. When an incident or accident is discovered, the employee making the discovery will immediately notify his/her direct supervisor of the discovery. If the event requires immediate action from the Administrator (resident safety, family's reaction, or state regulatory requirements), the Administrator will be notified immediately . For incident and accidents involving residents, pertinent clinical information and observations must be recorded in the medical record .Record the relevant facts regarding the resident in the medical record e.g., where resident was found, assessment conducted, care provided, follow up care provided, etc.

This citation pertains to intake # MI 418. Based on interview and record review the facility failed to ensure timely medical care was provided (x-ray) based on resident assessment (complaints of pain left hip) for one sampled resident (R#501) out of a total sample of five residents reviewed for medical services resulting in delayed [DIAGNOSES REDACTED]. Findings include: Record review revealed that R#501 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A competency evaluation dated 4/26/18 documented, (R#501) was evaluated for competency and it was found that she is not able to make decisions regarding her care. Her Power of Attorney (POA) was activated at that time .It was found that her POA states he wants everything done for her. A pain evaluation dated 6/26/18 documented for R#501, Resident currently not experiencing pain at this time. Review of the clinical record revealed the following documentation regarding R#501's new onset pain: -Nurses Note (NN) 8/7/18 @ 8:36 am; Patient showed signs of discomfort during therapy session in Left Lower Extremity, Medical Doctor (MD) called and stated no new orders at this time, asked MD if a X-RAY was needed, she stated no patient is palliative care. -NN 8/8/18 @ 2:19 am; Writer spoke with MD relating to resident pain. Resident grimacing (facial expression that indicates disapproval, pain, etc.) when touched specifically in the left lower leg .MD stated she will be in to see resident. -SBAR Communication form (a form used to communicate a change in a residents condition) dated 8/8/18 documented, Pain (uncontrolled) .left leg and hip . -NN 8/8/18 @ 7:05 am; Writer spoke with emergency contact (PO) relating to change in condition (for R#501). Emergency contact stated that he will be in to see resident today and for nurse to notify him once the MD arrives and with any new orders. -NN 8/8/18 @12:41 pm; Patient shows signs of discomfort in Left Lower Extremity, called MD and asked if could get order for Tylenol 325 milligrams (mg) for the discomfort, MD stated that's fine. -Palliative Care (additional care services provided to the resident) note dated 8/8/18 (no time) documented, Per facility staff, patient is experiencing more pain than normal today Palliative recommends Tylenol 650 mg every 6 hours as needed. -NN 8/8/18 @ 5:57 pm; All labs addressed with MD, she stated she will be in. -NN 8/8/18 @ 6:51 pm; MD arrived and stated she wanted Intravenous fluids (IV) for patient . -Physician Note 8/8/18 @ 8:22 pm; Due to increasing sodium, decreased responsiveness of the patient will start IV hydration. Has occasional grimacing, no specific increased rigidly of her arms. -Dietary Note 8/9/18 @ 3:50 pm; (R#501's) food acceptance records (FAR) shows reduced intake over the past few days. Intake less than 50% x 2-3 days. Usually eats more than 50% of meals. Weekly weights initiated . -NN 8/10/18 @ 4:07 pm (3 days after initial onset of pain); Spoke with MD relating to resident pain in left hip. Resident remains grimacing and crying out when left leg is moved. Also notified of resident not eating and drinking as usual .MD gave orders to obtain urine culture and x-ray left hip . Review of an x-ray report dated 8/10/18 documented, Conclusion: Acute displaced left femoral neck fracture. Review of the Physical therapy notes dated 8/6/18, 8/7/18, 8/8/18 and 8/9/18 documents that R#501 continued to receive therapy during this time frame. On 11/28/18 at 1:41 pm during an interview with Staff Nurse C she was asked about R#501's pain. Nurse C stated On 8/8/18 the resident complained of left hip pain during check and changes (when the staff would change the resident's soiled brief). I was in the room with the Certified Nurse Assistant (CNA) and she (R#501) would holler out when being changed. I did an assessment and she had pain in left lower extremity. I notified the doctor and she (the doctor) did not talk about x-ray, just ordered lab work I spoke to nephew and told him about (R#501's pain and new lab orders). I completed a change in condition assessment. Nurse C went on to say that on 8/10/18 (2 days later) was the next time she was assigned to provide care to R#501. Nurse C stated, (R#501's) pain was excruciating with movement, she was crying out with care. It seemed like nothing was being done. I called the doctor and told her the pain was causing her (R#501) not to be her usual. She was declining, not eating or drinking. I asked to get an order for [REDACTED]. On 11/28/18 at 2:45 pm, During a phone interview with Attending Physician (MD A) she was interviewed about the left hip pain for R#501. MD A she was not aware that R#501 was having left hip pain since 8/7/18. MD A said that she would have ordered an x-ray even if the resident was palliative care, I would never say that (defer an x-ray because a resident is palliative care). I can only guess that the reason that I didn't order an x-ray was because when I saw her and I did my assessment she did not complaint of pain. When asked about the facial grimacing that was noted in her physician's progress note she stated,The grimacing could have been from just about anything, for example not moving her bowels. MD A was queried as to why after multiple phone calls from the nursing staff from 8/7/18 to 8/10/18 regarding R#501's left leg pain and her own observation of R #501's facial grimacing on 8/9/18, she didn't order an x-ray to rule out a fracture for 3 days to which she respond, If the nurses would have told me she was in that much pain I would have ordered an x-ray. At 3:15 pm, the facility's Director Of Nursing (DON) said We had concerns about the physician not addressing the residents pain. Review of the facility's policy titled Physician Services released 9/2013 documented, 2. Physician services include, but are not limited to: .A medical evaluation of the resident and review of orders for care and treatment; Resident [DIAGNOSES REDACTED].

