Every finding on record at St. Anthony Healthcare Center

This citation pertains to Intake 3096981. Based on observation, interview, and record review, the facility failed to provide timely dressing changes for one resident (R149) out of three residents reviewed for wound care. Findings include:On 08/18/2026 at 12:53 PM, an interview was conducted with R149 who said that since they have been in the facility, the bandage on their right foot has not been changed daily as required, and sometimes it had only been changed once or twice a week. They further stated they were concerned because they noticed for the past 3 weeks a green bad smelling fluid coming out of the heel area of their right foot soaking the bandage.A review of R149's electronic medical record (EMR) revealed they were admitted into the facility on 6/10/2026 with diagnoses of Type 2 Diabetes Mellitus with Diabetic Neuropathy (Nerve damage caused by diabetes), cellulitis (bacterial infection) of left lower limb, and non-pressure related chronic ulcer to right lower leg. A review of R149's latest Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9/15, indicating impaired cognition.A review of an active physician order for R149 with a start date of 7/24/2026 revealed an order for a topical product used to remove dead skin tissue. Apply it to the right heel every day (morning) shift, cleanse right heel with wound cleanser solution (1/4 strength), pat dry, apply a nickel thick layer of topical product to remove dead skin tissue plus Calcium Alginate (used to absorb fluid from wounds) to the wound base, cover with dry dressing, apply elastic bandage used to provide compression from toes to knee once daily or as needed.On 08/20/2026 at 11:12 AM, an additional interview was conducted with R149 who was observed to remove their right outer footwear and showed a large amount of dark greenish-brown fluid saturating the entire heel of the bandage on their right foot. A date of 8/18/2026 (2 days prior) was written on the bandage. No elastic compression bandages were observed applied to either of the resident's lower legs. R149 said they asked at least three staff members several times a day for the bandage on their right heel to be changed, but it had not been. They expressed concern about losing their foot, and that on some days it is difficult to find the staff member responsible for changing the bandage.A review of R149's August 2026 Treatment Administration Record (TAR) for wound care to the right heel (including bandage change) revealed on 8/19/26 a 5 was entered on the TAR, by LPN E indicating, Hold/See Nurse Notes. A review of R149's EMR did not reveal any notes documenting or explanation why the right heel bandage change was held.On 8/20/2026 at 11:49 AM, during an interview the facility's wound care nurse, Licensed Practical Nurse (LPN) D stated they have been treating R149's heel wound and were familiar with the green drainage. Along with LPN D observation was made of R149's fluid saturated bandage that should have been changed the previous day. The nurse also noticed R149 had edema (fluid buildup that impedes wound healing) of both lower legs saying, the resident should also have elastic compression bandages placed on both legs for this edema. At this time, LPN D was asked to provide documentation of why R149's bandage change or wound care on 8/19/26 was held. No documentation regarding the held treatment was received prior to survey exit.On 08/20/2026 at 12:21 PM, an interview was conducted with the Director of Nursing (DON), who was speaking to LPN E on the phone. The DON stated LPN E told them they had entered the 5 in the TAR by mistake and did not input a note. The nurse went on to say they meant to enter a 2, which indicates the resident refused the bandage change. No documentation was provided which verified the resident refused the bandage change.A review of R149's care plan revealed a focus area of [R149] has actual impairment to skin integrity r/t (related to) .Right heel is an acute partial thickness vasculitic ulcer (wound in the outer layer of skin related to problems with the blood vessels). Interventions for this focus area include, Compression wraps to BLE (Bilateral-both- Lower Extremities), on in am off in pm, as patient tolerates. and Treatment to skin impairment per order.On 08/20/2026 at 2:32 PM, an additional interview was conducted with the DON who stated even for residents who are known to refuse care, each refusal should be documented in their medical record. They further explained when a resident refuses care, they would hope they would be reapproached to try again later. The DON also said since R149's order for wound care was PRN (as needed), the bandage change could be done at any time, multiple times a day.A facility policy related to wound care was requested via email at 2:38pm on 8/20/2026 but was not received by the end of the survey.

Based on observation, interview, and record review, the facility failed to prevent the development of pressure ulcers for three residents (R104, R106 and R110) out of three residents with pressure ulcers reviewed, resulting in the development of facility acquired stage 4 (full thickness tissue loss with exposed muscle, tendon and or bone) pressure ulcers. Findings Include: This citation includes intake number 3005546. Resident 104 (R104) Review of the Face Sheet and Minimum Data Set (MDS) with Assessment Reference Date(ARD) of 12/9/25 reflected R104 was a [AGE] year old male admitted to the facility on [DATE] with recent readmission post hospital transfer 3/20/26 related to facility acquired stage 4 (full thickness tissue loss with exposed muscle, tendon and or bone) pressure ulcer, and sepsis related to wound infection, with additional diagnoses that included hemiplegia and hemiparesis following cerebral infarction, hypertension, dysphasia(difficulty with swallowing) and communication deficit. The MDS reflected R104 had a BIM (assessment tool) score of 4 which indicated his ability to make daily decisions was severely impaired, and he was dependent on staff for repositioning in bed, transfers, dressing, hygiene, and eating. Continued review the MDS reflected R104 was at risk for pressure ulcer (PU) and had no pressure wounds with no recent weight loss. Review of the MDS, with ARD date of 2/26/26, reflected R104 had 2 facility acquired stage 3 pressure wounds (full thickness tissue loss that extends into subcutaneous fat), and one facility acquired stage 4 pressure wound. Review of complaint received by the State Agency alleged the facility failed to provide adequate and appropriate interventions to prevent and care for facility acquired pressure wounds and infection. Review of the facility Matrix, dated 6/17/26, reflected the facility had five residents with facility acquired pressure ulcers. During a telephone interview on 6/17/26 at 1:12 pm, complainant C verified had concerns that R104 had not received appropriate care and services to prevent the development of multiple stage 3 and 4 pressure wounds that became infected and contributed to R104 death. Complainant C reported family was R104 responsible party and reported facility did not make responsible party aware of extent of wound development and decline until R104 was transferred to the hospital on 2/13/26 when R104 was admitted for sepsis related to osteomyelitis (infection in bone secondary to wound infection). Complainant C reported facility contacted responsible party after R104 was transferred to the hospital on 3/22/26 after continued decline and R104's responsible party informed the facility staff that R104 had passed away. Review of R104 Braden assessment score, dated 11/27/25, reflected score of 14, which indicated moderate risk for developing pressure ulcers. Review of R104 Nurse Progress Skin Issue Note, dated 12/21/2025, reflected, New skin Issue. Location: Coccyx Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound acquired in-house. Wound is new.Length (cm): 0.5 Width (cm): 0.5 Depth (cm): 0.1.Skin issue notification: Wound nurse Review of R104 Skin Issue Progress Notes, dated 12/31/2025, reflected, Skin Issue: #001: Skin issue has been evaluated. Location: Coccyx. Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Wound acquired in-house. Wound is new.Length (cm): 3.34 Width (cm): 3.44 Depth(cm): 0.1 Area (cm2): 8.92 .Other primary dressing: Triad Paste to wound base Secondary dressing: Dry. Modalities: None. Note was completed by facility Wound Nurse (WN) D. Review of Electronic Medical Record (EMR) reflected no evidence R104's wounds had been assessed between 12/21/25 and 12/31/25 (10 days after new facility acquired pressure wound identified) that included measurements and wound nurse assessment. Review of R104 Skin Issue Progress Note, dated 1/8/26, reflected, .Other primary dressing: Santyl (a nickel thick layer) + Calcium Alginate.Skin Issues Note: Sacrococcyx is a chronic Stage 4 Pressure Injury Pressure Ulcer and has received a status of not healed. Subsequent wound encounter measurements are 3.7cm length x 6.5cm width x 1.2 cm depth, with an area of 24.05 sq cm and a volume of 28.86 cubic cm. No tunneling has been noted. Undermining has been noted at 1:00 and ends at 3:00 with a maximum distance of 5cm. There is a large amount of serosanguineous drainage noted. Note completed by WN D. Significant increase in size in past 8 days and decline from stage 2 to stage 4. Review of R104 Treatment Administration Record (TAR), dated 1/1/26 through 1/15/26, reflected R104 received the following treatments as indicated by initials on TAR: 1/1/26 through 1/15/26-clean coccyx wound with wound cleaner, apply triad [NAME] cover with dry dressing every day shift -Start Date-12/22/2025.-D/C[discontinue] Date-01/15/2026. Continued review of the TAR reflected no evidence Provider ordered treatments were implemented on 1/8/26 for Santyl (a nickel thick layer) + Calcium Alginate. Review of R104 Provider Note, dated 1/9/26, reflected, Exam Findings General Positive: Well developed, Well nourished, Appears comfortable, Alert, Awake. Review of R104 Nurse Note, dated 1/11/26, reflected, Resident has what appears to be a blister that bust open on his L[left] heel. Area was cleansed with wound cleaner and a dry dressing was applied. Wound care consult was placed. Review of R104 Skin Check Notes, dated 1/12/26, reflected, Coccyx. Stage 2 Pressure. New skin Issue. Location: Left heel.Blister. Progress: New: new wound. Wound acquired in-house.Length (cm): 0.5 Width (cm): 0.5 Depth (cm): 0. New skin Issue. Location: Right heel.Issue type: Bruising. Progress: New: new wound. Wound acquired in-house.Length (cm): 0.5 Width (cm): 0.2 Depth (cm): 0. Review of R104 At Risk Progress Note, dated 1/14/2026, reflected, Clinical Indicator: Wound Action Taken: Seen by the wound care team weekly. Please note the change in diagnosis. Sacrococcyx is an acute Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Review of R104 Skin Issue Progress Note, dated 1/15/26, reflected, Skin issue has been evaluated. Location: Left heel.Issue type: Pressure ulcer / injury. Progress: New: new wound. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. It is unknown how long the wound has been present. [documented in Progress Notes on 1/11/26].Length (cm): 1.73 Width (cm): 2.1 Depth (cm): 0.1 Area (cm2): 2.76. Generic wound cleanser. Debridement: Enzymatic. Other primary dressing: Santyl (a nickel thick layer) + Calcium Alginate Secondary dressing: Dry. #003: Skin issue has been evaluated. Location: Right heel.Issue type: Pressure ulcer / injury. Progress: Stable: previously deteriorating wound characteristics plateaued. Pressure ulcer staging: Unstageable pressure injuries presenting as deep tissue injury. Wound acquired in-house. It is unknown how long the wound has been present. [documented in Progress Notes on 1/12/26]. Length (cm): 1.85 Width (cm): 1.75 Depth (cm): 0.1 Area (cm2): 2.63.Generic wound cleanser. Debridement: Autolytic. Other primary dressing: Betadine + Dry Dressing. #004: Skin issue has been evaluated. Location: Coccyx.Issue type: Pressure ulcer / injury. Progress: Deteriorating: wound characteristics deteriorated. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house. Wound is new. Cleansing solution: Generic wound cleanser. Debridement: Enzymatic. Other primary dressing: Santyl (a nickel thick layer) + Calcium Alginate Secondary dressing: Dry.Sacrococcyx is an acute Stage 3 Pressure Injury Pressure Ulcer and has received a status of not healed. Subsequent wound encounter measurements are 6cm length x 3.8cm width x 0.2 cm depth, with an area of 22.8 sq cm. Review of R104 Skin/Wound Progress Notes, dated 1/29/26, Follow up wound consult was completed by Physician [named] Wound Care Specialists. Seen by the wound care team on 1/29/26. Sacrococcyx is an acute Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed.The wound is deteriorating. Review of R104 EMR reflected no evidence that R104s wounds were assessed including measurements between 1/29/26 and 2/12/26 (14 days after wound documented as, deteriorating on 1/29/26.) Review of R104 Provider Note, dated 2/11/26, reflected, CHIEF COMPLAINT Deteriorating sacral coccyx wound with odor.General: Patient is a [AGE] year old male seen today for follow-up evaluation of a known Stage 3 pressure ulcer of the sacral region. Nursing staff report the wound has been worsening, with noted increased eschar, malodor, and overall deterioration in appearance.Pressure ulcer of sacral region, stage 3 deteriorating wound, odor and increased eschar.Check xrays r/o OM [osteomyelitis(infection of bone] Start Augmentin course [antibiotic]. Review of R104 Skin Issue Progress Note, dated 2/12/26, reflected, #002: Skin issue has been evaluated. Location: Coccyx.Progress: Deteriorating: wound characteristics deteriorated. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house.Signs and symptoms of infection: Size has increased. Signs and symptoms of infection: Increased exudate. Signs and symptoms of infection: Erythema/edema. Signs and symptoms of infection: Smell increased. Signs and symptoms of infection: Temperature is increased. Painful: Yes. Wound pain (Frequency): Intermittent. Pain description: Numbness. Pain description: Stiffness. Pain description: Aching. Wound pain interventions: Medicate after dressing change. #003.Location: Left heel.Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house.Painful: Yes.Length (cm): 1.29 Width (cm): 1.49 Depth (cm): 0.1 Area (cm2): 1.42. #004: Skin issue has been evaluated. Location: Right heel.Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house.Painful: Yes.Length (cm): 1.16 Width (cm): 0.56 Depth (cm): 0.1 Area (cm2): 0.35.Skin Issues Note: Sacrococcyx is a chronic Stage 3 Pressure Injury Pressure Ulcer and has received a status of not healed. Subsequent wound encounter measurements are 10cm length x 9cm width x 1.6 cm depth, with an area of 90 sq cm and a volume of 144 cubic cm.There is a large amount of sero-sanguineous drainage noted which has a Mild odor.90% slough; no eschar and no epithelialization present. The wound is deteriorating.periwound skin presents with s/s of infection. Confirmation Description & Treatment Plan is: Systemic Antibiotics Prescribed, Topical Antibiotics Prescribed. Review of R104 Wound/Skin Progress Note, dated 2/12/26, reflected, X-ray to R/O [rule out] Osteomyelitis. Review of facility document, Clinically Unavoidable Injury, dated 2/12/26, reflected R104 had a stage 3 pressure wound to Sacrococcyx that developed 1/15/26 (EMR reflected 12/21/25). The document reflected intervention in place were barrier cream, turn every 2 hours, pressure reducing mattress, specialty mattress, offload boney prominences, pressure reducing equipment in chair, and other positioning devices. The document included, The pressure injury identified has been determined to be clinically unavoidable due to the indicated circumstances. Diagnosis, behaviors and treatments that are contributing factors to the development of a pressure ulcer with the following areas marked: incontinence, malnutrition, and braden score. Continued review included, If Braden Score, Terminal Diagnosis, or Non-Compliance with care was selected, please explain: Triggered High Risk Braden, Adult Failure to Thrive. (Provider diagnosis of Failure to thrive first documented in R104 EMR on 3/9/26. Facility failed to provide evidence of several missing documentation for tasks and physician ordered treatments.) Review of R104 Provider Progress Note, dated 2/13/26, reflected, Deteriorating sacral coccyx wound with odor follow up/ xray review.Patient is an [AGE] year-old male seen today for follow-up evaluation and review of recent sacral imaging in the setting of a known Stage 3 sacral pressure ulcer. Since last evaluation, wound deterioration was noted by nursing staff with increased eschar and malodor. The patient has remained afebrile with stable vital signs and no reported systemic symptoms. Recent plain radiographs of the sacrum/coccyx were concerning for acute distal coccygeal osteomyelitis. The patient was started empirically on Augmentin. Labs reviewed, WBC 10.8, hgb 8.5, plt 227. ESR 44, CRP 11.5, K 3.1, GFR 104, Cr 0.45, BUN 23, albumin 2.0. Given imaging findings concerning for acute osteomyelitis and high-risk location associated with a chronic pressure injury, the decision has been made to transfer the patient to the hospital today for urgent imaging (MRI), further evaluation, and Infectious Disease consultation for definitive management and antibiotic guidance. Review of R104 Skin/Wound Note, dated 2/13/26, reflected, Results for X-Ray Rt osteomyelitis. There is a probable bone loss at the distal coccygeal tip. There is a soft tissue defect. There is soft tissue swelling and soft tissue emphysema. There is bony demineralization. No dislocation. CONCLUSION: Findings highly concerning for acute distal coccygeal osteomyelitis. Review of R104 Dietary Note, dated 2/14/25, reflected, Resident recently reviewed on 2/4 for quarterly nutritional review- no sig weight changes noted at time of review. Resident triggering at this time for weight loss, however, is now currently out at hospital due to osteomyelitis of his coccyx. Review of R104 Nursing Summary Note, dated 2/17/26, reflected, Resident readmit to facility from [named] Hospital for wound infection on sacral region.Resident a/o[alert and oriented times] 2; Regular diet/ puree texture/ thin liquid.Resident on ABT[antibiotic] po[oral] for wound infection; Writer administer wound care and place order for wound consult. Review of R104 Braden assessment score, dated 2/17/26, reflected score of 14, which indicated moderate risk for developing pressure ulcers. Review of R104 Provider Progress Note, dated 2/18/26, reflected, Patient is an [AGE] year-old male was seen today post readmission. Patient was recently admitted to the hospital for osteomyelitis and sepsis. PHYSICAL EXAM Findings General Positive: Well developed, Well nourished, Appears comfortable, Alert, Awake. ASSESSMENTS AND PLANS.Other acute osteomyelitis, unspecified site: Sacral osteomyelitis, debridement was done at the hospital. Patient is on antibiotic. Review of R104 Skin Issue Note, dated 2/19/26, reflected, Skin Issue: #001: Skin issue has been evaluated. Location: Coccyx.Progress: Deteriorating: wound characteristics deteriorated. Pressure ulcer staging: Stage 4 Pressure ulcer / injury - full thickness skin and tissue loss. Wound acquired in-house.Signs and symptoms of infection: Red and bleeding surface or granulation tissue. Signs and symptoms of infection: Size has increased. Signs and symptoms of infection: Erythema/edema. Painful: Yes. Wound pain (Frequency): Intermittent. Pain description: Aching.Sharp.Stiffness.Numbness. #002: Skin issue has been evaluated. Location: Right heel. Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house.Length (cm): 1.13 Width (cm): 1.01 Depth (cm): 0.1 Area (cm2): 0.85. #003: Skin issue has been evaluated. Location: Left heel.Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house.Length (cm): 0.54 Width (cm): 0.63 Depth (cm): 0.1 Area (cm2): 0.26.Palliative care consult.Skin Issues Note: Sacrococcyx is a chronic Stage 4 Pressure Injury Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 10cm length x 10cm width x 2.5 cm depth, with an area of 100 sq cm and a volume of 250 cubic cm. Bone is exposed. Review of R104 Provider Note, dated 3/1/26, reflected, [AGE] year-old male with past medical history of A.fib[irregular heart rate], right MCA[middle cerebral artery] CVA [cerebral vascular accident]. Chronic sacral ulcer. Recent hospital stay with sepsis infected sacral ulcer AMS[altered mental state] and fecal impaction.Patient status post disimpaction, sacral decubitus ulcer debridement and IV antibiotic treatment. Review of R104 Skin Issue Note, dated 3/5/26, reflected, Location: Left heel. Stage 3Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house.Length (cm): 0.74 Width (cm): 0.57 Depth (cm): 0.1 Area (cm2): 0.33.Eschar: 100% . Location: Right heel.Pressure ulcer staging: Stage 3 Pressure ulcer / injury - full thickness skin loss. Wound acquired in-house.Length (cm): 0.55 Width (cm): 0.56 Depth (cm): 0.1 Area (cm2): 0.25. Location: Coccyx.Progress: Deteriorating: wound characteristics deteriorated. Pressure ulcer staging: Stage 4 Pressure ulcer / injury - full thickness skin and tissue loss. Wound acquired in-house. Painful: Yes. Wound pain (Frequency): Intermittent. Pain description: Numbness.Stiffness.Stabbing.Sharp.Aching.Skin Issues Note: Sacrococcyx is a chronic Stage 4 Pressure Injury Pressure Ulcer and has received a status of not healed. Subsequent wound encounter measurements are 9.2cm length x 12cm width x 2.5 cm depth, with an area of 110.4 sq cm and a volume of 276 cubic cm. Undermining has been noted at 6:00 and ends at 12:00 with a maximum distance of 14.1cm. There is a large amount of sero-sanguineous drainage noted. Two of three wounds have declined. Review of R104 Provider Notes, dated 3/9/26, reflected, was seen today for not eating well. Upon evaluation, patient had good breakfast. Was awake and alert nonverbal most of the times.Pain Level: 6. Review of R104 Provider Note, dated 3/11/26, reflected, seen today upon nurse managers request. As per staff patient is not eating or drinking. Patient was awake without any acute distress. Nurse manager is advised to call the family if they agreed upon PEG tube for patient. Meanwhile, patient is started on maintenance fluids. Review of R104 Nurse Progress Notes, dated 3/11/26, reflected, resident sent to [named hospital]. Review of R104 Nursing Summary Progress Note, dated 3/20/26, reflected, [AGE] year old Asian male admitted from [named hospital], with dx[diagnosis] of palliative care.Resident is alert will follow staff with eyes and will grasp writers hand when instructed to with R hand, not L hand. Review of R104 Nurse Progress Note, dated 3/22/26, reflected, writer assessed resident, resident lerthargic, resident has blank stare, resident unable to arouse, when writer called resident name ,resident did not respond. resident has gurgling breath sounds. resident has rapid breathing.writer notified doc, writer notified family, writer notified supervisor. Pt[patient] sent to hospital Review of the Care Plan, dated 8/29/18, reflected [named R104] is at risk for skin breakdown/pressure injury r/t[related to] decreased mobility, incontinence, unable to change position independently needs assistance with bed mobility.Goal; Minimize risks of pressure injury development, through review date.Administer treatments as ordered and observe effectiveness. Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician.created on 9/6/18.Encourage to float heels while in bed and assist as needed. Apply heel boots while lying in bed. Date Initiated: 01/12/2026. Follow facility policies/protocols for the prevention/treatment of impaired skin integrity. Date Initiated: 09/06/2018. Turn/reposition resident every 2 hours as tolerated Date Initiated: 08/29/2018. Review of R104 Treatment Administration Records, dated 1/1/26 through 3/22/26, reflected 20 holes on the record with no evidence that R104 received physician ordered wound treatments on 20 occasions. Review of R104 Task Report, dated 1/1/26 through 3/22/26, reflected 55 times the report had holes(missing documentation with no evidence task was completed) or NA(No Applicable) or RX(Resident Not Available) was marked for, Turned and Repositioned every 2 hours and PRN. Resident #110 (R110) Review of the Face Sheet and Minimum Data Set (MDS) with Assessment Reference Date(ARD) of 6/14/26 reflected R110 was a [AGE] year old male admitted to the facility on [DATE] with recent readmission post hospital transfer 6/10/26 related to facility acquired stage 4(full thickness tissue loss with exposed muscle, tendon and or bone) pressure ulcer, and sepsis related to wound infection, with additional diagnoses that included diabetes mellitus, heart failure, hypertension, and anxiety. Review of R110 Provider Note, dated 6/12/2026, reflected, History and Physical Date of Service: 6/12/2026.readmission history and physical Anemia ,hyperkalemia and adult failure to thrive infected sacral ulcer/osteomyelitis Anxiety , panic attacks HISTORY OF PRESENT ILLNESSES General: [AGE] year-old male with past medical history of diabetes ,CKD[chronic kidney disease], hypertension ,CHF[congestive heart failure], CAD[chronic arterial disease],PAD[peripheral arterial disease] status post right BKA[below the knee amputation] and left foot amputation with chronic osteomyelitis, anemia of chronic disease. Recent hospital stay with adult failure to thrive anemia.on CKD hyperkalemia infected sacral ulcer s/p debridement. During an observation on 6/18/26 at 10:37 a.m., WN D entered R110 room with facility provider and Certified Nurse Assistant (CNA) G and reported plan to perform treatment change for R110. R110 had tube feeding running via Nasal Gastric tube and WN D paused and positioned R110 on right side. R110 did not appear to have air mattress with pump. WN D removed old dressing from sacral wound that appeared to be softball size with slough present and undermining between 2 and 3 o'clock about 4 cm deep. WN D performed treatment change with use of dakins solution and Santyl to wound bed and covered with clean dressing. WN D also performed treatment to left lateral stump that appeared to have golf ball size eschar(nonviable skin), attached. WN D performed treatment according to provider orders. During an interview on 6/18/26 at 11:09 a.m., Provider H reported another wound team had followed R110 and was unable to say when wound started. Review of R110 Provider Notes, dated 9/11/2025, reflected, Date of Service: 9/11/2025 Visit Type: Telehealth – Asynchronous.NOTES Res has open wound to left buttock; Treatment wound care to eval and treat. Continued review of R110 EMR reflected no wound assessment until 9/18/26 (7 days after wound reported to provider.) Review of R110 Nurse Progress Notes, dated 9/11/26, reflected, Open area to left buttock, treatment in place, woundcare to eval and treat, oncall notified resident aware of situation and is his own responsible party. Review of R110 Skin/Wound Progress Note, date 9/18/26, reflected, Coccyx is an acute Stage 3 Pressure Injury Pressure Ulcer and has received a status of not Healed. Initial wound encounter measurements are 2cm length x 2.5cm width x 0.2 cm depth, with an area of 5 sq cm and a volume of 1 cubic cm.There is a Moderate amount of sero-sanguineous drainage noted which has no odor.The wound margin is well defined wound bed has 50%, pink, granulation, 50% slough (first wound assessment noted in EMR.). Review of R110 Skin/Wound Note, dated 6/18/26, reflected, Follow-up wound consult was completed by Physician Residential Wound Care Specialists. Seen by the wound care team on 6/18/26. Coccyx is a chronic Stage 4 Pressure Injury Pressure Ulcer and has received a status of not healed. Subsequent wound encounter measurements are 7.2cm length x 9cm width x 3 cm depth, with an area of 64.8 sq cm and a volume of 194.4 cubic cm Bone is exposed.Undermining has been noted at 9:00 and ends at 3:00 with a maximum distance of 4.2cm. There is a large amount of sero-sanguineous drainage noted. Noted decline. Review of R110 Treatment Administration Records, dated 4/1/26 through 6/18/26, reflected several holes with no evidence that treatments had been completed. Review of R110 Task report, dated 4/1/26 through 6/18/26 reflected several holes (missing documentation with no evidence task was completed) or NA(No Applicable) or RX(Resident Not Available) was marked for, Turned and Repositioned every 2 hours and PRN. During an interview on 6/23/26 at 2:55 p.m., Wound Nurse (WN) D reported R104 pressure ulcers were facility acquired and were unavoidable related to failure to thrive and completed unavoidable wound document on 2/12/26. WN D reported R104 sacral wound started 12/21/25 and mentioned would verify date. WN D reported R104 was at high risk for skin breakdown prior to 12/10/25 and had one facility acquired stage 4 pressure ulcer and two facility acquired stage 3 pressure ulcers when R104 transferred to the hospital on 3/22/26 and did not return to facility. WN D reported R104 was his own responsible party so no one besides R104 was notified of changes and report did inform son of changes. Reported would expect staff to follow care planned interventions including positioning and would expect nurses to complete treatments as ordered by physician. Reported wound team monitored and assessed wounds weekly along with wound provider. WN D reported was unsure why R104 MDS dated [DATE] indicated pressure ulcers were not facility acquired. WN D reported R110 admitted to facility with a pressure ulcer and R110 had a current facility acquired stage 3 pressure ulcer that was no present on admission. WN D reported R110 wounds were unavoidable relate to failure to thrive and reported R110 was at high risk for skin breakdown. WN D verified both R104 and R110 had history of osteomyelitis. During an interview on 6/23/26 at 4:20 p.m., MDS staff E reported had been in position for about 10 years. MDS E verified multiple errors on both R104 and R110 MDS including question to reflect resident had pressure ulcers and R104 MDS dated [DATE] related to pressure wounds present on admission. (verified wounds were facility acquired). MDS staff E staff reported she was responsible for reviewing MDS prior to submission and had several other MDS staff. MDS F was also present and reported did complete R104 MDS dated [DATE] and was not aware required to mark pressure wound as facility acquired if present prior to transfer to hospital. MDS E reported plan to make corrections and review all current residents with pressure wounds to check for accuracy. During an interview on 6/23/26 at 4:42 p.m. Director of Nursing (DON) B reported expected staff to follow Care Plans and Physician orders and expect staff to document tasks as complete of done. DON B verified several missing documentation for tasks completed and expect nursing staff to complete progress note if treatment not completed. DON B reported would review both R104 and R110 EMR and provided evidence if available. DON B reported would expect MDS assessment to be accurate. DON B reported R104 responsible party was R104 son. Resident #106 (R106) Review of the medical records reflected that R106 was admitted to the facility on [DATE]. Diagnoses of Heart Failure, Dementia, Muscle Weakness, Depression and Anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/07/2024 revealed R106 had a Brief Interview of Mental Status (BIMS) of 03 (Severe cognitive impact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R106 needed substantial to maximum assistance with showering and personal care. R106 was dependent on toileting and perineal hygiene. Record review revealed on the Minimum Data Set (MDS) ARD/Target date of 07/07/2024. 3.0 Section M- Skin Conditions, M0100. Determination of Pressure Ulcer/Injury Risk was marked no, resident did not have a pressure ulcer/injury, a scar over bony prominences, or a non-removeable dressing/device. Record review revealed R106 was admitted to this facility on 07/01/2024 without a pressure ulcer on her sacrum/coccyx. Record review also revealed discrepancy in wound care assessments, varying measurements, not treating the undermining and not following the providers orders. Record review also reflected the facility failed to heal the pressure ulcer on her coccyx and it became full thickness down to the bone with signs and symptoms of infection requiring treatment with antibiotics. R106 requires repositioning every 2 hours as care planned, but this task was not consistently documented as completed, resulting in continued skin breakdown on her coccyx. Record review revealed the history of the resident skin break down with in house acquired pressure ulcer dating back to 08-08-2024. Pertinent history notes follow: Record review revealed R106 had a wound care assessment on 06/18/2026 by DNP, FNP-C H Wound #1, Sacrococcyx stage 4 pressure ulcer measuring 3cm x 5.3cm x 1.2cm. Undermining had been noted at 12:00 and ends at 3:00 with a maximum distance of 6.2cm. Large amounts of sero-sanguineous drainage, no odor. Wound margin is thickened and rolled under. Wound bed is had 100% pink, granulation, no slough, eschar. Wound care orders included clean wound with 1/4 strength of Dakin's solution. Apply Calcium Alginate every day and prn. Apply Calmoseptine daily and as needed to peri-wound. Apply Calcium Alginate rope every day and prn to undermining. Secondary dressing, apply silicone super absorbent dressing. Reposition every two hours, avoid direct pressure to wound site. Record review revealed R106 had a wound assessment on 06/11/2026 by DNP, FNP-C H Wound #1, Sacrococcyx stage 4, pressure ulcer measuring 2.9cm x 5.5cm x 1.2cm. Undermining had been noted at 12:00 and ends at 3:00 with a maximum distance of 6.4cm. There was a large amount of sero-sanguineous dr