This citation pertains to intake MI 670: Based on observation, interview, and record review, the facility failed to properly assess and implement measures to ensure the safe positioning of the feet, while in a motorized wheelchair, for one (#801) two residents reviewed for wheelchair positioning out of a total of 3 sampled residents, resulting injury to the resident's toes that required amputation. Findings include: On 7/24/17 at 7:44 AM, Resident #801 was observed lying in bed and was asked if she had hurt her foot. Resident #801 stated, Yeah. My right foot had come off the foot thing (foot rest) and it got caught in the wheel thing and I ran over it. In the room, was observed a motorized wheelchair revealed was hers. The wheelchair had no leg rest attached and no supportive device for the legs or borders on the foot rest to prevent feet from slipping off. No additional devices were observed in the room. On 7/24/17 at 7:55 AM, A review of the of the clinical record began and revealed that Resident #801 was re-admitted on [DATE] with diagnose that included Multiple Sclerosis (MS), [DIAGNOSES REDACTED], and muscle wasting and atrophy. The Minimum Data Set (MDS), dated [DATE], indicated that Resident #801 was cognitively intact, had impaired functional mobility of both lower extremities, and required extensive to total assistance from staff of complete activities of daily living. A nursing care plan that addressed Resident #801's use of and leg positioning in the motorized wheelchair was not seen in the clinical record. The physician's progress noted, dated 3/22/17 at 9:07 PM, stated, Patient has weakness/[DIAGNOSES REDACTED] to bilateral lower extremities with no sensation below the knees. A review of the History of Present Illness from the hospital, dated 7/11/17, documented, Past medical history, [DIAGNOSES REDACTED], bed bound with debility secondary to advanced MS .presents to the emergency room (ER) with complainant of right foot toe injury. Patient states she was outside and her right foot was dragging on the concrete while she was in her electric wheelchair. Patient states once she went inside her nurse noticed there was blood coming from her right foot, but the patient didn't know she has injured her toe secondary to no sensation from the waist down. Patient was seen by podiatry in the ER, whom recommended a possible amputation of the 4-5th digit on the right foot secondary to the abrasion being down to the bone . A review of the nursing notes, dated 7/10/17 at 8:30 PM, documented, Called to resident's room and observed resident's right foot dragging on the floor and bleeding profusely. Placed (resident) in the bed and bleeding controlled .Doctor notified and instructed to send out (to hospital) . This note was made by Nurse E. The nursing progress note, dated 7/18/17, documented, Received resident from (local hospital) .Resident is missing her right 4th and 5th digit due to amputation . A review of the facility's incident report, dated 7/10/17 at 8:30 PM, stated, Called to room at 20:30 (8:30 PM). Observed resident with her right foot dragging on the floor. Sock was ripped or cut and toes were bleeding profusely. On 7/24/17 at 8:49 AM, Nurse A was observed standing at the nursing station and revealed she was Resident #801's regular nurse. Nurse A was asked about Resident #801's condition and use of the motorized wheelchair. Nurse A had MS and was asked if Resident #801 have any feeling or control of her lower extremities. Nurse A stated, Not at all. Nurse A revealed she thought that Resident #801 had the wheelchair for 4-5 years and stated, At first she couldn't use it unless she was approved. A week later she was in it. She was approved by therapy. On 7/24/17 at 9:00 AM, the Therapy Director was asked if his department does wheelchair evaluations. The Therapy Director asked, Is this Resident #801. We do (wheelchair evaluations). We let the family know the wheelchair was not appropriate for her, about a year ago. A CNA (Certified Nurse Aide) and nurse approached me and told me her foot was falling off the foot rest. She had a custom chair, but when it broke, the family bought this one. The Therapy Director was asked why the chair wasn't appropriate for Resident #801. The Therapy Director stated, Because it has a straight foot rest and the custom on had foot rest that positioned her feet better. She had been using this chair for the last 1-1/2 years. I brought it up in morning meeting and I spoke to her son and told him the chair was not appropriate for her, because of the foot rest and he said it was her choice - she wanted it because she wanted to be more mobile . On 7/24/17 at 9:15 AM, during a telephone interview, Interested Party D was asked about the motorized wheelchair. Interested Party D revealed the wheelchair had been donated by the MS Society. Interested Party D was asked about staff explaining the chair was not appropriate for Resident #801. Interested Party D stated, No. Never. No one has said anything, nothing about the wheelchair no being appropriate for her. On 7/24/17 at 12:13 PM, Interested Party C was observed exiting Resident #801's room. Interested Party C was asked about Resident #801's use of the motorized wheelchair. Interested Party C stated, I complained about a month ago because I came in and found (Resident #801) slumped down in the wheelchair. I got mad. Her butt was down forward in the wheelchair. But they didn't tell me the wheelchair was not appropriate. I hurt me to see her, how she took that,when they (hospital) told her they had to amputate her toes. I know she doesn't have any feeling, but . Resident #801 was asked if staff had informed her the wheelchair was not safe for her to use. Resident #801 stated, No. On 7/24/17 at 1:13 PM, during a telephone interview, Nurse E was asked about Resident #801's use of the motorized wheelchair and injury to her right foot. Nurse E stated, It happened in her room. There was no blood in the hallway. Everything was in her room. I was passing evening snacks and brought her a peanut butter and sandwich. It was around 8:00ish. Five to six minutes after that is when she (CNA) called 'Nurse come here'. Nurse E was asked if there had been a problem with Resident #801's foot sliding from the foot rest. Nurse E stated, Yes. It has happened before. We tried Dycem in the (seat)chair to prevent her from sliding. I can't remember anything in place to keep her feet on the foot rest. On 7/24/17 at 3:36 PM, CNA F was asked about Resident #801's positioning in the motorized wheelchair. CNA F stated, She slides down in the wheelchair. Just the right (foot) comes off (foot rest). When she slides down, her foot comes off the foot stool. We have to constantly pull her up so her foot won't drag . It was revealed protective foot wear had not been placed on Resident #801's when up in the wheelchair. On 7/24/17 at 4:47 PM, the Wound Care Coordinator (WCC) stated, Resident #801 has skin tears to the right lateral foot that reported to me on 3/7/17 and are currently being treated. I asked her how it happened and she said she knocked them on something, but was unable to give me other details. At 4:50 PM, the Administrator was asked for incident reports for the previous injury to Resident #801's right foot. The Administrator stated, It was not reported to me. We do complete incident reports for skin tears. But I don't have them. On 7/24/17 at 2:40 PM, the Therapy Director revealed he had no documentation of a conversation with the family, but that Resident #801 really wanted to keep the chair for increased mobility. The Therapy Director was asked what interventions had been tried to make the chair safer for Resident #801 to use. The Therapy Director stated, At that time she would cross her legs and that would keep her foot from falling off the foot rest. There are no devices for the chair. It was not made for her .I guess I can call the company and see if they can modify it (motorized wheelchair) for her. The Therapy Director was asked why the company had not been called in April 2017 about modifications when staff reported that Resident #801's foot would come off the foot rest. The Therapy Director had no explanation. On 7/24/17 at 6:10 PM, the Administrator and Director of Nursing (DON), during the exit, were asked if there was any additional information they wanted to submit. The Administrator stated, If we had know about the other skin tears maybe . They revealed there was no additional information. On 7/24/17, a review of the facility's policy Physical Function, dated 2017, stated, Residents are evaluated upon admission, quarterly, annually, and with a significant change to determine their ability to perform activities of daily living, using the Minimum Data Set (MDS) .assistive devices/adaptive equipment determined necessary to enhance the resident's self performance are incorporated into the resident's plan of care .

Based on observation, interview and record review, the facility failed to conduct an adequate skin assessment and implement interventions to prevent a pressure ulcer for one sampled resident (#509) of nine residents reviewed for pressure ulcer care in a total sample of 24, resulting in the development of an unstageable pressure ulcer. Finding include: On 1/23/17 at 2:15 p.m., Resident #509 was observed in bed lying in a supine (on back and buttocks) position, heels in contact with bed surface. On 1/24/17 at 9:44 a.m., during wound care observation with the Wound Care Coordinator Nurse Q, revealed, the left lateral heel revealed a black circular area. Nurse Q was queried regarding the wound to the left heel and stated, I wasn't aware of this wound. I will call the physician, responsible party, inform the DON (Director Of Nursing), and put interventions in place. Nurse Q was asked to describe the wound to left heel and stated, Left heel pressure ulcer, eschar (hard non-viable tissue, usually black like scab), unstageable and dry base. On 1/24/17 at 10:26 a.m., the DON was queried regarding the ulceration to resident #509's left heel, and stated, It's our standard of practice to float the heels. On 1/24/17 at 10:59 a.m., observation revealed that resident was in bed lying in the supine position with heels in contact with bed surface. A device to float the heels off the bed surface was not present. On 1/24/17 at 1:34 p.m., the clinical record for resident #509, revealed resident #509 was admitted into the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment dated , 12/28/16, revealed a BIMS (Brief interview for Mental Status) score of three out of 15 which indicated severe cognitive impairment. The MDS further indicated the need for extensive assistance with bed mobility and all ADL's (Activities of Daily Living). On 1/24/17 at 2:15 p.m., upon further review of resident #509's clinical record revealed: 1. Document titled, Wound/Skin revealed an evaluation date of 1/18/17 at 1:24 p.m. No documentation of a left heel pressure ulceration was noted. 2. Document titled, Change in Condition (e-interact) dated, 1/18/17, signed 1/23/17, which listed pressure ulceration to the right buttock but none to the heels. 3. Document titled, Nursing Weekly Head To Toe Skin Assessment dated 1/11/2017 and signed 1/12/17. No documentation of a left heel pressure ulceration was noted. 4. Document titled, MDS dated 12/28/2016, Section M0150, states, Yes, Resident at risk for the development of pressure ulcers. On 1/25/17 at 10:15 a.m., the Consultant Wound Care Physician was queried following his assessment of resident #509, he stated, the initial measurement of the left heel pressure ulceration is 1.2 cm (centimeters) by 0.6 cm, necrotic, unstageable. The wound care physician was queried regarding the length of time it takes for eschar to form and stated, Approximately a month, but it vary's. The wound care physician recommended Santyl, debridement and heel protectors. On 1/25/17 at 11:34 a.m., during QA (Quality Assurance) interview with facility Administrator and DON, the DON was queried regarding standard of practice related to pressure ulcers on heels, she stated, We perform weekly skin assessments. If we have a resident in bed their heels should be floated. On 1/25/17 at 2:14 p.m., review of the facility policy titled, Skin Management dated 7/2014 revised, states, It is the policy of the facility that a resident does not develop pressure ulcers unless clinically unavoidable. Residents with wounds and/or pressure ulcers 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. On 01/25/17 at 3:30 p.m., the facility Certified Nursing Assistant Job Description undated, revealed: Essential Functions and Responsibilities: Observes resident's skin when giving care and reports changes to licensed nurse. On 1/25/17 at 4:30 p.m., the Administrator was asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and reported there was none. ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 189. BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO CONSISTENTLY ASSESS, DEVELOP AND IMPLEMENT TIMELY INTERVENTIONS NECESSARY TO PREVENT THE DEVELOPMENT OF NEW PRESSURE SORES FOR ONE (#505) OF ONE SAMPLED RESIDENTS REVIEWED FOR WOUNDS FROM A TOTAL SAMPLE OF SIX RESIDENTS. THIS FAILURE RESULTED IN HARM, WHEN RESIDENT #505 DEVELOPED NEW PRESSURE SORES THAT WERE NOT ASSESSED OR TREATED BY THE FACILITY. FINDINGS INCLUDE: ACCORDING TO THE CLINICAL RECORD, RESIDENT #505 WAS A [AGE] year OLD AFRICAN FEMALE, readmitted INto the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE RESIDENT DID NOT SPEAK ENGLISH. REVIEW OF THE MINIMUM DATA SET (MDS) assessment dated [DATE] REVEALED RESIDENT #505 WAS RARELY OR NEVER UNDERSTOOD BY STAFF. SHE HAD MODERATELY IMPAIRED COGNITIVE SKILLS FOR DAILY DECISION MAKING WITH SHORT AND LONG TERM MEMORY PROBLEMS. SHE REQUIRED TOTAL DEPENDENCE FROM STAFF FOR BED MOBILITY AND ALL ACTIVITIES OF DAILY LIVING. THE MDS FURTHER INDICATED THAT RESIDENT #505 WAS AT RISK OF DEVELOPING PRESSURE ULCERS, BUT SHE HAD NO PRESSURE SORES AT THE TIME OF ADMISSION INTO THE FACILITY. ON 04/22/2013 AT APPROXIMATELY 10 A.M., DURING THE INITIAL TOUR OF THE FACILITY, RESIDENT #505 WAS OBSERVED LYING IN BED IN A SUPINE POSITION (ON HER BACK). THERE WERE NO POSITIONING DEVICES NOTED ON EITHER SIDE OF RESIDENT #505. RESIDENT #505'S BED HAD BEEN PLACED IN A HIGH POSITION, AND SHE APPEARED TO BE ASLEEP. RESIDENT #503 WAS OBSERVED THROUGHOUT THE DAY LYING IN THE SAME POSITION, NEVER AWAKE. ON 04/22/2013 AT 2:30 P.M., RESIDENT #505 WAS OBSERVED STILL LYING ON HER BACK, BUT NOW HER LEGS INCLUDING HER KNEES WERE PRESSED TOGETHER, TURNED TO THE LEFT SIDE. THERE WERE NO POSITIONING