This citation pertains to intake 2609532Based on interview and record review, the facility failed to ensure timely identification and treatment of pressure ulcers for one (R701) of four residents reviewed for pressure ulcer care. Findings include:Review of Intake 2609532 revealed a concern regarding the presence and/or condition of multiple pressure ulcers on R701 upon their most recent admission to the hospital on [DATE]. At the time of this investigation on 09/09/25, R701 remained hospitalized .Review of R701's facility record revealed an original admission date of 10/08/21 and a most recent admission date of 08/13/25 with diagnoses including Protein-Calorie Malnutrition, Sepsis, and Profound Intellectual Disability. This admission followed a hospitalization from 08/08/25 to 08/13/25. Review of the hospital Discharge summary dated [DATE] revealed the Wound Detail section which included the following:A right anterior ankle wound staged as a Deep Tissue Pressure Injury (DTPI-Persistent non-blanchable deep red, purple, or maroon areas of intact or non-intact skin), measuring 1.5 cm (centimeters) length x 1.5 cm width and wound base color of purple/red.A left anterior ankle DTPI measuring 4 cm length x 3 cm width.Additional review of R701's facility record revealed the resident was readmitted to the facility on [DATE] following hospital discharge and a Nursing Comprehensive Evaluation was completed on 08/13/25 by Licensed Practical Nurse (LPN) A. The skin assessment portion of the evaluation (K. Skin) included the question Does the resident have any skin conditions? which was answered No. This assessment included no additional notation identifying any ankle/foot skin conditions. The facility records also included the Total Body Skin assessment dated [DATE] completed by LPN B which included the item Enter the number of new wounds which was answered 0. No notation to this assessment identified any ankle/foot wounds. Notation was made of buttocks pink/red to red with no excoriation. Review of R701's last Total Body Skin Assessment prior to the 08/08/25 hospitalization dated 08/02/25 as well the active physician orders revealed no presence or treatment of any ankle/foot wounds.On 09/09/25 at 1:55 PM, LPN B was interviewed in person and reported they were able to recall R701. They were asked about the skin assessment they authored/completed on 8/14/25 and whether they could recall if they had inspected the resident's feet/ankles. LPN B reported they could not specifically recall if they had or not. LPN B was asked if this assessment would normally include inspection of the entire body and they indicated that it would.On 09/09/25 at 2:21 PM, LPN A was interviewed via phone call and asked whether they could recall if R701 had any skin or wound issues during their 08/13/25 nursing admission assessment. LPN A indicated the resident did not have any that they were aware of and reported if there were any skin issues they would have noted it in the assessment.Further review of the facility record revealed a Change in condition note dated 08/24/25 requesting wound physician consult due to a skin/pressure ulcer issue. The record indicated the wound care consult was completed 08/28/25 and included the following findings:Left lateral foot, deep tissue injury, present on admission, 2.7 cm length x 2.6 cm width.Right dorsum foot, deep tissue injury, present on admission, 2.2 cm length x 1.1 cm width. On 09/09/25 at 2:30 PM, LPN C reported they were the Unit Manager covering R701's room at the time of the 08/13/25 admission. LPN C was informed of the concern that R701 was documented as having bilateral foot/ankle DTPI's upon their 08/13/25 hospital discharge and that the DTPI's were not identified in the facility until 08/28/25, indicating a 15-day delay in initiation of treatment. LPN C reported their expectation is the nursing admission skin assessments should be thorough, include the entire body, and any skin concerns whether previously present or new should be documented.On 09/09/25 at 3:00 PM, the facility Director of Nursing (DON) reported their expectation is the initial admission skin assessments should include the entire body, and any skin concerns should be identified and initial treatment orders put in place.Review of the facility policy Skin Management dated 09/19/24 revealed the Practice Guidelines items:1. Upon admission/re-admission all residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record.4. Residents admitted with any skin impairment will have: .Appropriate interventions implemented to promote healing A physician's order for treatment, and Skin impairment location, measurements and characteristics documented.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: On 6/9/25 between 8:45 AM-9:30 AM, during an initial observation of the kitchen with Dietary Manager F, the following items were observed: The vent hood was observed with a heavy buildup of grease. There was a sticker observed on the vent hood, noting it was last cleaned 3/26/25. Dietary Manager F stated that company comes out every 3 months to clean the vent hood. There was no cleaning schedule set up for the months in between to ensure the vent hood was cleaned more frequently. According to the 2017 FDA Food Code section 4-602.13 Nonfood-Contact Surface, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. There were gnats observed in the dish machine room and near 3 compartment sink. The floor in the dish machine room was very wet, with standing water in wells between the tiles. There was water pooled on the floor in the corner behind the door. According to the 2017 FDA Food Code section 6-501.111 Controlling Pests, The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: .4. (D) Eliminating harborage conditions. There was a continuous leak from the recessed drain well on the soiled side of the dish machine. In addition, the drain pipe from the soiled side sink basin was leaking water onto the floor. The floor was extremely wet, with pooling water in several areas. When queried on 6/9/25 at 10:00 AM, Maintenance Director G stated he would have the leaks repaired right away. According to the 2017 FDA Food Code section 5-205.15 System Maintained in Good Repair, A plumbing system shall be: (A) Repaired according to law; P and(B) Maintained in good repair. The high temperature dish machine was checked for sanitization with an irreversible temperature indicator strip. The strip sent through the dish machine did not change color, indicating the surface temperature had not reached 160 degrees Fahrenheit. A dishwasher plate thermometer sent through the dish machine 3 times, recorded the maximum surface temperature between 145 degrees Fahrenheit and 151 degrees Fahrenheit. It was observed that the inner long curtain inside the dish machine was missing, and the short curtain at the end of the dish machine was also off. Observation of the temperature log revealed the last temperature strip had been done on 6/6/25, and the temperature of the dish machine had last been logged on 6/8/25. When queried, Dietary Manager F stated temperature strips should be run through the machine once a day, and the temperatures should be logged daily at breakfast, lunch, and dinner. Staff was observed actively doing dishes at the dish machine. Dietary Manager F instructed staff to stop using the dish machine, and stated she would call a service company. According to the 2017 FDA Food Code section 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. (A) The temperature of the wash solution in spray type warewashers that use hot water to SANITIZE may not be less than: (1) For a stationary rack, single temperature machine, 74°C (165°F); Pf (2) For a stationary rack, dual temperature machine, 66°C (150°F); Pf (3) For a single tank, conveyor, dual temperature machine, 71°C (160°F); Pf or (4) For a multitank, conveyor, multitemperature machine, 66°C (150°F). Pf There was a wet wiping cloth lying on the food preparation counter across from the oven. There was no sanitizer bucket observed. According to the 2017 FDA Food Code, Section 3-304.14 Wiping Cloths, Use Limitation, .(B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution at a concentration specified under § 4-501.114; In the 1st floor kitchenette, the interior of the microwave was observed to be soiled, and the side vents on the ice machine were dusty. In addition, there was a pinkish orange slime along the bottom edge of the ice chute. The ice machine drain line observed to extend down approximately 3 inches below top of the floor drain. According to the 2017 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the 2017 FDA Food Code section 4-602.11 Equipment Food-Contact Surfaces and Utensils, (E) Except when dry cleaning methods are used as specified under § 4-603.11, surfaces of utensils and equipment contacting food that is not potentially hazardous (time/temperature control for safety food) shall be cleaned: (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. According to the Food & Drug Administration (FDA) 2017 Model Food Code, Section 5-402.11 Backflow Prevention, (A) Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. In the 2nd floor kitchenette, there was a BUNN LCA-2 coffee maker attached to the water supply line. There was no backflow protection for the water line hook-up to the coffee maker. On 6/9/25 at 11:30 AM, Maintenance Director G was queried about the lack of backflow protection for the coffee maker, and stated It's been like that for as long as I've been here. According to the Installation and Operating Guide for the BUNN LCA-2 coffee maker, As directed in the International Plumbing Code of the International Code Council and the Food Code Manual of the Food and Drug Administration (FDA), this equipment must be installed with adequate backflow prevention to comply with federal, state and local codes. For models installed outside the U.S.A., you must comply with the applicable Plumbing /Sanitation Code for your area.