DEVICES NOTED NOR WAS THERE A PILLOW OR OTHER DEVICE SEPARATING HER KNEES TO KEEP THEM FROM TOUCHING OR RUBBING TOGETHER. THE RESIDENT'S HEELS WERE NOT FLOATING, AS HER KNEES WERE BENT AND HER FEET WERE RESTING ON THE BED. AT APPROXIMATELY 5:00 P.M. RESIDENT #505 REMAINED IN THE SAME SUPINE POSITION, WITH HER KNEES BENT, TURNED TO THE LEFT AND PRESSED TOGETHER. DURING A TELEPHONE CONVERSATION ON 04/22/2013 AT 11:30 A.M. WITH FAMILY MEMBER #19, IT WAS REPORTED THAT RESIDENT #505 WAS admitted INTO THE FACILITY WITH INTACT SKIN, BUT HAD SINCE DEVELOPED MANY WOUNDS WHILE IN THE FACILITY. FAMILY MEMBER #19 SAID "SHE (#505) HAS WOUNDS ALL OVER HER BODY, EVEN ON HER EARS AND ON HER BACK." ACCORDING TO THE CLINICAL RECORD, RESIDENT #505 HAD SEVERAL hospitalization S FOLLOWING HER READMISSION ON 01/02/2013. ON 04/23/2013 AT APPROXIMATELY 4:00 P.M., AN INTERVIEW WAS CONDUCTED WITH THE DIRECTOR OF NURSES (DON) DURING THE REVIEW OF RESIDENT 505'S CLINICAL RECORD. IT WAS IDENTIFIED THAT RESIDENT #505 HAD MULTIPLE CO-MORBIDITIES AND HER HEALTH STATUS HAD DECLINED. THE DON WAS QUERIED ABOUT THE FACILITY TREATMENT NURSE AND SHE EXPLAINED THAT THE FACILITY WAS IN THE PROCESS OF HIRING A NEW TREATMENT NURSE, BUT LICENSED PRACTICAL NURSE (LPN) #14 HAD BEEN PROVIDING WOUND TREATMENT IN THE INTERIM. REVIEW OF A NURSE'S NOTE DATED 02/07/2013 REVEALED "ADVISED BY STAFF THAT RESIDENT HAS OPEN AREA TO BUTTOCK. ASSESSED RESIDENT AND OBSERVED OPEN AREA TO COCCYX 3 X 3.2 PINK WOUND BED WITH IRREGULAR EDGES, SCANT SEROSANGUINOUS DRAINAGE. ORDERED ALLEVYN QID AND PRN (FOUR TIMES DAILY AND AS NEEDED) TO COCCYX...." RESIDENT #505 WAS TRANSFERRED OUT TO THE HOSPITAL ON THE NEXT DAY, 02/08/2013, AND RETURNED to the facility on [DATE]. ACCORDING TO THE READMISSION ASSESSMENT, RESIDENT #505 RETURNED TO THE FACILITY WITH AN OPEN AREA TO HER COCCYX (THE SAME AREA IDENTIFIED PRIOR TO HER DISCHARGE) AND BRUISING TO HER RIGHT HIP AND RIGHT ANTERIOR CALF. PHYSICIAN ORDERS [REDACTED]. RESIDENT #505 HAD ANOTHER HOSPITAL TRANSFER ON 03/06/2013 AND RETURNED to the facility on [DATE]. UPON RETURN TO THE FACILITY, ACCORDING TO THE SKIN ASSESSMENT, RESIDENT #505 STILL HAD THE COCCYX WOUND (MEASURING 8 X 6 X 3) AND BILATERAL HIP WOUNDS. PHYSICIAN ORDERS [REDACTED]. ACCORDING TO WOUND/SKIN HEALING RECORD FOR THE MONTH OF APRIL 2013, RESIDENT #505 HAD THE FOLLOWING AREAS ON HER BODY IDENTIFIED AS REQUIRING WOUND TREATMENT: BILATERAL EARS (DATE OF ONSET NOT DOCUMENTED); RIGHT HEEL (DATE OF ONSET 03/18/2013); RIGHT GREAT TOE (DATE OF ONSET 03/18/2013); AND, SACROCOCCYGEAL/BUTTOCK (DATE OF ONSET NOT DOCUMENTED). EACH WOUND IDENTIFIED HAD BEEN TREATED WITH SANTYL. ON 04/23/2013 AN INTERVIEW WAS CONDUCTED WITH LPN # 14 WHO EXPLAINED THAT RESIDENT #505 HAD FIVE IDENTIFIED OPEN AREAS THAT REQUIRED TREATMENT. WHEN LPN #14 WAS QUERIED AS TO WHETHER RESIDENT #505 HAD ANY WOUNDS ON HER BACK, SHE (#14) ANSWERED "NO." ON 04/24/2013 AT 9:50 A.M., A WOUND TREATMENT OBSERVATION WAS MADE WITH LPN #14, LPN #4 AND DOCTOR #16. LPN #14 REPORTED THAT TWO NEW OPEN AREAS HAD BEEN DISCOVERED (ON #505) ON 04/23/2013 LOCATED AT "HER RIGHT INNER KNEE AND HER LEFT INNER CALF." DOCTOR #16 EXPLAINED THAT THE NEW OPEN AREAS AT RESIDENT #505'S KNEES LOOKED AS THOUGH SHEARING HAD OCCURRED. WHEN DOCTOR #16 WAS QUERIED AS TO WHETHER THE SHEARING COULD POTENTIALLY BE THE RESULT OF RESIDENT #505'S KNEES RUBBING TOGETHER, HE ANSWERED, "IT COULD BE MOST LIKELY." ON OBSERVATION, THE FOLLOWING AREAS WERE IDENTIFIED AS REQUIRING TREATMENT: BILATERAL EARS: RIGHT EAR 1.5 CM (CENTIMETER) X 1.5 CM (UNSTAGEABLE) AND 0.5 X 0.8 STAGE 2; AND, LEFT EAR 2 X 0.5 CM AND 0.5 CM X 0.1 CM. THE RIGHT HEEL HAD RESOLVED, BUT DRY SKIN WAS NOTED. RIGHT LATERAL FOOT 5.5 CM X 11.5 CM, UNSTAGEABLE DTI (DEEP TISSUE INJURY). RIGHT LATERAL ANKLE 2 CM X 1.5 CM, ALSO A DTI. LEFT LATERAL FOOT 4.2 CM X 4.5 CM, DTI. OBSERVATION OF RESIDENT #505'S FEET REVEALED VERY DRY, FLAKY SKIN. LEFT LATERAL ANKLE 1.2 CM X 2 CM. LEFT INNER CALF 3 CM X 2 CM (STAGE 2 SHEARING). RIGHT INNER KNEE 3.5 X 4.7 CM (DESCRIBED AS SHEARING). SACROCOCCYGEAL 9 CM X 9 CM X 3.2 (NECROTIC BASE, UNSTAGEABLE). RIGHT POSTERIOR THORAX (RIGHT UPPER BACK) 2.5 CM X 4 CM, (UNSTAGEABLE WOUND WITH NECROTIC BASE). THIS WOUND HAD NOT BEEN IDENTIFIED BY THE FACILITY. LPN #14 STATED "I DIDN'T KNOW IT WAS THERE." THERE WAS NO DOCUMENTATION TO SHOW THAT THE WOUND HAD BEEN IDENTIFIED OR TREATED. LEFT POSTERIOR THORAX (LEFT UPPER BACK) 4 CM X 4.5 CM (UNSTAGEABLE WITH NECROTIC BASE). THIS WOUND WAS COVERED WITH A 4 X 4 (GAUZE COVERING) THAT WAS DATED 4/23. IT WAS UNCLEAR WHEN THE WOUND WAS IDENTIFIED, AND IF THE WOUND WAS TREATED OR JUST COVERED WITH GAUZE. THERE WAS NO DOCUMENTATION IN THE CLINICAL RECORD SHOWING THE IDENTIFICATION OF THE LEFT POSTERIOR THORAX WOUND. RIGHT HIP 3.5 X 4.0 DTI WITH A SMALL OPEN AREA NOTED WITHIN. LEFT HIP 6 CM X 6 CM (UNSTAGEABLE WITH A NECROTIC BASE). IN ADDITION TO THE SEVEN AREAS THAT THE FACILITY HAD IDENTIFIED AND PROVIDED TREATMENT FOR, THERE WERE SIX NEW AREAS OF IMPAIRED SKIN INTEGRITY THAT HAD NOT BEEN ASSESSED, OR TREATED. WHEN INTERVIEWED, THE DON EXPLAINED THAT A SKIN SWEEP OF THE ENTIRE FACILITY WAS COMPLETED TO ASSESS ALL RESIDENTS' SKIN INTEGRITY. THE DON COULD NOT EXPLAIN WHY THE UNIDENTIFIED WOUNDS HAD NOT BEEN DOCUMENTED FOR RESIDENT #505, BUT SHE DID SAY THAT THE FACILITY INTENDED TO HIRE A PHYSICIAN ASSISTANT TO OVERSEE WOUND CARE IN THE FACILITY. REVIEW OF THE CARE PLAN DATED 04/08/2013 REVEALED "(RESIDENT #505) HAS A STAGE 3 SACRAL ULCER AND SHE IS AT FURTHER RISK FOR PRESSURE SORE DEVELOPMENT...4/23/13 ADD HAS NEW OPEN AREAS RIGHT INNER KNEE AND LEFT INNER CALF AND LEFT LATERAL SIDE OF FOOT..." INTERVENTIONS INDICATED "APPLY MOISTURIZER TO SKIN, ASSESS/MONITOR WOUND HEALING...ASSIST WITH TURNING AND REPOSITIONING EVERY 2 HOURS AND PRN, FLOAT HEELS OFF MATTRESS..." THE FACILITY POLICY ENTITLED "SKIN MANAGEMENT" APPROVED ON 05/2012 REVEALED "RESIDENTS WITH WOUNDS AND OR PRESSURE ULCERS AND THOSE AT RISK FOR SKIN COMPROMISE ARE IDENTIFIED, ASSESSED AND PROVIDED APPROPRIATE TREATMENT TO PROMOTE HEALING." ( )

THIS CITATION PERTAINS TO INTAKE NUMBER MI 101 BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ASSESS A CHANGE IN CONDITION AND FAILED TO APPLY INTERVENTIONS IN ACCORDANCE WITH THE physician's orders [REDACTED].#505 SUSTAINING A FALL WITH HEAD INJURY AND RESULTANT RIGHT THALAMIC INTRAPARENCHYMAL HEMORRHAGE (IPH). FINDINGS INCLUDE: A REVIEW OF THE FACILITY'S ADMISSION RECORD REVEALED THAT RESIDENT #505 WAS admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE CLINICAL RECORD INDICATED AN ADDITIONAL [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) assessment dated [DATE], DOCUMENTED THAT RESIDENT #505 REQUIRED EXTENSIVE TO TOTAL ASSISTANCE WITH ALL ACTIVITIES OF DAILY LIVING INCLUDING BED MOBILITY, TRANSFERS TOILETING, PERSONAL HYGIENE AND BATHING. THE MDS FURTHER INDICATED THAT #505 WAS NON-AMBULATORY AND WAS NOT STEADY WITH SURFACE TO SURFACE TRANSFERS. A REVIEW OF THE FACILITY'S "INCIDENT AND ACCIDENT REPORT" DATED 3/21/12, REVEALED THAT ON 3/21/12 AT 1:00 A.M., RESIDENT #505 WAS OBSERVED IN HER ROOM ON THE FLOOR WITH A BUMP TO HER RIGHT FOREHEAD. "...DURING ROUNDS AROUND 11:30 P.M. NOTED RESIDENT LAYING IN BED ATTEMPTING TO GET OUT OF BED. FLOOR MATS WERE IN PLACE. AT 1:00 A.M. CERTIFIED NURSING ASSISTANT (CNA #2) WALKING DOWN THE HALLWAY AND OBSERVED RESIDENT (#505) ATTEMPTING TO GET OUT OF BED, BEFORE SHE (CNA #2) COULD GET INTO THE PATIENT'S (#505) ROOM, #505 fell OUT OF THE BED ONTO THE FLOOR MAT. NURSE (LICENSED PRACTICAL NURSE #3) ENTERED ROOM AND OBSERVED (#505) LAYING ON THE FLOOR MAT ON HER ABDOMEN. A LUMP LOCATED ON THE RIGHT SIDE OF (#505'S) FOREHEAD..." "...INTERVENTIONS IMPLEMENTED: (#505) WAS INSTRUCTED NOT TO ATTEMPT TO GET OUT OF TH BED WITHOUT ASSISTANCE. (#505'S) CALL LIGHT WAS PLACED WITHIN REACH AND EYESIGHT. WRITER WILL CONTINUE TO MONITOR (#505) FREQUENTLY TO MAINTAIN SAFETY. MONITOR PATIENT EVERY 15 MINUTES. WILL ENDORSE TO ONCOMING SHIFT. RESIDENT (#505) SENT TO HOSPITAL FOR FURTHER EVALUATION..." THE FACILITY'S "INCIDENT AND ACCIDENT INVESTIGATION FORM" DATED 3/21/12, DOCUMENTED, "...THROUGH IN HOUSE INVESTIGATION, IT WAS CONCLUDED THAT RESIDENT HAD SOME MENTAL STATUS CHANGES AND ATTEMPTED TO GET OUT OF BED MULTIPLE TIMES AND RESULTING IN A FALL..." "...PROVIDE A BRIEF DESCRIPTION OF THE PLAN TO AVOID THIS SITUATION IN THE FUTURE IF APPLICABLE: MAKE SURE SAFETY DEVICES ARE IN PLACE. ASSESS RESIDENTS FOR CHANGE IN CONDITION AND NOTIFY M.D. (MEDICAL DOCTOR/PHYSICIAN)..." A REVIEW OF RESIDENT #505'S HOSPITAL "CONSULTATION NOTE" DATED 3/21/12 REVEALED, "...SHE (#505) IS A [AGE] year OLD FEMALE WHO PRESENTS status [REDACTED]. AN ADDITIONAL CONSULTATION NOTE DATED 3/21/12 NOTED, "...IMPRESSION: HEADACHE, SMALL RIGHT THALAMIC INTRAPARENCHYMAL HEMORRHAGE, status [REDACTED]. ADMIT TO INTENSIVE CARE UNIT..." A HOSPITAL PROGRESS NOTE DATED 3/22/12 FURTHER IDENTIFIED "S/P (status [REDACTED]." RESIDENT #505'S "HISTORY AND PHYSICAL," REPORT DATED 10/15/11, NOTED, "...FOR FALL RISK, SHE (#505) WILL HAVE THE FOLLOWING: BED ALARM, WHEELCHAIR ALARM, FLOOR MATS, LOW BED..." A REVIEW OF #505'S "PHYSICIAN'S ADMISSION ORDER SHEET" FOR THE MONTH OF OCTOBER 2011 REVEALED, "...BILATERAL FLOOR MATS FOR SAFETY PRECAUTION, BED AND WHEELCHAIR ALARM, CHECK FUNCTIONING AND PLACEMENT EVERY SHIFT AND AS NEEDED..." REVIEW OF THE CLINICAL RECORD REVEALED THAT THE ABOVE INTERVENTIONS WERE ORDERED FOR THE MONTHS OF DECEMBER 2011, JANUARY 2012, FEBRUARY 2012 AND MARCH 2012, THE ORDER FOR PREVENTIVE FALL INTERVENTIONS HAD NOT BEEN DISCONTINUED. A REVIEW OF RESIDENT #505'S "FALL" CARE PLAN DATED 10/23/11 REVEALED, "...HIGH RISK FOR FALLS RELATED TO RESIDENT HAS IMPAIRED MOBILITY SECONDARY TO SPINAL STENOSIS..." THE FALL CARE PLAN LISTED THE FOLLOWING INTERVENTIONS: "...FLOOR MATS AT BEDSIDE. KEEP BED AT LOWEST POSITION. TAKE RESIDENT TO SUPERVISED AREAS AS NEEDED..." ON 3/29/12 AT 11:00 A.M., DURING AN INTERVIEW, THE DIRECTOR OF NURSING (DON) REPORTED, "...SHE (#505) fell OUT OF HER BED. SHE WAS ALONE IN HER ROOM WHEN SHE fell . ONE OF THE CNAS SAID SHE KEPT TRYING TO GET OUT OF BED, WHICH IS VERY UNUSUAL FOR HER. HER FAMILY MEMBER (FM #1) WAS TELLING THE STAFF THAT SHE (#505) KEPT TRYING TO GET OUT OF BED SO WE PUT WEDGES IN PLACE..." THE DON FURTHER REPORTED, "...THAT TYPE OF BEHAVIOR WAS ATYPICAL FOR HER. THE NURSE (LICENSED PRACTICAL NURSE #3) SHOULD'VE GOTTEN A UA (URINALYSIS). I WOULD'VE GOTTEN ONE. NOTHING ELSE HAPPENED UNTIL AFTER THE FALL. THAT'S WHEN WE DID NEUROLOGICAL CHECKS. THE BED ALARM WAS PUT IN PLACE AFTER THE FALL..." ADDITIONALLY, THE DON REPORTED, "...LICENSED PRACTICAL NURSE (LPN) #4 SENT HER OUT TO THE HOSPITAL..." WHEN ASKED ABOUT THE EXTENT OF #505'S INJURIES, THE DON SAID, "...I KNOW THERE WAS BRUISING. I SAW THEM MYSELF ON HER FOREHEAD. I CALLED THE HOSPITAL LATER AND THEY INFORMED ME THAT SHE WAS IN THE INTENSIVE CARE UNIT AND HAD A SMALL BLEED IN HER BRAIN..." WHEN ASKED IF LPN #3 HAD NOTIFIED THE PHYSICIAN ABOUT #505'S ATYPICAL BEHAVIOR OF MULTIPLE ATTEMPTS TO GET OUT OF BED, THE DON SAID, "NO." ON 3/29/12 AT 11:35 A.M., THE FACILITY'S ADMINISTRATOR, WHO WAS PRESENT DURING THE INTERVIEW WITH THE DON, REPORTED, "...WHEN THERE WAS A CHANGE IN CONDITION, SHE (LPN #3) SHOULD'VE CONTACTED THE PHYSICIAN..." ON 3/29/12 AT 11:50 A.M., DURING AN INTERVIEW, LPN #4 REPORTED, "...I GOT REPORTED THAT SHE (#505) fell . I SENT HER OUT TO THE HOSPITAL BECAUSE OF THE STATE OF HER BRUISING TO HER FACE AND HER MENTAL STATUS AND CONFUSION. YOU COULD TELL THERE WAS SOME CHANGE. MY INSTINCTS TOLD ME TO SEND HER OUT. SHE NEVER had a history of [REDACTED]. WHEN ASKED IF RESIDENT #505 HAD ALARMS IN PLACE THAT WOULD ALERT STAFF OF ANY ATTEMPTS TO SELF TRANSFER OR GET OUT OF BED, LPN #4 SAID, "...THERE WERE NO ALARMS IN PLACE PRIOR TO HER FALL..." ON 3/29/12 AT 1:00 P.M., IN A SUBSEQUENT INTERVIEW, THE DON WAS QUERIED ABOUT THE physician's orders [REDACTED]. I SEE THEY (STAFF) DIDN'T FOLLOW THE physician's orders [REDACTED]. I KNOW WE HAVE A PROBLEM WITH CARE PLANS. WE'RE ADDRESSING THOSE ISSUES NOW..." THE DON COULD NOT EXPLAIN WHY NURSING STAFF FAILED TO TRANSCRIBE physician's orders [REDACTED].