Based on observation, interview, and record review, the facility failed to eliminate harborage conditions to maintain an effective pest control program. This deficient practice had the potential to affect all residents in the facility. Findings include: On 6/9/25 at 9:15 AM, there were numerous gnats observed in the dish machine room and near the 3 compartment sink in the kitchen. There was a continuous leak of water onto the floor, from the recessed drain well on the soiled side of the dish machine. In addition, the drain pipe for the sink basin located on the soiled side of the dish machine was leaking water onto the floor. The floor in the dish machine room was very wet, with standing water in the wells between the floor tiles. In addition, there was water pooled on the floor in the corner behind the door. On 6/9/25 at 10:15 AM, Maintenance Director G was queried about the gnats and the water leaks/pooled water in the kitchen. Maintenance Director G stated they needed to regrout the floor and stated he would get a repair company out to fix the leaking pipes. Review of the pest control service reports noted: 11/8/24 Noticed a lot of vinegar flies in the basement dish area and in the hallways where the food carts are sitting out. I suggested .to perhaps put a couple of floor fans in the dish room to dry it out .there's heavy water everywhere . 1/29/25 Water pouring out of the pipes under the dishwasher. Repair or replace as needed. 2/10/25 Floor tiles need repair/grout. Vinegar flys will breed between the missing grout lines. Seal cracks and crevices throughout the kitchen and dish room .Did find some vinegar flies underneath the kitchen 3 compartment sink. This is due to standing water along the baseboards and where there is no grout lines between the tiles in the kitchen This is a structural issue that needs to be addressed . 3/18/25 Spoke with (Maintenance) and reiterated about the standing water especially where grout lines are low and/or missing. These areas allow vinegar flys to feed and breed. 5/27/25 I did find a few dozen vinegar flies coming out from behind the tiles in the kitchen area. It is highly important that all broken tiles are replaced, and all gaps are sealed to prevent fly breeding. 6/4/25 There was still significant fly activity in the kitchen today. It is my recommendation that the deep grout lines are filled in to prevent the flies from breeding. I did also observe a significant amount of standing water in the dishwasher area on the floor.

Based on observation, interview, and record review, the facility failed to consistantly implement an effective measure (seperation) to prevent further abuse during an abuse investigation for one resident (R324) out of two residents reviewed for abuse. Findings include: A review of R324's progress notes revealed the following, Date: 6/8/2025 at 15:26 (4:26 PM) .Writer notified about another resident (R325) observed with hands touching in resident (324's) brief. Witness statement completed Admin (Administrator), DON (Director of Nursing) and family member notified, skin assessment completed no bruises nor redness noted. Resident currently sitting at nursing station. A review of the medical record revealed R324 admitted into the facility on 6/5/2025 with the following medical diagnoses, Anxiety Disorder, Delirium, and Insomnia. Information was not available to review on the Minimum Data Set (MDS) assessment. R324 also required staff assistance with bed mobility and transfers. On 6/10/2025 at 9:44 AM, R324 was observed sitting at the nurse's station in the view of R325. R325 was observed to be sitting on the other side of the nurse's station in close proximity of R324 with the desk observed in between the two of the residents. R325 was observed to be talking to R324. A staff member was observed to be at the nurse's station with their back to both R324 and R325. On 6/10/2025 at 9:53 AM, an interview was completed with Licensed Practical Nurse (LPN) A. LPN A reported on the day of the incident R324 and R325 were both sitting behind the nurse's station and eating lunch. LPN A reported that Certified Nursing Assistant (CNA) B was picking up the lunch trays and came and told them they observed R325 putting their hand in R324's brief. LPN A indicated CNA B separated R324 and R325 and came and told them. LPN A reported R325 was very aggressive, and they called the physician and obtained an order for Ativan (Antianxiety). LPN A reported they then called the NHA (Nursing Home Administrator), DON, Physician's, and both responsible parties. ON 6/10/2025 at 9:57 AM, an interview was conducted with CNA B. CNA B reported they were picking up the lunch trays on the day of the incident and saw R325 with their hand in R324's brief. CNA B reported both R324 and R325 were both sitting behind the nurses' station, next to each other. CNA B reported they immediately went over to R324 and R325 and separated them. CNA B reported R325 told them to f*** off and told them they could not tell them what to do. CNA B reported when R324 currently sees R325 they mention things, such as, they needed to watch out for (R325), and they were staying away from them. On 6/11/2025 at 9:17 AM, Unit Clerk C was asked if they were given any instructions regarding R324 and R325. Unit Clerk C indicated they were told to keep them an arms reach apart. On 6/11/2025 at 11:11 AM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the alleged perpetrator (R325) continually having access to R324 and interventions put in place to keep the resident safe (day 3) of the 5-day abuse investigation. The DON reported they (R324) were to be always watched and be a arms length apart. The DON was informed of the observation of R325 sitting in front of R324 talking to them, and reported they are monitoring R324, and they do not seem to be having any adverse reactions from the incident. The DON reported R324 and R325 laugh and talk throughout the day. On 6/11/2025 at 1:00 PM, an interview was conducted with Social Worker (SW) E. SW E reported they conducted a trauma evaluation on R324, but the resident was unable to fully comprehend the results due to they're cognition. A review of a facility policy titled, Abuse Prohibition noted the following, .F. Protection of Guests/Residents during the Investigation .4. When a guest/resident displays behavior against another guest/resident that is suspected abuse, the guests/residents will be separated from each other.

This citation relates to Intake #MI00148781. Based on observation, interview, and record review, the facility failed to provide food which accommodated residents' allergies for two Residents (R703, R706) of seven residents reviewed for food allergies. Findings include: R703 On 12/26/24 at 9:10 a.m., Family Member (FM) A reported during a phone interview R703 had been served chicken or chicken soup several times during their stay at the facility, beginning in September 2024. FM A stated, It says right on the meal ticket (they are) allergic to chicken .I have had meetings with them, the facility manager, the people in charge of nutrition, and the nursing manager (about their concerns) . FM A explained there were times when they had to drive to the facility to bring R703 an alternate meal. FM A stated R703 had chicken broth again this month for dinner, which still had chicken in it, and caused them concern. On 12/26/24 at approximately 9:30 a.m., R703 stated, They (facility staff) still give me chicken from time to time .I get bad, persistent diarrhea (from chicken). I have tried to get them (kitchen staff) to acknowledge this since I got here. Then they give me chicken noddle soup .I call down to the kitchen and ask for an alternate meal. It is (served at) lunch and dinner .I just send it back. There are times I don't get an alternate meal and at that point I will ask for a sandwich .They should automatically know by now (about their food allergy). R703 reported this made them feel frustrated and discouraged, as they had been at the facility over two years. R703 clarified, My diet and allergies don't change. Review of R703's meal ticket, observed from their tray during the interview, showed in bold capital letters, with a black outline, Diet: Regular .Allergies: Chicken. Notes: No chicken - Allergic (in bold print) . The Dining Location showed Eats in Room. On 12/26/24 at approximately 10:30 a.m., R703's weekly menu, beginning 12/22/24, posted on their closet, was reviewed with them. R703 was able to read the menu, and showed how chicken was the entree four times for dinner, and once for lunch, for a total of 5 times of 14 opportunities for lunch and dinner. R703 was asked if there was an alternate menu and reported they had never seen one. R703 reported they had to begin calling down to the kitchen when they noticed chicken was being served, and it was hard to reach the kitchen sometimes. On 12/26/24 at 11:28 a.m., Licensed Practical Nurse (LPN) E confirmed R703 had reported they received chicken when they were in isolation, and their family member reported it. LPN E reported R703 was not supposed to receive chicken, as this was designated on their meal ticket. Review of a text message received on 12/27/24 at 8:19 a.m. from FM A, revealed R703 was served chicken twice between November 28th and December 12th, and there were several times they were served chicken in September and October 2024. Review of R703's Minimum Data Set (MDS) assessment, dated 10/30/24, revealed R703 was admitted to the facility on [DATE], with diagnoses including stroke, muscle weakness, and neuropathy (nerve damage). The assessment revealed R703 could feed themself. The Brief Interview for Mental Status (BIMS) assessment showed a score of 14/15, which showed R703 was cognitively intact. Review of R703's Electronic Medical Record (EMR) revealed in the Allergy tag, dated 10/27/21: Allergen: Chicken. Allergy Type: Intolerance. Severity: Mild. Reaction manifestation: Nausea. Review of R703's Care Plans, accessed 12/26/24, including Nutritional Care Plans, showed no resident allergies designated. Review of the weekly menu, beginning 12/22/24, revealed a chicken salad plate was being served for dinner on 12/26/24. On 12/26/24 at 2:21 p.m., CDM G reviewed the menu for the week beginning December 22nd, which showed chicken being served several times, and acknowledged This is the main entree. CDM G reported they were aware R703 was allergic to chicken. CDM G stated they served an alternate, which was generally a meal. CDM G reported the substitutes were fish, grilled cheese, soup, hamburger, salad, or peanut butter and jelly sandwiches which they said were available.CDM G clarified they had been made aware of R703's and their family's concerns, along with Registered Dietician H recently, although they could not recall a date. R706 On 12/26/24 at approximately 12:00 p.m., R706 stated in an escalated voice they were angry, as they had been served walnuts yesterday (12/25/24) for the holiday dessert, and they were allergic to them. R706 stated, My throat closes up, and they know (they were allergic to tree nuts). R706 confirmed they had not ingested the walnuts. R706 continued, .Every time they serve cake for dessert, I get walnuts. I went to a food committee meeting and they said, 'Pick them off.' .I don't think they know what it's like to have your throat close up. It says no tree nuts on my ticket. It makes me feel like they don't give a d@mn about me . R706 reported they also continued to receive food that was listed on their meal ticket as dislikes, including pork, strawberry banana yogurt, and bananas. R706 reported they had spoken to the kitchen manager, Certified Dietary Manager, (CDM) G, who had done nothing, as they continued to received cake with walnuts on the icing or in desserts. Review of R706's meal tickets, provided on 12/26/24 at 12:04 p.m. by R706, showed they were allergic to tree nuts in bold print. The meal tickets showed R706 was on a regular diet and ate their meals in their room. The breakfast ticket spelled out, No tree nuts (in bold) - hazelnuts, cashews, almonds, walnuts, pecans, pistachios . Dislikes included ham, pork, walnuts, strawberry banana yogurt, and bananas. On 12/26/24 at 2:40 p.m., CDM G was asked about the process in the kitchen for residents regarding food allergies and preferences. CDM G shared there were typically five staff on the tray line. This included the staff who put the food in the food cart, who was primarily responsible for catching the allergies and preferences/dislikes, and the cook, as they were also aware of resident food allergies and preferences and dislikes saying, All of them (kitchen staff) should be responsible for it (catching when a resident had an allergy or food preference). On 12/26/24 at approximately 2:45 p.m., CDM G was asked if they were aware R706 received tree nuts on their food tray on 12/25/24 confirming it was pecan pie . and were aware of R706's tree nut allergy. On 12/27/24 at approximately 9:30 a.m., Certified Nurse Aide (CNA) D confirmed they were R706's aide on 12/25/24, and they observed R706 served tree nuts at lunch on 12/25/24. CNA D stated, The pie (dessert) had nuts on it; it was walnuts or pecans, I saw it on her tray. I knew (R706) was allergic to it. I told the nurse. (R706) was upset . Review of R706's MDS assessment, dated 9/27/24, revealed R706 was admitted to the facility on [DATE], with diagnoses including ankle fracture, anxiety, and irritability. R706 could feed themself, and scored 15/15 on the BIMS assessment, which showed they were cognitively intact. Review of R706's Care Plans, accessed 12/26/24, including Nutritional Care Plans, showed no resident allergies designated. Review of R706's EMR revealed in the Allergy tag, dated 3/20/24: Allergen: Tree Nuts. Allergy Type: Allergy. Severity: Moderate. Reaction manifestation: (Blank) On 12/26/24 at approximately 4:00 p.m., Registered Dietician (RD) H was asked if they knew about R703 and R706 being served food they were allergic to which they responded, they get rushed (kitchen staff) .The cook should be reading the ticket, and the last person on the tray line should be reviewing the meal ticket and tray for accuracy. On 12/26/24 at approximately 4:30 p.m., the concerns related to R703 and R706 receiving food designated as food allergies for them were reviewed with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). Both ensured they were addressing the concerns, and residents' Care Plans and Kardex's (Care guides) would be updated to reflect their allergies. Review of the policy, Diet Orders, revised 12/10/24, revealed, Policy: Diets will be ordered in accordance with the menu guide, with available diets planned and prepared as stated on the Menu Extensions .5. If a Nutritional Services professional is unsure about whether or not a food item is permitted on a particular diet, he or she should refer to the Nutritional Professional. Nursing shall notify the Nutritional Services Department of diet order changes, new admissions/readmission diet orders, food allergies . Review of the policy, Food Preferences, revised 11/12/21, revealed, It is the policy of the facility to obtain food preference for all guests/residents. 4. The guest's/resident's clinical record (care plan, or other appropriate location) will document the guest's/resident's likes and dislikes and special dietary instructions or limitations .6. The dietary department will offer alternate meals for individuals who do not want to eat the primary meal .7. The facility's Quality Assurance Performance Improvement (QAPI) committee will periodically review issues related to preferences and meals to try to identify more widespread concerns about offerings, food preparation, etc .8. Food preferences will be identified on tray tickets to ensure guests/residents are provided with appropriate food items.