#505'S NEEDS WERE MET. ON 3/29/12 AT 1:45 P.M., DURING AN INTERVIEW, FM #1 REPORTED THE FOLLOWING, "...I WAS HERE VISITING ON THE EVENING BEFORE HER FALL. SHE (#505) JUST KEPT TRYING TO SCOOT OUT OF HER BED. HER FEET TOUCHED THE FLOOR SEVERAL TIMES AND SHE KEPT SAYING SHE WAS TRYING TO GET OUT OF THE BED. I TOLD CNA #3 AND WE PUT HER BACK IN THE BED. SHE (#505) TRIED IT AGAIN, SO I PUT HER LEGS AND FEET BACK IN THE BED. I WENT AND TOLD (LPN #3) BUT SHE WAS PASSING HER PILLS (MEDICATIONS). (LPN #3) LATER CAME IN THE ROOM AND TOLD (#505), "PROMISE ME YOU WON'T GET OUT OF THE BED," THEN SHE (LPN #3) LEFT AND STARTING PASSING PILLS AGAIN..." FM #1 FURTHER REPORTED, "...I LEFT AROUND 11:00 P.M. AND (LPN #3) WAS STILL HERE SITTING BEHIND THE COUNTER (NURSES STATION). BEFORE I LEFT, I TOLD HER (LPN #3) THAT SHE (#505) WAS STILL TRYING TO GET OUT OF THE BED SO (CNA #3) SAID HE WOULD GET SOME FOAM WEDGES. I ASKED (LPN #3) IF SHE COULD PUT ALARMS ON THE BED AND SHE TOLD ME SHE HAD TO GET A DOCTOR'S ORDER IN ORDER TO PUT ALARMS ON. I ASKED HER TO MAKE A NOTE THAT I ASKED FOR THE ALARMS BUT I GUESS SHE WAS OFF WORK BY THAT TIME. THERE WERE NO ALARMS BUT I DO RECALL SEEING TWO MATS ON THE FLOOR..." ADDITIONALLY, FM #1 REPORTED, "...I WASN'T SHOCKED THAT SHE (#505) fell . IF SOMETHING HAD BEEN DONE, THIS WOULDN'T HAVE HAPPENED. HER FACE WAS BLACK AND BLUE..." ON 3/29/12 AT 2:35 P.M., CNA #2 WAS INTERVIEWED AND REPORTED, "...I WAS THE ASSIGNED CNA THE NIGHT SHE fell . I WAS WALKING DOWN THE HALL AND BY THE TIME I GOT TO HER ROOM, SHE WAS HANGING OUT OF HER BED. SHE JUST fell AS I WAS WALKING BY. SHE DIDN'T HAVE ANY ALARMS. SHE JUST HAD FOAM WEDGES. WHEN SHE fell , SHE LANDED ON A FLOOR MAT. SHE fell on HER FACE..." ON 3/29/12 AT 3:10 P.M., DURING AN INTERVIEW, LPN #3 REPORTED, "...(FM #1) WAS VISITING WITH HER (#505) AND SAID SHE KEEPS TRYING TO GET UP. (CNA #3) TOILETED HER AND I TALKED TO HER AND TOLD HER THAT SHE WAS TOO WEAK TO GET UP. I HAD NEVER SEEN HER DO THAT BEFORE. BEFORE (FM #1) LEFT, HE SAID THAT SHE (#505) STILL KEEPS TRYING TO GET OUT OF BED SO (CNA #3) WENT AND FOUND SOME WEDGES TO PUT ON HER BED. (CNA #3) ELEVATED THE HEAD AND FOOT OF HER BED SO SHE COULDN'T GET OUT. I STOOD AND WATCHER HER AS HE DID THIS. IT WAS REALLY UNUSUAL. (FM #1) WAS REALLY CONCERNED ABOUT HER. SHE WAS SO WEAK. SHE COULDN'T EVEN STAND. I ENDORSED IT TO THE NEXT SHIFT AND TOLD THEM SHE USUALLY DIDN'T TRY TO GET OUT OF BED SO WE HAD TO PUT WEDGES ON THE BED..." LPN #3 FURTHER REPORTED, "...THIS WAS ATYPICAL BEHAVIOR. I HAD NEVER SEEN HER LIKE THAT BEFORE BUT I DIDN'T THINK THAT MUCH OF IT..." WHEN ASKED IF THE PHYSICIAN HAD BEEN NOTIFIED OF #505'S CHANGE IN CONDITION AND ATYPICAL BEHAVIOR, LPN #3 SAID, "NO." WHEN ASKED IF ALARMS WERE IN PLACE, LPN #3 SAID, "...NO. SHE DIDN'T HAVE ALARMS. SHE HAD NOTHING BEFORE WE PUT THE WEDGES ON..." WHEN ASKED IF #505 HAD AN ORDER TO HAVE ALARMS, LPN #3 SAID, "...NO. THEY HAD NOT BEEN ORDERED BY THE PHYSICIAN..." THE SURVEYOR PRESENTED LPN #3 WITH #505'S physician's orders [REDACTED]. AFTER REVIEW OF THE DOCUMENTATION, LPN #3 SAID, "...EVER SINCE I'VE BEEN DOWN THAT HALL, SHE (#505) HAS NEVER HAD THOSE THINGS..." WHEN ASKED IF SHE (LPN #3) HAD REVIEWED THE CLINICAL RECORD AND physician's orders [REDACTED]. I USUALLY GO BY WHAT'S ON THE MEDICATION ADMINISTRATION RECORD (MARS)..." WHEN ASKED IF THE PHYSICIAN HAD BEEN NOTIFIED OR IF A URINALYSIS (U/A) HAD BEEN PERFORMED IN ORDER TO DETECT THE PRESENCE OF A UTI WHICH WOULD CAUSE MENTAL STATUS CHANGES, LPN #3 REPORTED, "...I ENDORSED IT TO THE ONCOMING SHIFT. I HAD DONE A U/A TWO WEEKS PRIOR BECAUSE HER FAMILY SAID SHE WAS ACTING DIFFERENT AND SHE ENDED UP NOT HAVING A UTI..." LPN #3 FURTHER REPORTED, "...IF I COLLECTED A SPECIMEN ON EVERYONE WHO ACTED DIFFERENTLY, I'D BE COLLECTING SPECIMENS ALL THE TIME..." LPN #3 OFFERED NO VIABLE EXPLANATION OF WHY SHE FAILED TO PROPERLY ASSESS RESIDENT #505'S ATYPICAL BEHAVIOR AND SUBSEQUENT CHANGE IN CONDITION AND NOTIFY THE PHYSICIAN AND WHY SHE FAILED TO APPLY ALARMS TO #505'S BED IN ACCORDANCE WITH physician's orders [REDACTED]. A REVIEW OF THE FACILITY'S "FALL MANAGEMENT' POLICY DATED 5/2010 REVEALED: "...THE FACILITY WILL IDENTIFY HAZARDS AND RESIDENT RISK FACTORS AND IMPLEMENT INTERVENTIONS TO MINIMIZE FALLS..." "...EACH RESIDENT IS ASSISTED IN ATTAINING/MAINTAINING HIS OR HER HIGHEST PRACTICAL LEVEL OF FUNCTION BY PROVIDING THE RESIDENT ADEQUATE SUPERVISION, ASSISTIVE DEVICES, AND/OR FUNCTIONAL PROGRAMS AS APPROPRIATE TO MINIMIZE THE RISK FOR FALLS. RESIDENTS WILL BE EVALUATED BY THE INTERDISCIPLINARY TEAM FOR THEIR RISK FOR FALLS. A PLAN OF CARE IS DEVELOPED AND IMPLEMENTED BASED ON THIS EVALUATION WITH ONGOING REVIEW..." "...THE LICENSED NURSE WILL ASSESS RESIDENTS FOR FALL RISK UPON ADMISSION, RE-ADMISSION, QUARTERLY, ANNUALLY AND WITH A SIGNIFICANT CHANGE..." "...RESIDENTS IDENTIFIED AT RISK FOR FALLS WILL HAVE A CARE PLAN DEVELOPED AND IMPLEMENT APPROPRIATE FALL PREVENTION INTERVENTIONS..."