This citation pertains to Intake M100147381. Based on observation, interview, and record review, the facility failed to ensure one of one kitchen hand washing station was supplied with soap and paper towel. Findings include: On 10/29/24 at 1:35 PM, a tour of the kitchen was completed with the facility Dietary Manager (DM), Registered Dietician (RD) B and RD C. There were two other dietary staff working in the kitchen. Along with the DM, RD B and RD C, the hand washing station was observed. The hand soap dispenser and the paper towel dispenser were both observed empty. There was no secondary or back-up soap or paper towel readily available. On 10/29/24 at 2:56 PM, the facility DM reported the expectation is when the kitchen hand washing station is out of either soap or paper towel supplies, kitchen staff will call housekeeping staff to refill. On 10/29/24 at 3:00 PM, the facility Administrator (NHA) reported their expectation is the hand washing station in the kitchen would not be left without soap or paper towels and expressed the importance of hand washing in the kitchen versus relying on hand sanitizer. The 2017 Food & Drug Administration (FDA) Food Code Section 6-301.11 Handwashing Cleanser, Availability states Each handwashing sink or group of 2 adjacent handwashing sinks shall be provided with a supply of hand cleaning liquid, powder, or bar soap. Section 6-301.12 Hand Drying Provision states Each handwashing sink or group of adjacent handwashing sinks shall be provided with: (A) Individual, disposable towels; Review of the facility Dietary Infection Control policy dated 11/11/21 revealed the general policy statement It is the policy of this facility to follow local, State and Federal standards and regulations in order to assure a safe and sanitary Dietary department. The policy guidelines included 3. Employees will wash their hands just before they start work in the kitchen and when they have used their hands in an unsanitary way such as sneezing, handling chemicals, dirty dishes, etc.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the main floor kitchenette, and in the rehab and second floor pantry. This deficient practice had the potential to affect all residents in the facility that consume food. Findings include: On 5/7/24 between 8:30 AM-9:15 AM, during an initial dietary tour with Dietary Manager (DM) M, the following items were observed: Rehab Pantry: In the resident refrigerator located in the Rehab Unit pantry, there was an undated container of spaghetti, a container of macaroni salad with a use-by date of 5/3, an undated bag of sliced ham, and 3 undated slices of pie. When queried, DM M stated nursing staff is responsible for ensuring resident food items are dated. In addition in the Rehab pantry, there were ants observed on the floor surrounding the floor drain next to the ice machine, with piles of ant dirt observed around the floor drain. DM M stated she would let maintenance know about the ant problem. Main 1st floor dining room: In the kitchenette located in the first floor dining room, the interior top surface of the microwave was observed to be heavily soiled with dried on food debris. DM M confirmed the soiled microwave. The flooring in the kitchenette was heavily soiled with sticky spills, food debris and trash. DM M stated housekeeping was responsible for cleaning the floors. In the resident refrigerator located in the kitchenette, there was an undated container of cut strawberries and an undated box of pizza. There was no refrigerator temperature log for the current month (May), and the April temperature log located on the front of the refrigerator was observed with incomplete entries for the last half of the month. DM M confirmed the refrigerator temperature should be logged daily. 2nd floor pantry: In the resident refrigerator, there were 4 undated containers of unidentified food items, some of which were emitting a pungent, rotten odor. In addition, the interior of the refrigerator was soiled with food debris and sticky spills. Review of the facility's policy Food From Outside Sources revised 11/12/21 noted: 5. All food brought in .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.

Based on observation, interview, and record review, the facility failed to ensure paper towel dispensers were accessible for one (R9) resident and two anonymous group residents of five residents reviewed for accommodations. Findings include: Review of the facility record for R9 revealed an admitted [DATE] with diagnoses that included Osteoarthritis, Pain in the Right Shoulder, Pain in the Left elbow, and Left Tibia/Fibula Fractures. On 05/07/24 at 7:44 AM, during initial resident screening R9 reported the paper towel dispensers in their bathroom and in the first floor dining room were too high and they couldn't reach them. R9 reported that they are not able to stand independently and they have limited shoulder range of motion. On 05/08/24 at 2:02 PM during Resident Council, two anonymous group members reported they were not able to reach the paper towel dispenser in their bathrooms or in the first floor dining room. These group members reported they had communicated this concern to the facility Maintenance Director and the facility Administrator (NHA) multiple times with no response or resolution. On 05/09/24 at 10:17 AM, R9 reported they expressed their concern about not being able to reach the paper towel dispensers to management and they were told we'll look into it. R9 stated they had brought the issue up in previous Resident Council meetings and they were told by the Resident Council President that they had also mentioned it to management. R9 was observed demonstrating the ability to wheel their chair into the bathroom and reach for the paper towel dispenser without being able to reach or grab the paper towel. R9 reported they usually end up wiping their hands on their clothing unless staff happen to be nearby to assist. Review of the facility Resident Council meeting minutes for April 2024 indicated that the paper towel dispenser issue was discussed and documented as a maintenance department-related concern. On 05/09/24 at 4:11 PM, the facility Resident Council President reported they had brought up the issue of the paper towel dispenser being too high on the wall when there was a different Maintenance Director saying, it's been months since initially reported. On 05/09/24 at 1:39 PM, the NHA reported the expectation is the paper towel dispensers should be accessible to all resident's. Review of the facility policy Federal & State - Guest/Resident Rights & Facility Responsibilities dated 04/19/22 revealed the entry 3. Reasonable Accommodation. The right to reside and receive services in the facility with reasonable accommodation of guest/resident needs and preferences except when to do so would endanger the health or safety of the guest/resident or other guests/residents. The Safe, clean, comfortable & homelike environment portion of the policy included the entry i. This includes ensuring that the guest/resident can receive care and services safely and that the physical layout of the facility maximizes guest/resident independence and does not pose a safety risk.

Based on observation, interview, and record review the facility failed to ensure care planned interventions were implemented for two residents (R74, R102) of three reviewed for care and repositioning needs resulting in and the potential for unmet care needs. Findings include: R74 On 05/07/24 at 8:55 AM R74 was observed to be supine (flat on the back and buttocks) in bed with the head of the bed up around 30-45 degrees. R74 was asked about their care and reported they had a wound to their buttocks which felt sore and had consistent pain from the area along with their feet. The pain level was reported to be a ten out of ten sometimes and an eight at the time of the interview. R74 was asked about positioning off the wound area and reported they had a wedge in their old room but it did not come with them and needed a new one. An observation of the resident area revealed no wedge or pillow or other device to be used to off load pressure. R74 reported they needed assistance to turn side to side. On 05/07/24 at 4:24 PM, R74 was observed with their eyes closed and appeared to be asleep supine in bed. The head of bed was up around 30-45 degrees and the resident leaned slightly to the left. On 05/08/24 at 8:01 AM, R74 was observed to be supine in bed with the head of the bed elevated around 20-30 degrees. R74's torso leaned slightly to their left and R74 had their eyes closed and appeared to be asleep. A wedge nor other device to redistribute weight was observed. On 05/08/24 at 10:10 AM, R74 was observed to be supine in bed without the benefit of a wedge or other device. A nurse used the control to sit R74 higher up in bed and R74 made a noise (like oh). R74 indicated they were in pain and the nurse reported they would call the doctor. On 05/08/24 at 11:46 AM, R74 was supine in bed asleep with the head of bed up 30-45 degrees without an observed wedge or device. The torso and head leaned slightly toward their left. On 05/08/24 at 5:00 PM, R74 was observed to be supine in bed, the head of the bed around 30-45 degrees. A wedge, pillow or other device was not observed at the side of the resident nor in the resident area. On 05/09/24 at 7:57 AM, R74 appeared to be asleep supine in bed, no wedge or device visible, heel booties on and the head of the bed elevated 30-45 degrees with their torso and head leaned slightly over to the their left. On 05/09/24 08:44 AM, R74 buttocks wounds were observed with the wound care nurse and Certified Nursing Assistant (CNA) G. R74 was supine as before without any observed devices to offload. R74 did not appear to assist when turned onto their side. The wound areas covered the medial aspects of both buttocks along the gluteal cleft and appeared in width about the size of a softball. The surface appeared slightly raw and red with some darker maroon and purple areas as with a deep tissue injury. As the nurse touched the wound area to cleanse it from the barrier paste R74 reacted with (ooh like noise) and reported pain. R74 was returned to their backside (supine) without any devices in place. On 05/09/24 at 9:10 AM, CNA G was asked about the care of R74 and reported R74 did not like the wedge or the pillow and had found it on the floor at times. CNA G also reported R74 had told them they thought having a dressing in place would help the pain. On 05/09/24 at 9:14 AM, R74 reported they had a wedge in their old room, the wedge is comfortable, and liked it especially at night. R74 was observed to be supine in bed with the head of the bed elevated around 30-45 degrees. A review of the record for R74 revealed R74 was admitted into the facility on [DATE]. Diagnoses included Stroke, Diabetes and Urine Retention. The Minimum Data Set (MDS) assessment dated [DATE] indicated intact cognition and the need for substantial to maximal assistance to roll left to right, personal hygiene, upper and lower body dressing, sitting to lying, lying to sitting, sitting to standing and transfer. Review of the .has actual impairment to skin integrity . care plan (initiated 08/22/23) revealed, .Apply pressure reducing/relieving mattress, pillows . (initiated 08/22/23).Positional wedge for effective positioning to relieve pressure to bony prominences as tolerated . (initiated 04/18/24). The .at risk for impaired skin integrity . care plan revealed: .Cue to reposition self as needed (initiated 08/22/23). Turn/reposition resident every two hours and as needed . (initiated 08/22/23). The .at risk for pain . care plan (revised 01/02/24) revealed, .Anticipate resident's need for pain relief . (initiated 08/22/23).Encourage/provide non-pharmacological interventions to prevent/manage pain as needed such as positioning devices . (initiated 08/22/23). A review of the .at risk for catheter related trauma . care plan (revised 02/20/24) revealed, .Ensure catheter tubing is secured . (initiated 02/20/24). On 05/09/24 at 12:18 PM, the Director of Nursing (DON) reported they had challenges with the care of pressure sores in the past but felt the facility had been doing a good job with the care of wounds. The DON also noted R74 had a history of refusing the wedge or other assistance. The DON reported R74 was on an LTC 105 FLO mattress which was rated for stage three and four pressure sores and did not require and the wedge was contraindicated. The manufactures' specifications were requested and revealed, .wound clinicians have trusted (name) for the most severe wounds (Stage I - IV). Both Pressure & Shear Relief Therapy (name) consistently delivers interface pressures below 32 mmHg (millimeters of mercury), while the six degrees of cell movement combat shear forces associated with repositioning . The information provided did not prohibit the use of devices for repositioning and the included pictures documented increased pressure (two millimeters of mercury) and surface contact area (373 square centimeters) for a supine person when the bed was elevated from zero degrees to 30 degrees. R102 On 05/07/24 at 8:29 AM, R102 was observed to be seated supine in a recliner in the dining room. R102 was dressed, had their head back, face up toward ceiling, and eyes closed. The eyes opened to a call of their name. A pad was visible under the resident and extended to the head and foot and over the arms of the chair. This was reported as a pressure relieving device. On 05/07/24 at 11:42 AM, R102 was seated supine in a recliner elevated 60-90 degrees during an activity in the dining room. On 05/07/24 at 1:53 PM, R102 was seated supine in recliner in dining room head back eyes closed. The recliner elevated 45-60 degrees. On 05/07/24 04:22 PM, R102 was observed to be in bed supine, torso toward left slightly, head of bed, 20-30 degrees and appeared asleep. On 05/08/24 at 8:05 AM, R102 was supine in the recliner at nurse station elevated around 20-30 degrees, head back with face toward ceiling. Staff entered area, said hello, R102 returned a greeting and returned their head back to pillow again with their face toward the ceiling. On 05/08/24 at 8:47 AM, R102 was supine in the recliner in the dining room, elevated 60-90 degrees with head back and face toward the ceiling. On 05/08/24 at 9:45 AM, R102 was seated supine in the recliner elevated 60-90 degrees and leaned forward while eating breakfast. On 05/08/24 at 11:47 AM, R102 was observed seated supine in the recliner elevated 60-90 degrees during an activity in the dining room. On 05/08/24 at 1:40 PM, R102 was observed in the same spot at the table as before, seated supine in the recliner elevated 60-90 degrees. On 05/08/24 at 2:00 PM, R102 was observed in the day room area during a puzzle activity. R102 was seated supine in the recliner elevated 60-90 degrees. R102 was observed to press their elbows and forearms into the arms of the chair in attempts to push themselves up from the seat of the recliner. Their legs were off the elevated footrest. R102 reported they were uncomfortable upon query as to why they were moving. On 05/09/24 at 7:40 AM, R102 was observed at the nurse's station, supine in the recliner elevated around 20-30 degrees and had their eyes closed. On 5/09/24 at 1:38 PM, R102 was seated supine in the recliner elevated 60-90 degrees, eating lunch in the dining room. At 2:36 PM R102 was as before in the same spot. On 05/09/24 at 3:28 PM, CNA G was asked about the positioning of R102 and reported the pad under R102 in pressure relieving and R102 had been returned to bed three to four times for incontinence care. A review of the record for R102 revealed R102 was admitted into the facility on [DATE] and readmitted on [DATE]. Diagnoses included Pressure Ulcer of the Sacral Region, Stroke and Dementia. The MDS dated [DATE] documented impaired cognition and the need for substantial to maximal assistance to roll left to right, personal hygiene, upper body dressing, sitting to lying, lying to sitting, sitting to standing and transfer. Review of the .at risk for impaired skin integrity . care plan revealed: .Cue to reposition self as needed (initiated 10/25/23). Turn/reposition resident every two hours and as needed . (initiated 10/25/23). The .has actual impairment to skin integrity . care plan (revised 08/17/23) revealed, .Positional wedge for effective positioning to relieve pressure to bony prominences as tolerated . (initiated 06/08/23). A wedge or similar device was not observed to be used while R102 was in the recliner and R102 did not appear to be turned left or right while up in the recliner. A wound note dated 04/26/24 documented a sacral pressure ulcer five cm long by two .five cm wide by 0.5 cm deep. On 05/09/24 11:43 AM and 4:17 PM, care concerns were reviewed with the DON. The DON reported R102 had refused the wedge and pillow in the past and when staff had attempted to place it that day. The DON acknowledged the wedge was still in the care plan and was asked about care planned interventions and reported interventions should be followed until they are not in effect anymore and residents up in the recliners should be repositioned every two hours and as needed. Review of the facility policy titled, Care Planning revised 06/24/21 revealed, Every resident in the facility will have a person centered plan of care developed and implemented that is consistent with the resident's rights, based on the comprehensive assessment . A review of the facility policy titled, Skin Management revised 07/14/21 revealed, .It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries .

Based on observation, interview, and record review, the facility failed to ensure an incontinence pad and gown were changed during incontinence care and clothing was available for one resident (R119) of one reviewed for care. Findings include: On 05/07/24 at 8:05 AM, R119 was asked about their care. R119 was observed to be dressed in a hospital style gown and brief which hung loosely on them. The gown was off the shoulder. R119 was asked about wearing a gown and if they wanted to wear clothes and said they would prefer to wear clothes but did not have any. The drawers and closet were observed and a single pair of pants were seen to be folded over a pants hanger in the closet. On 05/07/24 at 11:24 AM, Certified Nursing Assistant (CNA) I was observed to exit the room of R119. On 05/07/24 at 11:25 AM, R119 was observed to be supine in bed wearing a brief and a gown. R119 was interviewed about their care and reported the pad and gown were wet. A gloved hand was used to test the bed and gown which were found to be wet. The call light was activated by R119 and at 11:35 CNA I returned and asked R119 if they were wet to which R119 confirmed they were wet and CNA I went out and returned with a brief and pad. On 05/07/24 at 4:02 PM, R119 was observed dressed in a gown and brief. The feet were bare. On 05/08/24 at 8:45 AM, R119 was observed to be in bed, supine in a gown, a brief was observed on the floor. On 05/08/24 at 9:47 AM, R119 was observed to be supine in bed and had on the pants that hung in the closet the day before. R119 did not have a shirt on. On 05/08/24 at 11:53 AM, a laundry staff member was asked about clothes for R119 and was not sure what R119 had but had delivered clothes to the room the day before. R119 was asked if they would like more clothes and said of course. A white printed t-shirt was noted on night stand with a gray pair of sweat pants. R119 was dressed in the other pair of pants and no shirt. The pants were observed to have a split seam on the left pant leg. On 05/08/24 at 2:09 PM, Licensed practical nurse (LPN) K was asked about the protocol for residents without clothes as R119 had been a resident at the facility since December 2023. LPN K reported they had donated items in the laundry but R119 particular on what they want to do and may or may not wish to have clothes when asked. LPN K went in and asked R119 about clothes and at first reported they did not care, then prompted another time R119 asked for clothes and discussed sizes and style. LPN K then reported they would check the laundry for some clothes for R119. On 05/08/24 at 2:55 PM, Social Worker L reported R119 had not asked for clothes until 04/26/24 and had emailed the guardian for approval to purchase some clothes but had not heard back. A review of the admission inventory sheet documented one pair of pants and one shirt and a pair of shoes. On 05/09/24 at 7:54 AM, R119 was observed to be in bed, laying on their left side, asleep, shoes at side of bed, with pants and a t-shirt on. On 05/09/24 at 4:17 PM, the Director of Nursing (DON) was asked about the identified care concern and reported R119 is able to use the urinal independently and the CNA may not have checked the pad and gown. A review of the record for R119 revealed R119 was admitted into the facility on [DATE]. Diagnoses included Dementia and Heart Failure. A review of the active care plans documented R119, .has psychosocial well-being problem related to lack of motivation/does not ask for assistance .is incontinent of bladder and or bowel .has a functional ability deficit and require assistance with self care .Encourage to choose own clothing daily .Encourage to assist in self care as much as possible, provide positive reinforcement for all activities attempted . A review of the Minimum Data Set assessment dated [DATE] documented impaired cognition with a 7/15 Brief Interview for Mental Status score and the need for partial/moderate assistance for upper body dressing and substantial/maximal assistance for lower body dressing and putting on/taking off footwear. A review of the facilities Standard of CNA/STNA Practice revised 08/15/23 revealed, .The CNA/STNA makes routine rounds to check each assigned resident's condition and ensures their needs are met . A review of the facility policy titled, Guest/Resident Rights & Facility Responsibilities revised 04/08/22 revealed, .Guest/Residents Rights. The guest/resident has a right to a dignified existence, selfdetermination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. 1. Dignity, Respect & Quality of Life. A facility must treat each guest/resident with respect and dignity and care for each guest/resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each guest's/resident's individuality. The facility must protect and promote the rights of the guest/resident .Planning and Implementing Care. The guest/resident has the right to be informed of, and participate in, his or her treatment, including: 1. Information Regarding Health Status. The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. 2. Participation in Plan of Care. The right to participate in the development and implementation of his or her person-centered plan of care .