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO: 1. ASSESS AND IMPLEMENT INTERVENTIONS TO PREVENT THE DEVELOPMENT OF PRESSURE ULCERS FOR TWO OF FOUR RESIDENTS (#702 AND #703) IDENTIFIED WITH PRESSURE ULCERS OUT OF A TOTAL SAMPLE OF 20 RESIDENTS, AND; 2. FAILED TO PROVIDE APPROPRIATE CARE TO PREVENT POTENTIAL INFECTION FOR ONE RESIDENT (#702), RESULTING IN THE DEVELOPMENT OF FACILITY ACQUIRED PRESSURE ULCERS AND THE POTENTIAL FOR INFECTION. FINDINGS INCLUDE: A REVIEW OF THE ADMISSION RECORD, ON 2/16/11 AT 1:30 P.M., REVEALED THAT RESIDENT #702 WAS admitted TO THE FACILITY WITH [DIAGNOSES REDACTED]. A REVIEW OF A SIGNIFICANT CHANGE MINIMUM DATA SET (MDS), WITH AN ASSESSMENT REFERENCE DATE OF 11/23/10, REVEALED THAT RESIDENT #702 IS SEVERELY COGNITIVELY IMPAIRED, INCONTINENT OF BOWEL, HAS A URINARY CATHETER (TUBING INSERTED INTO THE BLADDER TO DRAIN URINE) AND A PERCUTANEOUS ENDOSCOPIC GASTROSTOMY TUBE (A TUBE INSERTED THROUGH A SMALL INCISION IN THE ABDOMEN INTO THE STOMACH AND IS USED FOR LONG-TERM NUTRITION). THE MDS ALSO INDICATED THAT THE RESIDENT IS TOTALLY DEPENDENT ON STAFF FOR CARE. ON 2/16/11 AT 9:45 A.M., CARE WAS OBSERVED FOR RESIDENT #702. CERTIFIED NURSING ASSISTANT (CNA) "B" BATHED THE RESIDENT AND PROVIDED MOUTH AND CATHETER CARE. AS CNA "B" TURNED THE RESIDENT TO HER SIDE, A STAGE FOUR PRESSURE ULCER (FULL THICKNESS TISSUE LOSS WITH EXPOSED BONE, TENDON OR MUSCLE) WAS OBSERVED ON THE RESIDENT'S SACRUM AND 2ND PRESSURE ULCER WAS NOTED ON THE RIGHT SCAPULA/UPPER BACK AREA. THERE WAS NO DRESSING ON EITHER OF THE PRESSURE ULCERS AND THERE WAS A MODERATE AMOUNT OF SERO-SANGUINOUS (BLOOD AND SEROUS FLUID) DRAINAGE ON THE RESIDENT'S ADULT BRIEF. CNA "B" WAS QUESTIONED ABOUT THE LACK OF DRESSINGS ON THE RESIDENT'S WOUNDS AND INDICATED THAT SHE HAD NOT CLEANED UP THE RESIDENT EARLIER AND HAD NOT REMOVED THE DRESSINGS. ON 2/16/11 AT 11:20 A.M. WOUND CARE WAS OBSERVED FOR RESIDENT #702. THERE WAS STILL NO DRESSINGS ON EITHER OF THE RESIDENT'S WOUNDS. WOUND CARE NURSE "A" INDICATED THAT THE CNA AND/OR HOSPICE AIDE WHO PROVIDE CARE FOR THE RESIDENT HAD NOT INFORMED HER OF THE RESIDENT'S DRESSINGS COMING OFF OR BEING REMOVED. WOUND NURSE "A" REVEALED THAT THE PRESSURE ULCER ON THE RESIDENT'S RIGHT UPPER BACK/SCAPULA DEVELOPED DURING A RECENT hospitalization . THE PRESSURE ULCER WAS PARTIALLY COVERED WITH A THICK AMOUNT OF YELLOW SLOUGH AND THEREFORE UNABLE TO STAGE ADEQUATELY. THE WOUND MEASURED 2.4 CM BY 2.0 CM. WOUND CARE NURSE "A" INDICATED THAT THE SACRAL PRESSURE ULCER DEVELOPED IN THE FACILITY AND HAD BEEN IDENTIFIED BY THE WOUND CARE PHYSICIAN AS A KENNEDY TERMINAL ULCER (A TYPE OF PRESSURE ULCER THAT IS USUALLY FOUND ON THE SACRUM OR COCCYX, IT CAN HAVE THE SHAPE OF A PEAR, BUTTERFLY OR HORSESHOE AND MAY DEVELOP RAPIDLY TO A STAGE 2, 3 OR 4 ULCER). THE SACRO-COCCYX WOUND MEASURED 8.0 CENTIMETERS (CM) BY 7.0 CM BY 3.5 CM. ON 2/8/11. A REVIEW OF THE WOUND CARE NOTES, REVEALED THAT THE RESIDENT'S PRESSURE ULCER WAS FIRST IDENTIFIED ON 8/31/10 AND WAS DESCRIBED AS "NECROTIC AREA TO COCCYX....UTD (UNABLE TO DETERMINE) WITH [MEDICAL CONDITION]." A WOUND CARE CONSULTATION REPORT, DATED 8/31/10, NOTED THAT THE PRESSURE ULCER MEASURED 3.2 CENTIMETERS (CM) BY 2.0 CM, WITH A NECROTIC BASE, [DIAGNOSES REDACTED] (REDNESS) AND INDURATION (HARDNESS). RECOMMENDATIONS LISTED ON THE REPORT INCLUDED: 1. [MEDICATION NAME] (A MEDICATION USED TO TREAT PREVENT AND TREAT INFECTIONS), 2. ROHO CUSHION TO WHEELCHAIR, 3. MAY SIT FOR ONE HOUR PER OCCURRENCE, 4. PRESSURE REDUCTION MATTRESS, 5. FREQUENTLY REPOSITION, 6. FLOAT HEELS, 7. [MEDICATION NAME] (ANTIBIOTIC) 875 MILLIGRAMS BID (TWICE A DAY) FOR 14 DAYS. THE RESIDENT WAS TRANSFERRED TO A LOCAL HOSPITAL THE FOLLOWING DAY - 9/1/10. THE FINAL REPORT FROM THE LOCAL HOSPITAL INDICATED THAT THE RESIDENT WAS admitted WITH FEVER, LETHARGY AND A NECROTIC SACRAL DECUBITUS (PRESSURE) ULCER. THE RESIDENT WAS PLACE ON INTRAVENOUS ANTIBIOTICS, THE PRESSURE ULCER WAS DEBRIDED (SURGICAL REMOVAL OF DEAD, DAMAGED TISSUE), AND A PEG TUBE WAS INSERTED TO IMPROVE THE RESIDENT'S NUTRITIONAL STATUS. THE RESIDENT RETURNED to the facility on [DATE]. A REVIEW OF THE NURSING WEEKLY SKIN ASSESSMENTS, PRIOR TO THE IDENTIFICATION OF THE UTD PRESSURE ULCER ON 8/31/10, REVEALED THAT THE RESIDENT HAD AN "OPEN ULCER...RE-OPENING INNER TOP BUTTOCK" ON 8/5/10. WEEKLY SKIN ASSESSMENTS, DATED 8/12/10, 8/19/10 AND 8/26/10 ALL NOTED THE RESIDENT AS