Based on observation, interview, and record review, the facility failed to store medication in a safe and secure manner for one resident (R439), failed to discard expired medication in one of two medication storage rooms, and failed to label medications in three of five medication treatment carts reviewed for medication storage and labeling. Findings include: R439 On [DATE] at 8:00 AM, during an initial tour of the facility an observation was made of four pills in a small plastic cup being on a table top located next to R439's bed. R439 was interviewed regarding the medication on the table top and asked if they self administered their medications. R439 stated, They give me my pills. On [DATE] at 1:34 PM, a record review was completed of R439's electronic medical record (EMR) and it revealed no assessment documentation which indicated that R439 was able to self administer their medication. Further review of R439's EMR revealed that R439 was admitted to the facility on [DATE] with diagnoses that included Multiple sclerosis (Autoimmune disease) and Hypertension. R439's most recent minimum data set assessment (MDS) dated [DATE] revealed that R439 had an intact cognition. On [DATE] at 12:15 PM, the Director of Nursing (DON) was interviewed about resident's self administering of their medications and medications being left at a resident's bedside unmonitored. The DON indicated that a resident's medication should only be unmonitored and left at the resident's bedside if the resident has been assessed and deemed to be appropriate to self administer their medications. 32220 On [DATE] at 5:34 PM, an observation of the second floor A medication cart with Licensed Practical Nurse (LPN) A revealed and open and undated, Basalgar insulin pen, and open and undated Glargine insulin pen and an open and undated Levemir insulin pen. A vial of glucose test strips also not dated when opened and or with an expiration date. On [DATE] at 6:05 PM, an observation of the Rehab medication cart A with Registered Nurse (RN) B revealed a Latanoprost .005% eye dropper vial were open and undated and without a resident identifier on the vial. On [DATE] at 9:08 AM, an observation of the one north A medication cart with LPN D revealed, a Humalog insulin vial was not labeled with a resident identifier, a Breo inhaler was not labeled with a resident identifier on the inhaler, and a Trellegy inhaler was not labeled with the date opened or the expiration date on the inhaler. 49699 On [DATE] at 10:55 AM, accompanied by Licensed Practical Nurse (LPN) F six bottles of Primidone Suspension (seizure medication) were observed with expired use by dates of [DATE], [DATE], [DATE],[DATE], [DATE], and [DATE]. Nurse F verified the use by date and indicated they had not administered that medication today. A review of the facility policy titled, 5.3 Storage and Expiration Dating of Medications, Biologicals was reviewed, with last revision date of [DATE]. In part it revealed. Facility should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy. Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines.

Based on interview and record review, the facility failed to ensure that one resident (R125) was offered a bedtime snack of eight residents reviewed for snacks, resulting in nighttime hunger. Findings include: On 5/7/24 at 7:56 AM, during an initial tour of the facility R125 was interviewed and asked about their level of satisfaction with the food and snacks provided to them at the facility. R125 stated, I just found out I could get a snack a couple weeks ago. I get hungry after dinner. On 5/8/24 at 10:30 AM, R125 was further interviewed about bedtime snacks and indicated they had never been offered a bedtime snack. R125 stated, I'm not sure what's available. On 5/9/24 at 10:29 AM, a review of R125's electronic medical record (EMR) and a thirty day review of bedtime snacks offered to R125 revealed documentation which indicated that R125 was not offered a bedtime snack on the following dates: 4/12/24, 4/13/24, 4/14/24, 4/18/24, 4/19/24, 4/27/24, 4/28/24, 5/4/24, 5/7/24, and 5/8/24. On 5/9/24 at 10:35 AM, a further review of R125's EMR revealed that R125 was admitted to the facility on [DATE] with diagnoses that included Metabolic encephalopathy (Brain disorder) and Generalized anxiety disorder. R125's most recent minimum data set assessment dated [DATE] revealed that R125 had a moderately impaired cognition. On 5/9/24 at 1:13 PM, Activity Director (AD) J was interviewed regarding the process for offering and documenting the offering of bedtime snacks to residents. AD J provided the surveyor with a paper with [corn chip product] listed by R125's name and the date 5/7/24. AD J indicated the evening activity aides offer and pass out bedtime snacks to residents and document the information on paper like the one that was provided to the surveyor. AD J indicated the Certified Nursing Assistants (CNAs) are supposed to put the snack documentation in the EMR. On 5/9/24 at 1:35 PM, the Administrator (NHA) was interviewed regarding their expectations for offering and providing bedtime snacks to residents. The NHA indicated the expectation was residents who do not have [dietary/medical restrictions] should have a snack offered nightly. On 5/9/24 at 2:00 PM, a facility policy titled, Snacks Last Revised: 11/8/2021 was reviewed and stated the following, Policy: It is the policy of this facility to provide snacks as ordered and Hour of Sleep (HS) snacks will be offered to all guests/residents. Procedure: 5. Bedtime snacks will be offered to guests/residents at HS; the Nursing department will document the acceptance or refusal on the Food Acceptance/Snacks form.

This Citation pertains to Intake Number M100131450. PNC was accepted for this citation. Based on observation, interview and record review, the facility failed to provide adequate supervision for one resident (R81) of six residents reviewed for elopement by allowing the resident, who was severely cognitively impaired, ambulatory and identified as an elopement risk, to exit the building unbeknownst to facility staff while wearing a Wanderguard bracelet, including use of an alarmed elevator and exiting an alarmed door between approximately 9:15 PM - 9:25 PM on 08/07/2022. This deficient practice resulted in the likelihood of serious injury or death from being unsupervised outside in the dark near a busy four-lane road in the parking lot of a business adjacent to the facility. R81 was returned to the facility, escorted by an agency staff member who located the resident while on their way into work on 08/07/2022 at approximately 9:35 PM - 9:45 PM. Immediate Jeopardy: The Immediate Jeopardy (IJ) started on 08/07/22 and the immediacy was removed 08/07/22 per review of the facility's responding interventions and associated staff education completed on 08/12/22 and verified on 02/28/2023. The IJ was identified on 02/28/23 during the recertification survey. The facility's Nursing Home Administrator (NHA) was notified of the IJ on 02/28/23 at 9:10 AM and was asked for an abatement plan. The IJ was removed on 08/07/2022, based on the facility's implementation of the abatement plan as verified onsite on 02/28/23. Findings include: Resident #81 (R81): Review of the facility record for R81 revealed an admitted [DATE] with diagnoses that included dementia with behavioral disturbance, history of traumatic brain injury, metabolic encephalopathy, Anxiety disorder, history of repeated falls, difficulty in walking, generalized muscle weakness and vertigo. Minimum Data Set (MDS) assessment dated [DATE] revealed Brief Interview of Mental Status (BIMS) score of 0 which indicated severe cognitive impairment and functional assessment section GG indicated R81 required maximum assistance for Activities of Daily Living (ADL) and that the ability to walk ten feet was not assessed due to medical or safety concerns. Despite the lack of walking assessment in the MDS, R81's record revealed that, at the time of the reported elopement, R81 routinely ambulated without physical assistance or use of an assistive device. Supervision was required due to instability and a history of repeated falls in addition to the supervision recommended due to the elopement risk. Review of the facility form Risk for Elopement - V2 for R81, dated 6/13/22, included Question #2. Does the [R81's] wandering place the resident at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility)? The response to this question is documented as Yes. R81 is identified on the Resident Elopement Risk grid as being recommended for and provided with a WanderGuard on the left wrist. Review of R81's care plan with a revision date of 5/30/22 revealed a Focus area that stated [R81] is at risk for elopement related to cognitive impairment/Dementia with behavior and wandering. The Goal associated with this Focus area stated [R81] will not leave the facility unattended through the review date (8/29/22). Interventions associated with this goal included: Observe wandering behavior and attempt diversional interventions when wandering into inappropriate locations such as attempts at exiting facility and Distract resident when wandering into inappropriate areas by offering pleasant diversions, structured activities, food, conversation, etc. On 2/27/23 at 11:50 AM, R81's family member and Responsible Party Q was interviewed via a telephone call. They were able to recall the incident during which R81 eloped on 8/7/22. Q reported that they were contacted by the facility shortly after R81 was returned to the facility and assessed. Q stated They told me they looked at the camera but did not provide an explanation of how R81 was able to exit the building undetected. Q expressed concern that they had not been contacted prior to R81 being located however they later realized that nobody was aware R81 was missing until they were located off the facility property. Q expressed that they still don't understand how R81 was able to exit due to having a WanderGuard and being on the second floor but that they are not overly concerned regarding further elopement as R81 is no longer ambulatory. On 2/27/23 at 10:59 AM, RN A was interviewed via a telephone call. RN A reported that they did recall the elopement incident on 8/7/22 involving R 81 and that they were working on the unit and assigned to R81 during the time of the incident. They recalled being at the nurses' station completing documentation and R81 walking past. RN A recalled hearing R81 interacting with other staff down the hallway out of sight and stated that what they recall as being approximately 15 minutes later being called by licensed practical nurse (LPN) T from the first floor who reported that R81 was being brought into the facility by a certified nurse aide (CNA) who found her in front of the hookah shop next door. Registered Nurse (RN) A reported being involved in completing R81's wellness assessment and contacting management and R81's family member Q regarding the incident. Regarding the possible means of R81 being able to exit the facility, RN A reported that they do not recall ever hearing an alarm and was not sure how R81 was able to exit. RN A reported that management had reported that the exit of R81 was viewed on the facility's CCTV (video) footage. RN A reported having four CNA's working on the 2nd floor that evening which was considered adequate as the normal CNA staffing for the floor was four to five CNA's. On 2/27/23 at 11:35 AM, CNA G was interviewed in the facility and reported that they recalled the incident on 8/7/22 when R81 eloped. CNA G stated they were assigned to the second floor during that shift and reported not being able to recall seeing R81 near the time of the elopement and that they were not aware of the situation until staff were notified that R81 had been returned to the building from near the business next door. CNA G did not recall hearing any alarms around the time of the incident. On 2/27/23 at 12:15 PM, CNA R who was listed as having worked second shift on the second floor the evening of 8/7/22 was interviewed via telephone and reported vaguely recalling the incident of R81's elopement but stated that they could not recall any details of the incident. On 2/27/23 at 1:30 PM, CNA S, who was identified as the agency CNA who found R81 at the business next to the facility, was interviewed by telephone. CNA S reported that they recalled the evening of R81's elopement. CNA S reported that their family member was driving them to work and had accidentally passed the facility. As they turned around in the plaza next to the facility the family member noticed R81 in front of the hookah shop and expressed concern as they noticed R81 did not have shoes on. CNA S reported that they did not know or recognize R81 as they normally did not work on the second floor. CNA S reported that they pulled up to check on the person thinking that it could be a resident and there was a man nearby. When they exited the vehicle CNA S reported that the man was stating that he was going to call the police if someone did not deal with the person [R81] as they were attempting to enter the hookah shop when it was closed. CNA S reported that they walked to the facility while their family member watched R 81 and found LPN T who returned to the parking lot with them and verified that the person was R81 and was a resident of the facility. CNA S reported that when they attempted to walk toward the facility R81 was walking gingerly as if their feet were hurting and therefore they decided to assist R81 into the vehicle and drive them next door to the facility. CNA S reported that when this occurred it was dark outside and as they usually arrived early for their shift, they felt that this incident occurred at approximately 10 PM however they were not sure exactly what time it was. Review of the facility time card for 8/7/22 for CNA S revealed a punch in time of 10 PM for a scheduled 11 PM start. On 2/27/23 at 2:15 PM, CNA P who was identified as working on the second floor during the shift of R81's elopement was interviewed in the facility. CNA P recalled the incident and reported being unable to recall any specifics other than being made aware of the incident after R81 had been returned to the facility. CNA P could not recall hearing any alarms around the time of the incident and stated I would've responded to an alarm if I heard it. On 2/27/23 at 2:32 PM, the Facility Administrator (NHA) was interviewed regarding R81's elopement on 8/7/22 and the corresponding Facility Reported Incident (FRI) report. In summarizing the incident the NHA reported that when R81 exited the building they were noticed and brought in by a CNA who was on shift and was outside taking a break. The NHA reported that there was video footage of the incident that contributed to the timeline of events described in the FRI however the footage had been subsequently lost due to a power failure. The NHA provided a walk-through demonstrating the reported route of R81's elopement and indicated that at the point of exit a staff member/s had responded to the exit door alarm however they were not able to recall who the staff member/s were and no such person was identified in the FRI. On 2/28/23 at 3:05 PM, LPN T was interviewed by phone. LPN T reported that they recalled the incident of R81 eloping on 8/7/22. LPN T stated that an agency CNA entered the building and reported that they thought a resident may be at the hookah shop next door and asked if LPN T could come next door to verify if the person was a resident. T agreed to walk next door and did verify that R81 was the person in front of the hookah shop. LPN T reported that they assisted R81 into the CNA's vehicle so that R81 did not have to walk in her socks and they pulled up to the front entrance and assisted R81 into the building and back to the second floor where R81's nurse, Nurse A, began to assess the resident. LPN T reported that prior to and during the time of this incident they were working on the first floor and did not hear any type of an alarm and had not been aware of a missing resident. On 2/28/23 at 11:51 AM, The facility Director of Nursing (DON) was interviewed and reported that the expectation regarding residents who are at risk for elopement is that staff provide supervision and respond immediately to the elevator and door alarms and follow the protocol for locating any missing residents. On 2/28/23 at 1:40 PM, The NHA reported that the expectation for supervision of residents identified as an elopement risk is that staff provide consistent and regular checks/supervision to verify the residents whereabouts. Review of the facility Elopement Policy with the most recent effective date of 5/1/22 revealed the general policy statement It is the policy of this facility to prevent to the extent reasonably possible, the elopement of guests/residents from the facility. This policy further defines elopement as occurs when a guest/resident who needs supervision leaves a safe area without authorization and/or any necessary supervision to do so. This policy also states in item C under Procedure and regarding WanderGuards that Verification of unit functionality will be tested by the midnight shift licensed nurse using wandering testing device and documented on the guest/residents MAR. Review of the MAR for R81 in the section Confirm that WanderGuard on resident is functioning appropriately. Left wrist. is marked N for No on the dates of 8/7/22 and 8/8/22. F-689 Abatement Plan February 28, 2023 Identification of Residents Affected or Likely to be Affected: (R81) There have been no further admissions and no current residents with Elopement since 08/07/2022. Actions to Prevent Occurrence/Recurrence: 1. The facility immediately placed Resident #81 on a 1:1 monitoring/supervision. 2. Immediate door checks were made on 08/07/2022 at 11:30 pm by maintenance staff. 3. Staff who were present in the building were educated on timely response to alarms and the elopement protocol. 4. Nurses reviewed the elopement books and ensured that residents who were on elopement protocols had functioning bracelets and the book was up to date. 5. Internal head count for correct census completed. 6. Administrator, DON and Responsible Party were immediately notified. Admin on site and physician and family alerted

This citation pertains to Intake Number MI00132074. Based on observation, interview and record review, the facility failed to complete/document accurate skin/wound assessments, and implement wound care interventions for three sampled residents (R64, R80, and R285) of six residents reviewed for skin care, resulting in unmet care needs and the potential for the worsening of wounds. Findings include: R285 A review of a complaint called into the State Agency revealed the following, My [family member] was not properly cared for in this facility. [R285] was left for several hours in soaked urine and feces, and was not attended by the staff. [This] resulted in [them] being hospitalized with a Stage 4 (Full Thickness Skin and Tissue Loss) bed sore . A review of R285's medical record revealed that they were admitted into the facility on [DATE], and discharged on [DATE] with diagnoses that included Diabetes, Muscle Weakness, and Bifascicular Block (heart block). A review of R285's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was severely cognitively impaired and required extensive assistance for bed mobility, transfers and personal hygiene. A review of R285's medical record revealed a Nursing Home Comprehensive Evaluation dated for 9/7/22 indicating the following skin conditions/concerns. Vertebrae (upper mid) Description: right mid-back shingles. Other: left upper chest incision with steri strips. In addition, the nurse's note from the admission summary indicated the following, admitted [identifying information] from [local hospital] .[R285] has shingles on [their] right mid-back and [R285] had a pacemaker implanted 9/2/22 with incision on left upper chest is dry and intact with steri strips. Patient has no other skin issue or breakdown . Further review of R285's weekly total body skin assessments (9/14/22, 9/21/22, 9/28/22 and 10/5/22) documented that the resident had no new wounds or skin concerns until their 10/6/22 total body skin assessment, which revealed that the resident had a Stage 4 Full Thickness Skin and Tissue Loss on their Coccyx (buttocks). Further review of the skin assessment revealed the following, Sacral is a Stage 4 pressure injury and has received an outcome of not healed wound measurements are 4 cm (centimeters) length x 10 cm width x 3 cm depth, with an area of 40 sq (square) cm and a volume of 120 cubic cm. There is a moderate amount of sero-sanguineous drainage noted which has a strong odor, wound bed has necrotic base epithelialization with irregular edges, fragile periwound, wound measurement is positional. The periwound skin presents with s/s of infection . The following treatment order was put into place on 10/6/22: Crushed flagyl (antifungal medication)500 mg (miligram) + Santyl (debriding agent) and PRN (as needed) x 7 days. Triad Paste-to the periwound. On 2/27/23 at 3:21 PM, the Director of Nursing (DON) explained that she became aware of R285's wound after their MDS nurse explained that the resident's wound was not captured when they were admitted from the hospital and as a result, a performance improvement plan was developed which included education, in addition to ongoing audits. The DON admitted that the wound was not documented correctly by the admitting nurse, and provided a copy of R285's admitting documentation from the hospital. R64 On 2/26/23 at 8:43 AM, R64 was observed lying in bed awake. Attempts to interview R64 were made to no avail due to their cognition. On 2/26/23 at 12:24 PM, R64 was observed sitting at a 45-degree angle being fed by a family member. On 2/26/23 at 4:01 PM, R64 was observed positioned in the same manner which was observed at 12:24 pm. A review of R64's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included Unspecified Atrial Fibrillation, Low Back Pain, Muscle Weakness, Muscle Wasting and Atrophy. A review of their most recent Minimum Data Set assessment dated [DATE] revealed that the resident had a Brief Interview for Mental Status score of 3/15 indicating a severe cognitive impairment and required extensive assistance for Activities of Daily Living. Further review of R64's medical record revealed the following progress note: 1/5/23 16:17 (4:17 pm) Skin/Wound Progress Note: Seen by wound care team on 1/5/2023. Re-Consult. left Buttock is Stage 3 pressure injury (full thickness loss potientially extending into the subcutaneous layer) and has received a status of not healed. Measurements are 1 cm (centimeter) length x 1 cm width x 0.01 cm depth, with an area of 1 sq (square) cm and a volume of 0.01 cubic cm. There is a small amount of serous drainage noted which has no odor, wound bed has pink base epithelization with irregular edges. The periwound skin does not exhibit signs or symptoms of infection. Treatment updated refer to wound care progress note. A review of R64's census revealed that the resident had been hospitalized and was readmitted on [DATE]. Further review of R64's medical record revealed the following Nursing Comprehensive Evaluation-Re-entry dated 1/21/23 noting the following skin concerns, Vertebrae (upper mid) excoriation, Sacrum-Excoriation, left antecubital-multiple discoloration; right antecubital-multiple discoloration, chest-pace maker to left chest; right lower leg front-multiple discoloration. Further review of R64's medical record revealed that weekly skin assessments were completed on the following dates noting no new skin concerns or issues: 1/27/23, 2/4/23, 2/11/23, 2/13/23, 2/20/23 and 2/27/23 however, the following progress notes revealed the following: .Seen by wound care team on 2.2.2023. Follow up consult. Left Buttock is a Stage 3 pressure injury and has received a status of not healed measurements are 0.5 cm length x 0.5 cm width x 0.1 cm depth, with an area of 0.25 sq cm and a volume of 0.025 cubic cm. There is a small amount of sero drainage noted which has no odor, wound bed has pink base epithelization with irregular edges. The periwound skin does not exhibit signs or symptoms of infection . On 2/28/23 at 3:14 PM, Wound Care Nurse AA was asked about R64's Stage 3 wound on their left buttocks, and she explained that R64 has a reoccurring Stage 3 wound, and when staging the wound, they never stage backwards. Wound Care Nurse AA further explained that R64 had some decline which may have contributed to the reopening of their pressure ulcer. Wound Care Nurse AA explained that the wound care team picked R64 up a couple of weeks ago based on the procedure for floor nurses to complete a wound consult which prompts them to assess and begin implementing interventions for the wound. A review of R64's medical record revealed that the last time they had a Stage 3 wound on their left buttock was over 2 years ago, and had been given a status of resolved. 44750 R80 On 2/26/2023 at 10:54 AM, R80 was observed in their room, laying in bed. R80 was unable to be interviewed. No heel protector boots were observed on R80. A review of the medical record revealed that R80 was admitted into the facility on [DATE] with the following diagnoses, Parkinson's Disease and Dysphagia. A review of the Minimum Data Set assessment (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIM) score of 12/15 indicating moderately impaired cognition. R80 also required extensive two-person assistance from staff. A review of physician orders revealed the following order, Bilateral Heel Protectors while in bed/off when up in w/c (wheelchair). Order Status: Active. Order Date: 8/15/2021. On 2/27/2023 at 12:00 PM and 2/28/2023 at 12:16 PM, R80 was observed in bed with no heel protectors applied. On 02/28/23 at 12:48 PM an interview was conducted with Unit Manager (UM) W regarding R80 not having on their heel boots. UM W stated that R80 has a history of developing blisters, so the boots are for protection, but R80 does not have anything on their heels. UM W stated that if it's ordered it should be applied. A review of the facility's Skin Management policy was reviewed and revealed the following, Practice Guidelines 1. Upon admission/re-admission all guests/residents are evaluated for skin integrity by completing a baseline total body skin evaluation documented in the electronic medical record. 3. Appropriate preventative measures will be implemented on guests/residents identified at risk and the interventions are documented on the care plan. 4. Guests/residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing, A physician's order for treatment, and Wound location, measurements and characteristics documented .11. 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. The CNA's will report any new skin impairment to the licensed nurse that is identified during daily care .

Based on observation, interview, and record review, the facility failed to care plan interventions for two residents (R114 and R286) of four residents reviewed for care planning, resulting in interventions not being implemented and monitored regularly. Findings Include: R114 On 2/27/2023 at 10:53 AM, R114 was observed in the bed. R114 was observed to have two large green body pillows on each side of them. R114 was unable to be interviewed. A review of the medical record revealed that R114 initially admitted into the facility on [DATE] with the following diagnoses, Muscle Wasting, Muscle Weakness, and Difficulty in Walking. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0/15 indicating a severely impaired cognition. R114 also required extensive two person assist with bed mobility and transfers. A review of the fall care plan did not note the body pillows. On 2/28/2023 at 12:46 PM, an interview was conducted with the Director of Nursing (DON) and Unit Manager (UM) W. The DON stated that the body pillows are used for different things. The DON stated that they are used for positioning with R114. UM W stated that R114 used to be busy and have their feet hanging out of the bed. UM W stated that the body pillows were being used as a preventative intervention to prevent falls. The DON and UM W were queried as to if the body pillows should be a care planned intervention. Both the DON and UM W stated that it should be care planned so that everyone is on the same page. R286 On 2/26/23 at 9:09 AM, R286 was observed in bed sitting with their breakfast tray sitting in front of them. R286 was observed feeding themselves from a plate of pureed textured food while coughing. R286's meal ticket was observed indicating 1:1 feed (requiring one staff assistance with feeding). R286 was asked if they always feed themselves, and stated, Yes. A review of R286's medical record revealed that they were admitted into the facility on [DATE] with diagnoses that included, Wedge Compression Fracture of T5-T6 Vertebrae Sequela, Dysphagia (difficulty swallowing), Generalized Anxiety and Alzheimer's Disease, Late Onset. Further review of their entry Minimum Data Set (MDS) assessment dated [DATE] revealed that R286 had a Brief Interview (BIMS) for Mental Status score of 11/15 indicating a moderately impaired cognition, and required Extensive Assistance of 2 persons for Activities of daily Living. Further review of R286's medical record revealed the following active Physician's Order dated for 1/23/23, Regular Diet Level 1 puree texture, honey consistency, 1 to 1 feed, seated upright, slowly ensure patient swallowed, cue [R286] to swallow. Further of R286's medical record revealed the following care plan, Alteration in nutritional and/or hydration status r/t (related to) enteral nutrition via PEG (Percutaneous Endoscopic Gastrostomy-feeding tube) due to NPO (nothing by mouth), status, dysphagia, and increased estimated needs related to fracture healing. Current body weight is 220 lbs . PO (oral) diet initiated per SLP (speech and language pathologist), . modified timing of enteral feeds to allow for PO intake during day .TF (tube feed) regime change, supplement added. Date initiated: 01/09/23. Revision on 02/06/23.Interventions: Assist resident with meals, including 1:1 feeding (initiated 01/24/23) .Observe and reported to physician PRN (as needed) for s/s (signs and symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth. Several attempts at swallowing, Pain when swallowing. Date initiated 01/09/2023 . On 2/26/23 at 12:10 PM, R286 was observed sitting up in bed, again feeding themselves. On 2/27/23 at 9:12 AM, R286 was observed in bed, breakfast tray observed in the room but not in reach. An unidentified nurse entered the room and moved the breakfast tray in front to R286, and explained that R286 was evaluated and is now able to feed themselves. R286's meal ticket was observed on their tray indicating that R286 required 1:1 feeding assistance. On 2/28/23 at 9:16 AM and 12:48 PM, R286 was observed eating their meals without 1:1 assistance. On 2/28/23 at 1:45 PM, an interview was completed with Registered Dietician F (RD F). She was asked about R286's orders for 1:1 feeding assistance, and indicated that speech therapy makes feeding assistance determination. A review of R286's medical record revealed a new Physician's Order dated 2/28/23 indicating the following, Regular diet, Level 3 Advanced (mechanical soft) texture, then consistency, 1 to 1 feed, seated upright. A review of the facility's Care Plan policy revealed the following, Purpose: 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 services, the resident or resident representative, therapy staff as required and any other ancillary staff. Additional resources will also be utilized to ensure that ay additional needs or risk areas are identified. 9. The care plan and resident Kardex will be updated on Admission, Quarterly, Annually and with significant changes. This include adding new focuses, goals, and interventions and resolving one that are no longer applicable as needed

This Citation pertains to Intake Numbers MI00129936 and MI00132074. Based on observation, interview, and record review the facility failed to ensure that toileting and/or emptying of a colostomy bag was addressed in a timely manner for two residents (R99 and R117) of three residents reviewed for Activities of Daily Living (ADL) care, resulting in feelings of frustration, aggravation, and dissatisfaction with care. Findings include: R99 On 2/26/23 at 9:01 AM, during an initial tour of the facility, R99 was interviewed about care at the facility and stated, I wait up to an hour for my colostomy bag (bag attached to opening in colon to collect stool) to be emptied. Staff should respond faster to call lights. On 2/28/23 at 10:58 AM, R99 was observed to have their call light on. When interviewed R99 indicated that their colostomy bag was full and needed to be emptied. R99 stated, I put my call light on at 10:35 AM, and no one has come to help me. On 2/28/23 at 11:01 AM, Certified Nursing Assistant (CNA) L entered R99's room, turned off the call light and indicated that they would return after they finished passing out water on the unit. CNA L then exited R99's room. On 2/28/23 at 11:02 AM, R99 reactivated his call light and CNA M entered R99's room. CNA M was observed to turn off R99's call light. CNA M was interviewed about the facility policy regarding answering resident's call lights and assisting residents with care. CNA M indicated that the call light should be answered and then could be turned off if the care needed by the resident was not an emergency. CNA M was asked how they were able to know that a resident had a care need that had not been addressed, if the call light was turned off. CNA M stated, I'll remember. CNA M then exited R99's room. At 2/28/23 at 11:04 AM, R99 was interviewed about how they felt when care was not provided. R99 stated, I feel upset and aggravated. That's a problem, staff turn off the call light and never come back. R99 further indicated that they had experienced their colostomy bag over flowing on a few occasions due to it not being emptied in a timely manner. On 2/28/23 at 11:12 AM, CNA L was observed re-entering R99's room with linens and supplies and indicated that they were going to assist R99 with their colostomy bag. Review of R99's electronic medical record (EMR) revealed that R99 was most recently admitted to the facility on [DATE] with diagnoses that included Unspecified protein calorie malnutrition and Benign prostatic hyperplasia (prostate enlargement) without lower urinary tract symptoms. R99's most recent quarterly minimum data set assessment (MDS) dated [DATE] revealed that R99 had an intact cognition and required extensive assistance with all ADL's (activites of daily living) other than eating. On 2/28/23 at 11:26 AM, the Director of Nursing (DON) was interviewed about their expectations for CNA's providing ADL care to residents and responding to call lights. The DON indicated that a resident's call light should be answered within approximately fifteen minutes. The DON indicated that the CNA should answer the resident's call light and if the care need was not an emergency, and if the CNA was in the middle of doing something else, they should let the resident know when they would return to provide care. The DON was asked if the resident's call light should be turned off prior to care being provided. The DON indicated that the call light could be turned off as long as the CNA was in the middle of doing something else, responded to the resident's call light, determined that the care required was not an emergency, and communicated with the resident when they would return to provide care. The DON was further interviewed about their expectations for CNA's providing care if the resident reactivates their call light and a different CNA enters the room to respond to the call light. The DON stated, Technically they should take care of the care need for the resident. 32220 R117 On 02/26/23 at 9:35 AM, R117 was observed to be in their room in their bed with the head of the bed lowered but not flat. R117 was down in the bed with their shoulders at the bend in the bed. On 02/26/23 at 11:47 AM, R117 was in their room, dressed and out of bed, up in a recliner style chair. The head of the recliner was up 30-45 degrees. R117 fidgeted with the lift sling under them. On 02/26/23 at 2:00 PM, R117 continued out of bed in their room and in the recliner. On 02/26/23 at 3:59 PM, R117 continued out of bed in their room and in the recliner. On 02/27/23 at 8:39 AM, R117 was observed to be in the recliner and in the common area/dining room. R117 was at one side of the table. R117 was dressed in a short sleeve sweat shirt and shorts. The head of the recliner was back about 30-45 degrees. The lift sling was under the resident. R117 made verbalizations and the eyes were closed. R117 made motions as if feeding themselves with their hands. R117 continued to gesture and make verbalizations intermittently. On 02/27/23 at 10:10 AM to 1:31 PM a continuous observation of R117 was made. R117 continued in the dining room, in the recliner as before. At 10:54 R117 continued in recliner in the dining area and while fidgeting with a sheet dropped it on the floor. A staff person brought them another and covered them up. Five residents and one visitor were also in the dining room area. At 11:00 AM R117 was visited by a member of the medical staff who spoke with the resident. At 12:05 PM, R117 had quieted and was less restless. At 12:39 the lunch tray was set on the table in front of R117. At 12:45 PM staff sat next to R117 and assisted them to eat. Staff did not adjust the head of the recliner to allow R117 to sit up for the meal. At 1:07 PM, the meal assistance was completed. At 1:31 PM, R117 continued up in the recliner in the dining area. Staff were not observed to toilet R117 nor adjust the recliner during the observation period. On 02/28/23 at 12:41 PM, the Unit Manager was asked about the toilet needs of R117 and reported R117 to be incontinent. The Unit Manager further noted the expectation was to toilet/check for incontinence every two hours. The Unit Manager was asked about staffing on the floor and reported they had worked the medication cart on another unit due to a staff call in and there may have been only two aides and two nurses on the floor initially and they average three aides on the floor. A review of the facility record for R117 revealed R117 was admitted into the facility on [DATE] and diagnoses included Repeated Falls, Difficulty Walking, and Muscle Wasting. The has ADL (Activities of Daily Living) self care performance deficit care plan with date initiated of 12/23/22, indicated an intervention for Toilet use: requires extensive assist of one with transfers, initiated 12/27/22 . The Admission Nursing Evaluation dated 12/22/22 documented R117 incontinent of bladder. The Minimum Data Set (MDS) assessment dated [DATE] indicated moderately to severely impaired cognition with a 7/15 Brief Interview for Mental Status Score and the need for extensive assistance of one or two persons for transfers, bed mobility, locomotion, dressing, eating, personal hygiene, toilet use and bathing. A review of the Resident Council Minutes dated 02/24/23 documented the concern New Business: .Not enough staff on each set . Review of the facility policy titled Call Lights Last Revised: 2/15/22 was reviewed and stated the following, Policy: Call Lights will be .answered in a timely manner. Responding to a Call Light: 1. Identify the location and answer the guest/resident promptly. 3. Go to the location of the call light, and turn off the light if you are able to meet the guest/resident request. 4. Do what the guest/resident requests of you, if permitted. 5. When finished, turn the call light off .

Based on observation, interview, and record review, the facility failed to complete and/or document catheter care according to physician's orders and the care plan for one resident (R80) of one resident reviewed for catheter care, resulting in the potential for recurrent urinary tract infections and discomfort. Findings Include: R80 On 2/26/2023 at 10:49 AM, R80 was observed laying in bed. R80 was observed to have an indwelling Foley catheter that was draining dark amber urine. A review of the medical record revealed that R80 was admitted into the facility on [DATE] with the following diagnoses, Parkinson's Disease and Dysphagia. A review of the Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 12/15 indicating moderately impaired cognition. R80 also required extensive two-person request. R80 was also noted to have an active urinary tract infection at the time of survey. A review of physician orders revealed multiple active orders for the indwelling catheter, however no orders appeared on the Medication Administration Record (MAR), Treatment Administration Record (TAR), or on the Task list. On 2/28/2023 at 12:46 PM, an interview was held with the Director of Nursing (DON) and Unit Manager (UM) W regarding catheter care for R80. The DON stated that there should only be active orders on the MAR and TAR. The DON stated that there is no documentation that the catheter was being cared for, because the order was not put in properly. A review of a facility policy titled, Infection Prevention Program did not address indwelling catheter care.