HAVING AN "OPEN AREA". NURSING NOTES, DATED 8/26/10, IDENTIFIED THE RESIDENT AS HAVING AN "OPEN WOUND IN INNER BUTTOCK PINK IN COLOR....NO DRAINAGE OR ODOR." STAFF WERE TREATING THE OPEN AREAS NOTED ABOVE WITH [MEDICATION NAME] PASTE (A PROTECTANT BARRIER CREAM). A REVIEW OF THE NURSING NOTES, PRIOR TO THE DEVELOPMENT OF THE RESIDENT'S PRESSURE ULCER ON 8/31/11, REVEALED THAT STAFF WERE TURNING THE RESIDENT IN BED. HOWEVER, THERE WAS NO INFORMATION IN THE NURSING NOTES OR IN ANY OTHER DOCUMENTATION, REGARDING HOW LONG THE RESIDENT REMAINED IN HER WHEELCHAIR DURING THE DAY AND/OR HOW OFTEN THE RESIDENT WAS ASSISTED WITH REPOSITIONING WHILE IN THE WHEELCHAIR. WOUND CARE NURSE "A", IN AN INTERVIEW ON 2/18/10 AT 12:15 P.M., STATED THAT"OPEN AREAS" WERE EXCORIATION AND NOT A PRESSURE ULCER. SHE ALSO INDICATED THAT SHE LEFT FOR VACATION ON 8/24/10 AND RETURNED ON 8/31/10, TO DISCOVER THE RESIDENT'S WOUND HAD DEVELOPED. ON 11/11/10 THE RESIDENT WAS PLACED UNDER HOSPICE CARE. THE FIRST DOCUMENTATION OF THE RESIDENT'S PRESSURE ULCER BEING TERMED A "KENNEDY TERMINAL ULCER" WAS IN A WOUND CONSULTATION RECORD DATED 12/7/10. ( ) ACCORDING TO A REVIEW OF THE ADMISSION RECORD ON 2/16/10 AT 9:15 A.M., RESIDENT #703 WAS admitted TO THE FACILITY IN JULY 2010 WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS), dated [DATE], REVEALED THAT RESIDENT #703 REQUIRED EXTENSIVE ASSISTANCE WITH TRANSFERS, DRESSING, HYGIENE AND BATHING, WAS INCONTINENT OF BOWEL AND BLADDER, DID NOT WALK, AND WAS admitted WITH PRESSURE ULCERS ON THE RIGHT HIP AND RIGHT BUTTOCKS (GLUTEAL). A BRADEN SCALE (USED TO PREDICT PRESSURE SORE RISK), DONE ON ADMISSION, RATED THE RESIDENT AT A "14" OR MODERATE RISK FOR DEVELOPING PRESSURE ULCERS. FURTHER REVIEW OF THE MEDICAL RECORD REVEALED THAT THE RESIDENT DEVELOPED A PRESSURE ULCER ON THE SACRUM THAT WAS FIRST IDENTIFIED ON 9/28/10 AS A STAGE 3 (FULL THICKNESS TISSUE LOSS). WOUND CARE NURSE "A", IN AN INTERVIEW ON 2/16/10 AT 2:10 P.M., STATED THAT SHE WAS NOT INFORMED OF ANY ABNORMALITIES TO RESIDENT #703'S SKIN UNTIL 9/28/10 AND ADDED THAT THE RESIDENT WAS NON-COMPLIANT WITH SUGGESTIONS TO LIE DOWN. A REVIEW OF THE NURSING NOTES WRITTEN BY WOUND CARE NURSE "A" , NOTED THAT THE WOUND MEASURED 3.5 CENTIMETERS (CM) BY 5.0 CM BY 0.2 CM. ON 9/28/10 WHEN IT WAS FIRST IDENTIFIED. A REVIEW OF THE NURSING WEEKLY (HEAD TO TOE) SKIN ASSESSMENT, DATED 9/3/10, REVEALED THAT THE BUTTOCK/SACRUM AREA OF THE BODY FIGURE ON THE ASSESSMENT FORM WAS CIRCLED WITH A NOTATION THAT THERE WAS AN OPEN AREA. THERE WAS NO EVIDENCE THAT A SKIN ASSESSMENT WAS DONE ON 9/14/10 AND 9/21/10. REVIEW OF NURSING NOTES, DATED 9/19/10 THROUGH 10/2/10, IDENTIFIED THE RESIDENT'S SKIN AS "WARM AND DRY " . THERE WAS NO OTHER DOCUMENTATION ABOUT ANY SKIN ABNORMALITIES OR WOUNDS PRESENT ON RESIDENT'S SKIN IN THE NURSING NOTES, DESPITE THE FACT THAT THE RESIDENT HAD DEVELOPED A STAGE 3 PRESSURE ULCER ON 9/28/10. A REVIEW OF THE NURSING CARE PLAN FOR ALTERATIONS IN SKIN INTEGRITY, WITH AN ONSET DATE OF 8/6/10, LISTED INTERVENTIONS THAT INCLUDED ASSIST RESIDENT OUT OF BED AS TOLERATED, ASSIST TO TURN /REPOSITION EVERY 2 HOURS AND AS NEEDED, AND TO EXAMINE SKIN DAILY DURING CARE AND DURING BATHS/SHOWERS AND REPORT ANY SKIN PROBLEMS TO PHYSICIAN. THERE WAS NO INFORMATION IN THE NURSING CARE PLAN ABOUT ASSISTING AND/OR INSTRUCTING THE RESIDENT ABOUT THE IMPORTANCE OF REPOSITIONING WHILE IN THE WHEELCHAIR. THE FACILITY'S POLICY FOR SKIN MANAGEMENT, DATED 5/2010, LISTED PRACTICE GUIDELINES FOR STAFF TO FOLLOW THAT INCLUDED "THE LICENSED NURSE WILL MONITOR, EVALUATE AND DOCUMENT CHANGES REGARDING SKIN CONDITION IN THE MEDICAL RECORD", "PLACE EACH RESIDENT ON A WEEKLY HEAD-TO-TOE SKIN ASSESSMENT THAT IS COMPLETED BY THE LICENSED NURSE" AND THAT THE CNA'S (CERTIFIED NURSING ASSISTANTS) "WILL REPORT ANY NEW SKIN IMPAIRMENT TO THE LICENSED NURSE THAT IS IDENTIFIED DURING DAILY CARE." THERE WAS NO INFORMATION IN THE RESIDENT'S MEDICAL RECORD TO INDICATE THAT THE FACILITY POLICY HAD BEEN FOLLOWED. ON 2/17/11 AT 9:20 A.M., RESIDENT #703 WAS QUESTIONED REGARDING THE REPORTS BY STAFF OF NON-COMPLIANCE AND REFUSALS TO LIE DOWN TO RELIEVE PRESSURE ON BUTTOCKS. RESIDENT #703 STATED THAT HE NEVER REFUSED TO GO BACK TO BED. THE RESIDENT INDICATED THAT HE WAS UNABLE TO REPOSITION HIMSELF IN THE WHEELCHAIR AND THAT STAFF WOULD "GET ME UP AND PUT ME IN THE WHEELCHAIR BEFORE LUNCH AND WOULD NEVER GET BACK TO PUT ME DOWN." ( )