Based on observation, interview, and record review the facility failed to serve food in a palatable manner and/or at the preferred temperature for five residents (R20, R126, R9, R38 and R78) of eight residents and two anonymous residents ([NAME] and RZ) reviewed for food palatability, resulting in resident dissatisfaction during meals. Findings include: On 2/26/23 at 9:54 AM during an initial tour of the facility R20 was interviewed about food palatability at the facility and stated, The food is frequently cold. On 2/26/23 at 11:00 AM, food committee meeting minute notes where reviewed for the months of October 2022 through January 2023 and revealed the following comments, Better temperature .french fries .lack of condiments .coffee needs improvement .coffee looks like a light tea. Would like it checked more often. Food Temperature is not up to par, mostly for breakfast. Eggs cooler than they should be. Coffee cold .watered down. On 2/27/23 at 12:15 PM, a random meal tray on the second floor of the facility was temperature tested by Registered Dietician (RD) F and the results were the following, roast beef with gravy: 121.9 degrees Fahrenheit; potatoes and carrot mix: 123.3 degrees Fahrenheit; biscuit: 124 degrees Fahrenheit. RD F was asked what the preferred temperature for the food was and stated, 120 degrees Fahrenheit or above. RD F was asked to taste the food on the lunch tray and agreed to taste the potatoes/carrot mix, which they indicated tasted Good. On 2/27/23 at 12:18 PM, the lunch tray was taste tested by the surveyor and the results were the following, the roast beef with gravy tasted Luke warm, was chewy, tasted processed, and the gravy was excessively salty tasting. On 2/27/23 at 1:54 PM Dietary Manager (DM) N was interviewed regarding food palatability and temperature involving the food served to the residents. DM N indicated that when the meal was passed to residents on their units it should be at a temperature of 120 degrees Fahrenheit or above. When asked about food palatability, DM N indicated that the dietary department attempted to accommodate resident requests, offer meal alternatives, and had a food committee. On 2/28/23 at 4:33 PM, R20 was further interviewed about food palatability regarding their most recent breakfast, lunch, and dinner. R20 stated, The roast beef served for lunch yesterday was tough, chewy, and grisly, it wasn't good. On 2/28/23 at 4:40 PM, R20's electronic medical record (EMR) was reviewed and revealed that R20 was most recently admitted to the facility on [DATE] with diagnoses that included Cellulitis (Bacterial infection of the skin) of right and left lower limbs and Hypertension. R20's most recent quarterly minimum data set assessment (MDS) dated [DATE], revealed that R20 had an intact cognition. 32220 On 02/26/23 at 9:13 AM, a rehab unit resident who requested to remain anonymous (R Z) reported they had been told the kitchen toaster and ice machine were broken. The resident reported the food often comes to them cold and the toast was served too hard. On 02/26/23 at 9:44 AM, a rehab unit resident who requested to remain anonymous (R Y) reported the food was not so good and they ordered out. On 02/26/23 at 12:40 PM, the food tray cart was observed on rehab floor at the nurse station and the doors were left open during the time it took to deliver the trays. At 12:47 PM, tray delivery was started on a second cart and the doors were left open. All meals from the carts were delivered by 12:53 PM. On 02/27/23 at 2:30 PM, during the resident group meeting care concerns were reviewed. Four (R9, R20, R38, R78) of the five in attendance reported The food was lousy today. The residents reported a lot of grizzle' and the roast beef was tough to eat. The residents were not sure if it was a different cut of meat, under cooked or over cooked but it was just hard and tough to eat. A resident further commented that many times the food has been served cold and served from open (not enclosed) carts. It was also reported a resident was served without a knife to cut the tough meat. A resident also noted that its been tough lately with three instead for four aides. It was reported some care needs take longer to get met. Snacks were reported as hit and miss and depended whose responsibility it was to pass them out. A review of the Resident Council Minutes dated 01/27/23 documented, Old Business: Dietary: Breakfast not at desired temperature New Business: Dietary: Cold Food for all meals . On 02/28/23 at 8:54 AM, R126 was asked about their food for breakfast. R126 commented they had eaten their cereal but had not eaten the rest. The food was observed to be two circles (about two inches in diameter) of ham and a waffle. The waffle was sponge like, appeared to be premade and did not appear to have been toasted. R126 also noted the food is often cold and the tomato soup that was served the other day was cold. R126 was also asked about the meat served the day before and reported it was really tough and they did not have a knife to cut it. On 2/28/23 at 4:50 PM, a facility policy titled Food Preferences Last Revised: 11/12/21 was reviewed and stated the following, Policy: It is the policy of the facility to obtain food preferences for all guests/residents. Procedure: 5. The Dietary Manager or Dietician will review food preferences at least quarterly. 7. The facility's Quality Assurance Performance Improvement (QAPI) Committee will periodically review issues related to preferences and meals to try to identify more widespread concerns.

This citation pertains to intake # 5. Based on interview and record review, the facility failed to transfer one resident (Resident #258) per standards of care, by not utilizing a gait belt, out of five reviewed for falls, resulting in the unsafe transfer and Resident #258 subsequently being lowered to the floor, fracturing their left femur and having to undergo emergency surgery, pain and hospitalization . Findings include: On 10/29/20 at 12:55 PM, Confidential Witness A was interviewed via phone. Confidential Witness A had explained that Resident #258 was just supposed to be at the facility for respite care under hospice for the weekend so that she could go to her son's wedding that was out of town. Confidential Witness A stated, I told them (facility staff) not to get (Resident #258) up, they were immobile. The next day I get a call that (Resident #258) fell during a transfer from the wheelchair to the bed. (Resident #258) was not supposed to be up! I was told that (Resident #258) was fine (after the fall) and then a few hours later I get another call that the Doctor was sending (Resident #258) out to the hospital because their knee hurt. Then, I get a call from the hospital that (Resident #258) has to have surgery. I was so upset, here I am driving to see my son get married and (Resident #258) has to have emergency surgery. Confidential Witness A began to cry and stated, It was terrible. (Resident #258) is back home now, and in a lot of pain. During the interview, Confidential Witness A was asked the reasoning of her directing the staff not to get Resident #258 up and out of bed. Confidential Witness A explained that the resident was terrified of falling and would get anxious while being transferred. A record review of Resident #258 was completed and revealed the resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #258 was discharged to the hospital on [DATE]. A record review of the progress notes revealed the following: 10/21/20 14:53 (2:53 PM) .@ 2:30pm cna (Certified Nursing Assistant/CNA B) From agency went to change resident. Resident was being transferred from chair to bed when (CNA B) say resident was being combative and fell . (CNA B) notified me and I went to assist to get resident off of floor. resident was laying on the left region on the floor next to the bed on the side near the window. resident was complaining of pain and when asked where resident touched knee which looked swollen and out of place. (Doctor) was notified, X-ray is order 10/21/20 16:37 (4:37 PM) .range of motion was done on resident. Resident unable to extend left lower extremity. Tylenol was given for pain. 10/21/20 18:13 (6:13 PM) .resident was transferred to (local hospital) at 5:20 pm, resident was picked up (via ambulance) . A record review of the Incident and Accident Report dated 10/21/20 for Resident #258 revealed the following: Description-(CNA B) was transferring (Resident #258) from chair to bed and (Resident #258) slid down to the floor on their side. (CNA B) came to notify me and for help to get them back in bed and knee was observed. Interventions implemented-Resident was being transferred a 1 person assist should be a two person assist. On 10/29/20 at 1:04 PM, CNA B was interviewed in regard to the incident that occurred while transferring Resident #258 on 10/21/20. CNA B explained that she had been a CNA since 2017 and was working for a staffing agency. CNA B stated, I was doing my second rounds. (Resident #258) was in the wheelchair next to the bed. I made sure (Resident #258) was a one person transfer before I transferred them. I told (Resident #258) to give me a big hug (wrap arms around CNA to hold on to) and they did. Then, I hugged (Resident #258) by wrapping my arms around them. We rocked back and forth and counted, '1-2-3' and then (Resident #258) stood half way and froze (CNA B demonstrated a stance of Resident #258 with their knees in a flexed/bent positioned and not able to bear full weight). I had to ease (Resident #258) back down (to the ground). I could tell their knee looked different and I told the nurse. (Resident #258) also was shaky. CNA B explained that Resident #258 was larger than her and was 'dead weight'. CNA B was asked if she utilized a gait belt (a belt that wraps around the resident and securely buckles in the front to allow for the CNA to hold on to the belt and have more control during the transfer) during the transfer. CNA B stated, They (the facility) don't have them (gait belts) here. My agency doesn't give us one and the facility doesn't give us one. You can look around (at other CNA's within the facility) and no one uses them. A record review of the x ray report dated 10/21/20 revealed the following: distal femoral diaphyseal (typically sustained from high impact) fracture. A record review of the Medication Administration Record [REDACTED]. On 10/29/20 at 1:33 PM, an interview was completed with the Director of Nursing (DON) and Nursing Home Administrator (NHA) in regard to Resident #258's transfer on 10/21/20. The DON explained that when a new resident is admitted usually therapy evaluates the resident for the transfer status and puts the changes in the care plan and Kardex (care plan for CNAs). The DON also explained that Resident #258 was on hospice and at the facility for respite care and was a one person assist at that time. The CNA B was transferring the resident and the resident became resistive with care. The DON stated, (Resident #258) was falling, she (CNA B) lowered them to the floor and got the nurse. The DON explained that if he is in the facility and a resident falls, he personally goes to assess the situation/resident. The DON stated, (Resident #258) had knee pain. I seen them myself. Later, the physician came in and assessed them and seen they were on eliquis (an anticlotting medication), and wanted to send them to hospital to rule out any injuries. The DON and NHA were asked if the facility requires the use of gait belts during transfers. The NHA stated, It is our policy to use a gait belt. The DON was asked if he was aware that CNA B had not used a gait belt during the transfer and stated, No, I was not aware of that. The DON was made aware that CNA B had mentioned that she was not provided a gait belt to use on residents to transfer them. The DON stated, The CNA's have gaitbelts to use and we provide them to agency staff, too. I will talk to her. The NHA further explained that if they (management) notice CNA's without gait belts, they ask them where they are and to get them and keep them around their waste (for easy access). A request for a transferring to/from bed/wheelchair policy was requested but not received by the end of the survey.

Based on observation, interview and record review, the facility failed to monitor for a weight loss, and intervene timely for one resident (Resident #79), of seven reviewed for nutrition, resulting in continued weight loss and the likelihood of an overall health decline from not receiving adequate nutrition to support normal, healthy bodily functions. Findings include: On 10/27/20 at 9:44 PM, Resident #79 was observed in bed awake. The resident was tall and very thin in appearance. Resident #79's oral cavity was very dry and had peeling lips. Resident #79 was alert and oriented to person and had very low speech tone. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #79 had a Brief Interview for Mental Status (BIMS) score of 13, indicating an intact cognition. Resident #79 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #79 needed extensive assistance with eating, transfers and bed mobility. Resident #79 was 70 inches (five foot ten inches) in height. A record review of the weights for Resident #79 revealed the following: 9/26/20 162.4# (pounds) 10/2/20 160.2# 10/26/20 139.4# There were no other weights recorded in the medical record. On 10/28/20 at 8:24 AM, Resident #79 was observed in their room lying flat in their low bed. Their mouth (lips and tongue) were dry. A breakfast tray was observed on the bedside table which was over one foot above the height of the resident. The bedside table was pushed out, away from the resident and was out of reach. Nothing was touched on the food tray. The tray was not set up. The drinks still had their lids on them. The tray was still covered. Resident #79 was queried if they ate breakfast today and stated, I don't eat much. Resident #79 then stated, I am sorry about my health situation. I don't know what to do about it. Resident #79 was unable to further elaborate. Upon exiting the room, Certified Nurse Assistant (CNA) C was observed walking down the hallway. CNA C was stopped and asked when the residents get fed on the hallway. CNA C stated, Mostly everyone down here can feed themselves. CNA C was asked how Resident #79 was to feed themselves without being set up properly. CNA C explained that she was not Resident #79's assigned CNA but then went into their room. She then asked Resident #79 if they were hungry and the resident confirmed that they were hungry. On 10/28/20 at 12:22 PM, Resident #79 was observed in their room sitting slumped down in a geri chair. The resident had a hug pile of crushed chips on the floor along the right side of the geri chair. Resident #79 was holding a half of sandwich in their right hand, which was hanging down the side of the chair. Resident #79's drinks were untouched and there was no other food that appeared to have been oaten. On 10/29/20 at 8:26 AM, Resident #79 was observed lying flat on their back in bed. There was a breakfast tray covered, and not set up on the bed side table. The breakfast tray was not in reach. There was uncovered coffee on the tray and the cold drinks were still covered. None of the food had been oaten. Resident #79 was asked if they were hungry and stated, I am a little hungry On 10/29/20 at 8:45 AM, CNA E was observed to then enter in Resident #79's room and assisted Resident #79 to eat. CNA E had closed the door and then came out at 8:49 AM. CNA E was asked if Resident #79 had ate breakfast and explained that Resident #79 had only ate three or four bites and that Resident #79 does not like to sit up (upright) and hollers out a lot. A record review of the nutritional evaluation assessment dated [DATE] revealed the following: Usual weight 170# .IBW (ideal body weight) 166# .Consistent Carbohydrate diet, Regular texture, Thin consistency. Variable PO (by mouth) intake per FAR (food acceptance record) & nursing. Eats independently with set up help, assistance needed sometimes .Disoriented confused .GOALS: maintain weight stability, skin integrity. A record review of the FAR for October 2020 for Resident #79 revealed the following dates/meals with no data entry: 10/1/20-No breakfast or lunch intake documented. 10/3/20-No breakfast or lunch intake documented. 10/4/20-No breakfast or dinner intake documented. 10/5/20-No breakfast intake documented. 10/6/20-No breakfast or lunch intake documented. 10/7/20-No breakfast or lunch intake documented. 10/8/20-No breakfast or lunch intake documented. 10/11/20-No breakfast or lunch intake documented. 10/12/20-No breakfast or lunch intake documented. 10/13/20-No breakfast intake documented. 10/16/20-No dinner intake documented. 10/17/20-No breakfast or lunch intake documented. 10/19/20-No lunch intake documented. 10/21/20-No meal intake recorded for the day. 10/22/20-No breakfast or lunch intake documented. 10/23/20-No meal intake recorded for the day. 10/24/20-No breakfast or lunch intake documented. 10/25/20-No meal intake recorded for the day. 10/26/20-No meal intake recorded for the day. A record review of the amount of assistance documented by the CNA's to feed Resident #79 ranged from independent to total dependence. A record review of the care plan (created 10/2/20 by Registered Dietician/RD D) for Resident #79 revealed the following: Focus-(Resident #79) has alteration in nutritional status r/t (related to) .missing cracked teeth .gunshot injury .Resident was confused & disoriented. Goal- .will be free from s/sx (signs and symptoms) of malnutrition and dehydration . Interventions- Obtain weekly x 4 weeks, then monthly, if stable. Observe and report to physician significant weight changes: 3% in 1 week, >5 % in 1 month, >7.5% in 3 months, >10% in 6 months. RD to evaluate and make recommendations PRN (as needed). Offer an alternate when 50% or less of meal is consumed. Provide and serve supplements as ordered. Assist resident with meals as needed . There were no interventions added after 10/2/20. On 10/29/20 at 11:01 AM, an interview was completed with RD D. RD D was asked about how weights are monitored with new admissions. RD D explained that when a new admission comes into the facility she evaluates them and gets their food preferences and diet order. RD D further explained that she orders weights to be taken weekly for the first month and then monthly. RD D stated that she assesses new residents after seven days of being admitted , every three months and then yearly. RD D was queried on the weight loss for Resident #79. RD D stated, Speech Therapy is working with (Resident #79) because there were some swallowing issues. RD D was asked what was initiated for the weight loss of Resident #79. RD D stated, I am gonna start them on a high calorie nutrition supplement. RD D was asked how was she notified of weight changes with residents and stated that usually unit managers or nurses will approach her to let her know of any changes with a resident. RD D was asked why weekly weights were not obtained for Resident #79 and stated, They must have been missed. RD D explained that no staff member had come to her to discuss Resident #79. RD D stated, I really don't know (why Resident #79 lost weight). They must not be eating well. I am going to have speech therapy look at them again and I will order a supplement today. On 10/29/20 at 1:38 PM, an interview was completed with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). They were both asked about how the facility handles the monitoring of weight loss. The DON explained that the RD's monitor the weights. The DON further explained that they used to have two RD's but had lost one. The DON further explained that they do a weekly at risk meeting and discuss residents that lose weight. The DON stated, Since the pandemic started, we have seen a lot of weight loss. The NHA explained that they used to have families that brought in home cooked food or food ordered out. Prior to the pandemic, family members often would help feed their loved ones (with feeding) and now they are not permitted to. The DON was asked what they do for residents that lose weight. The DON stated, We put them on supplements. We check weights upon admission then weekly for three weeks. If we see a trending of weights down or up we speak on it in the meeting. The goal is to increase the calories/weight for the resident. Currently we have two restorative aides that do weights, we try not to pull them (to the floor to help). We try hard. The dietician usually gives me a heads up (on weight changes), they usually give me a list. The DON was asked what had happened with the weight loss for Resident #79, the DON stated, I would have to look at (Resident #79). A review of the facility policy titled, Weight Management revised 10/2019 revealed the following: Practice Guidelines: All guests/residents will be weighed upon admission/readmission; weekly x 4, then monthly or as indicated by the physician and/or the medical status of the guest/resident and document the results in the medical record .5. Guests/residents determined to be at risk or have significant weight changes will be weighed on a weekly basis. Guests/residents at risk are .e. All new admits/readmits for 4 weeks .6. An initial care plan is developed upon admission and a comprehensive care plan should include .Identified causes of impaired nutritional status .identifies guest/resident-specific interventions and a time frame .7. Dietary Manager, Unit Manager and/or RD are to communicate weight changes to the IDT (interdisciplinary team), attending physician and guest's/resident's responsible party. This is documented in the medical record.

This citation pertains to intake MI 926. Based on interview and record review, the facility failed to institute and operationalize policy and procedure related to skin management, and thoroughly and accurately assess skin integrity for one resident (R#801) of three reviewed for pressure ulcers, resulting in a significant decline in skin integrity (Stage 4 pressure ulcer), hospitalization , pain, and the potential for surgery, and bone and/or systemic infection. Findings include: On 9/3/19 at 4:55 PM, an interview was conducted with Confidential Witness A regarding their family member's stay in the facility. Witness A stated, (R#801) was admitted into the facility about 8 or 9 months ago. They were taken to the hospital just recently because they have a Stage 4 bed sore (full thickness tissue loss with exposed bone, tendon, or muscle) and may be septic (infection that spreads to the blood and whole body). They used to make (R#801) sit in their wheelchair for hours and hours because if they were in bed they'd try to get up. I complained many times. If (R#801) needed to be changed, we would have to wait a while. My family and I visited very frequently. When queried further about the day she found out about the wound, Witness A stated, I was there and asked for (R#801) to be changed because they smelled absolutely horrible, and I knew something wasn't right. This was the first time I was ever present in the room while (R#801) was being changed. There was dried feces on them and urine all over. I noticed a patch on (R#801's) back and asked about it because I had never seen it there before. The CNA (Certified Nursing Assistant) opened the patch and the look and smell was absolutely unbearable. I had to step outside for a moment. The wound smelled as if it were infected. There was pus and green drainage. (R#801) was crying and saying it was burning, and they never used to cry about anything at all. The aide there told me that can happen if someone is not turned or moved around enough. I could not believe it. I went to tell the head nurse, they said they would call to send (R#801) to the hospital. After 30 minutes, they told us it wasn't a '911 emergency,' and that we had to call if we wanted (R#801) to go. They told me they could take care of it here and that it wasn't an emergency. When the ambulance came in to get (R#801), they asked for a report and documentation of (R#801) having a Stage 4 pressure ulcer, the nurse told them she didn't have anything because nothing was ever documented. The hospital called me a couple of hours ago to get my consent to do a procedure on the wound to clean it up. I just can't believe this. We were not hearing anything bad like this and now all of a sudden the people at the hospital are telling us anything can happen. So now we may have to get ready for a funeral if (R#801) cannot come back from this? A review of R#801's Minimum Data Set (MDS) assessment dated [DATE] revealed the following: R#801 was admitted into the facility on [DATE] and re-admitted on [DATE] with medical [DIAGNOSES REDACTED]. Further review revealed the resident's Brief Interview for Mental Status (BIMS) score was 00/15 indicating a severely impaired cognition, and the resident required physical assistance from two or more persons for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), transfers, and toileting. A review of R#801's record revealed that the resident's most recent Braden Score for Predicting Pressure Sore Risk assessment, dated 7/29/19, indicated a score of 14 - moderate risk. A review of R#801's progress notes revealed the following: 8/1/19 (Written by Nurse D): Total Body Skin Assessment: Number of new skin conditions: 0, Buttocks redden/blanchable [MEDICATION NAME] applied. 8/8/19 (Written by Nurse E): Total Body Skin Assessment: Number of new skin conditions: 0. 8/15/19 (written by Nurse D): Total Body Skin Assessment: Number of new skin conditions: 0, comments: buttocks redden blanchable, [MEDICATION NAME] applied. 8/22/19 (written by Nurse E): Total Body Skin Assessment: Number of new skin conditions: 0. A note from 8/22/19 written by Nurse Practitioner (NP) F included no mention of pressure ulcers or wounds on R#801. 8/29/19 17:36 (5:36 PM) (Written by Nurse G): Resident transferred to (hospital) as per family request very upset that (R#801) has a wound on .buttock the writer cleaned area and applied santyl and clean dry dressing as soon as it was notice and explained to family the process Don (Director of Nursing) was notified family wanted (resident) to go to hospital and they called 911 resident transferred to hospital. 8/29/19 18:51 (6:51 PM) (Written by Nurse G): Transfer from: transferred to hospital doctor notified and DON Family request. A review of R#801's acute care hospital documentation dated 8/29/19 to present provided by the facility revealed the following: Wound care consult related to sacral wound: .patient to ER with current sacral injury. Patient known from previous admission. Sacral area appears to have deteriorated from previous documented admission. Patient with unstageable pressure injury to the sacrum. Wound measures 4x3x1cm, 100% attached, moist, gray/black, malodorous, full thickness wound. The margins are slightly irregular with peri wound moisture, [DIAGNOSES REDACTED], warmth, fluctuance and induration. Area is inflamed and tender to the touch. Small/moderate, [MEDICATION NAME] tan, gray exudate on previous dressing .Reviewed plan with ER nurse to facilitate Surgery consult .Signed 8/30/19. Encounter info Inpatient, 8/29/2019 - Attending Physician Addendum: .nursing home resident complaining of back pain patient was noted to have a stage IV (4) sacral decub (decubitus) ulcer (pressure ulcer). Patient has a baseline of dementia .Skin shows stage IV sacral decub ulcer with surrounding [DIAGNOSES REDACTED] (red, swollen) .Sacral decubitus ulcer with the concern for underlying osteo[DIAGNOSES REDACTED] (infection in the bone) [MEDICAL CONDITION]-continue IV antibiotics ID (infectious disease) following .History of Present Illness: .presented to the emergency room with complaints of wound to .sacral area. The patient was complaining of back pain and sacral area pain which is getting worse few days .On examination there was a large sacral ulcer with increased redness in the area and folds .did have some intermittent fevers and chills .started on IV antibiotics for acute sacral .ulcer with surrounding [MEDICAL CONDITION] with the concern for underlying osteo[DIAGNOSES REDACTED] .Complains of low back pain and pain to the wound area .Signed 8/30/19. ID note from acute care hospital: Documentation Date: (MONTH) 03, 2019 10:14 .Examination of the wound was positive for necrotic sacral area persistent .currently on [MEDICATION NAME] and [MEDICATION NAME] (antibiotics), would recommend PICC (peripherally inserted central catheter) line placement, Needs surgical evaluation for debridement (cleaning of wound) .Sacral ulcer culture 8/29 with gram negative bacilli .(bacteria present in wound). On 9/4/19 at 10:26 AM, Nurse G was contacted and interviewed regarding their documentation and R#801's transfer to the hospital from the facility on 8/29/19. Nurse G stated, (R#801's family) was there and said the resident needed to be changed because they had a bowel movement and were wet. So I sent the CNA in to clean them up. The family was still in the room and asked why there was a bandage on (R#801's) butt. The CNA took the bandage off and (R#801) had an ulcer there. The family asked me what that was about. I told them, 'I don't know, this is new to me, I don't know anything about it.' There was an open area on (R#801's) bottom, smaller than a fist, probably like the size of a golf ball. And I said, 'Wow.' So what I did was tell them I was going to take care of it. I wrote an order for [REDACTED]. The family said they wanted (R#801) to go to the hospital. I told them that we could take care of it in-house, it wasn't emergent. They insisted on sending the resident to the hospital and they were very upset. Nurse G was asked if they had taken care of R#801 previously and stated, Yes. Nurse G was then asked if they had performed any skin assessments on R#801 and stated, No, they're done on the days they're assigned or on the day of the shower/bath. Nurse G was asked about the wound and stated, Probably Stage 3 or Stage 4, I would say. It was smelly. It looked like it had some yellow coloring to it and some black eschar. It wasn't looking good at all. It was draining. I had no idea it was there. I received nothing in report about it. I'm not sure wound care or anyone else was aware of this wound. When queried how a Stage 3 or Stage 4 wound could go unnoticed, Nurse G stated, Maybe a CNA was changing a resident and didn't say anything or they did report it to the nurse and the nurse didn't do anything but I can't speak to exactly what happened there. Some days, (R#801) would be up and be in the chair, and some days they would lay in bed for a couple of days. They didn't always get up. When asked if R#801 was known as being at risk for pressure ulcers, Nurse G stated, Not that I knew of, but any resident constantly laying down or on their bottom is at risk for getting a pressure ulcer. On 9/4/19 at 10:44 AM, Nurse Practitioner (NP) F was contacted and interviewed regarding R#801's wound and transfer to the hospital on [DATE]. NP F stated, I had assessed (the resident) on 8/22/19, but did not look at their bottom. I do that, maybe, every other month or so. On 8/29/19, they found a wound and called to let me know that it didn't look good, it was smelly, I remember they said it had an odor, and family wanted to send (R#801) out and that was the first I had heard of it. (R#801) had some issues with some weight loss this summer and was hospitalized . (R#801) was receiving assistance with eating and drinking after that and was doing better after the hospitalization and was more stable. On 9/4/19 at 10:58 AM, CNA B was interviewed regarding R#801. CNA B stated, I remember (R#801), I have been working with them for a while. They pretty much stayed in their wheelchair. They usually would get up in the morning in the wheelchair, go to the dining room, go to therapy, go to activities. They are incontinent. I would get (R#801) out of bed about 10 AM, check at about 12 PM, lay them back down in bed about 2:30 PM. When asked if R#801 was on a turn and repositioning schedule, CNA B stated, Not that I know of. When asked if they had worked with R#801 recently, CNA B stated, I'm not sure, a couple of weeks ago I let (Nurse D) know the resident had a red area on the bottom and I applied [MEDICATION NAME] (barrier cream). When asked if Nurse D came to look at the area, CNA B stated, I'm not sure. I did let her know that the resident was having some redness though. It was a regular red area. On 9/4/19 at 11:15 AM, Nurse [NAME] was interviewed regarding their skin assessments on R#801. Nurse [NAME] indicated they performed R#801's skin assessment on 8/22/19 and didn't see anything. Nurse [NAME] stated, I thought the skin was in good condition when I saw (R#801). They found the pressure ulcer when I was on vacation. When asked about R#801's pressure ulcer risk, Nurse [NAME] stated, I feel like (R#801) was prone to skin breakdown, they were immobile, incontinent, a smaller (person). Maybe some weight loss I'm not for certain. The CNAs are usually pretty good about reporting any skin issues. I was surprised and didn't know what happened when I heard about the wound. The resident wasn't followed by wound care because they hadn't had any problems. Nothing more than the standard for skin prevention. When asked if the resident was bed bound or got up, Nurse [NAME] stated, (R#801) was up in the wheelchair in the dining room for meals and activities, and needed feeding assistance in the dining room. (R#801) was incontinent and wore a brief. On 9/4/19 at 11:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) approached and the NHA stated, Regarding (R#801), this was a very serious concern, we did a whole head-to-toe skin sweep of other residents three days after this happened. When asked what happened on 8/29/19, the NHA stated, There was a bandage with some type of treatment in place. A nurse (Nurse C) identified that there was some type of area but did not follow up from it. There was a treatment on the wound but no follow-up after. The wound care nurse wasn't around before the resident got sent to the hospital to stage the wound. The family said they wanted to send (R#801) out. We wanted to start the wound consult and put the interventions in place before they got sent out but family wanted (R#801) out right away. On 9/4/19 at 11:49 AM, Nurse C was interviewed and queried regarding their care of R#801 and any skin issues that were noted on the resident. Nurse C stated, (R#801) had the potential for skin integrity breakdown. In the coccyx area, they may have had one before that was healed, and had fragile skin. Two or three weeks ago, I can't say for sure, there was a reddened area on their coccyx. When asked what they did when they saw the area, Nurse C stated, I gave attention to the bottom, I got wedges for turning and put on cream and a dressing. When asked if they documented the skin issue and treatment interventions, added orders, and/or updated the care plan, Nurse C stated, I thought I did but I was told I did not put a note in about the redness. It is protocol to put in an order for [REDACTED]. (R#801) had declined at one point, and was bed bound and wheelchair bound and needed a lot of assistance. Their appetite had come back, though, and we would feed them and provide ADL (activities of daily living) care. (CNA H) had brought the wound to my attention. A week later or so someone told me the family wanted (R#801) sent out to the hospital and that happened on my day off. When asked to further describe (R#801's) coccyx area that was assessed prior to applying the dressing, Nurse C stated, It was dark, right in the coccyx area, it wasn't open but I could see the bony prominence. It didn't look raw or opened but it was red. Non-blanchable redness on the bony prominence. We normally consult to wound care if we see something like that. Nurse C indicated they did not document this observation, and did not consult wound care after observing the non-blanchable redness and applying a dressing. On 9/4/19 at 11:59 AM, an attempt was made to interview CNA H regarding R#801. A voicemail was left for call back, however a call back was not received prior to survey exit. On 9/4/19 at 1:15 PM, Nurse D was interviewed regarding their care of R#801 and the skin assessments performed. Nurse D stated, On 8/15/19, the CNA informed me of redness on (R#801's) buttocks. I went and checked it out. There was protective cream there because it was not open at the time and I think it was blanchable. I did not see the resident's skin any time after that. When queried regarding R#801's mobility, Nurse D stated that R#801 was up often in the wheelchair. When asked if R#801 was a pressure ulcer risk, Nurse D stated, I mean, I guess all residents really are. I guess (R#801) would be. They may have been concerned about the resident's weight sometime prior, and the resident was hospitalized , but then the resident came back and was helped with feeding and was eating better. When queried regarding R#801's wound, Nurse D stated, I was really surprised there was anything there, I didn't hear from anyone else about any decline in the skin. Nothing was reported to me about (R#801) having a dressing present. On 9/4/19 at 2:10 PM, the Assistant Director of Nursing (ADON) was interviewed and queried regarding the day of 8/29/19 when R#801 was sent to the hospital. The ADON stated, I was here the day (R#801) was sent out. I was not called into the situation. But if a nurse does a new intervention and sees a new skin issue, it is expected to be put into a change in condition progress note. We usually like to see documentation also of notifying the DON, wound care, the family and the physician if something new is noted. And if a dressing is applied, we expect it to be entered as an order, even if it's something generic such as, 'dry dressing,' so other staff are aware. But per our policy, there should be some sort of documentation, and absolutely updated in the care plan. Also, it should be passed on in report to other shifts, or at least put in that progress note so other shifts can see it. The ADON was asked about the skin assessment performed on 8/22/19 that showed the resident with no skin issues, that was followed by the resident getting sent out to the hospital with a wound. The ADON stated, Clinically, I'm thinking something is wrong with that or something is off. I'm not sure if something got overlooked or if someone got confused about what they saw. I'm not sure if there were multiple skin assessments being done that day and something got confused. It was very surprising to hear about the wound. I did a sweep of multiple residents after that happened. On 9/4/19 at 3:03 PM, the DON was interviewed regarding R#801, the resident's wound, and subsequent hospitalization . The DON was asked what the expectation is of staff when a change in skin condition is noted. The DON stated, When the nurse sees an opening, I am to be notified as well as wound care who would put them on wound rounds. If there is redness and something seems off, do a progress note. Then we would see that in the morning meeting and be able to follow up on that. There should be documentation, and if there is a start of a treatment on the resident. Non-blanchable redness, based on a nurse's assessment, should be treated as an integrity issue. We want nurses to use their best judgement but we also want to be aware of things so we can follow up. The CNA (CNA H) stated to me that she told the nurse it was non-blanchable redness, and (Nurse C) did not quite describe that as such to me. The DON was asked about care planning for skin integrity and stated, There are risk for skin issue care plans and actual skin issue care plans. When a new issue is found, a new actual focus area and interventions should be entered based on that newly assessed area. When queried regarding the 8/22/19 skin assessment of R#801 with no skin issues, the DON stated, I've looked in the progress notes and I feel it's unfortunate that it happened if something got overlooked. But I feel it happened very quickly based on (R#801's) condition and diagnoses. We may have been able to intervene more quickly if a note had been put in sooner to alert us to a new area. A review of R#801's care plan revealed the following: Focus: (R#801) is at risk for impaired skin integrity/pressure injury R/T (related to): Recent hospitalization , [MEDICAL CONDITION], CAD ([MEDICAL CONDITION]), DM (diabetes mellitus), HLD ([MEDICAL CONDITION]),[MEDICAL CONDITION](high blood pressure), Metabolic [MEDICAL CONDITION], PCM, immobility, weakness, and unsteady gait. Initiated 1/28/2019, Revision on 1/28/2019 .Interventions: Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician 3/18/2019; Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care 3/18/2019; Turn/reposition resident per facility protocol 3/18/2019 . A review of the facility's policy titled, Skin Management, revised 7/2016, revealed the following: It is the policy of the facility that a resident does not develop pressure injury unless clinically unavoidable .Residents with wounds and/or pressure injury and those at risk for skin compromise are identified, assessed and provided appropriate treatment to promote healing. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes .Appropriate preventative measures will be implemented on residents identified at risk (a score of 18 or less on the Braden Scale) and the interventions are documented on the care plan .The licensed nurse will initiate documentation the electronic health record, which includes a description of the pressure and non-pressure injury as follows: In electronic health record facilities, the licensed nurse will document on the wound/skin healing record, document weekly until the area is healed .The licensed nurse will document preventative measures on the care plan/kardex .The licensed nurse will monitor, evaluate and document changes regarding skin condition (to include: dressing surrounding skin, possible complications and pain) in the medical record .If a new area of skin impairment is identified, notify the resident, responsible party, attending physician, DON and treatment team, if applicable .

This Citation Pertains to Intake Number MI 013. Based on observation, interview and record review, the facility failed to ensure comprehensive documentation, evaluation, and care per professional standards of practice to prevent the development of an avoidable stage III pressure ulcer (wound caused by pressure involving full-thickness loss of skin) and failed to ensure the application of infection control principles during wound care for one (#703) of two Residents reviewed for alterations in skin integrity, of a total sample of three, resulting in the development of a stage III pressure ulcer, lack of wound assessment, inappropriate wound care technique, and the potential for delaying wound healing, infection, and overall deterioration in health status. Findings include: Record review on 1/3/18 at 10:00 AM revealed Resident # 703 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was moderately cognitively impaired, required extensive assistance to perform activities of daily living, had a stage II pressure ulcer, and was frequently incontinent of urine. Additional review of Resident #703's medical record revealed the Resident was being treated for [REDACTED]. On 1/3/18 at 11:15 AM, Resident #703 was observed in their room. The Resident was lying in their bed, positioned on their back. On 1/3/18 at 11:20 AM, an interview was conducted with Nurse A. When queried, Nurse A stated, (Resident #703) has a pressure ulcer on their coccyx. With further inquiry regarding Resident #703's pressure ulcer, Nurse A stated, I'm not sure if they were admitted with it (pressure ulcer) or not but I think they did have something when they got here. When asked about wound care treatment and interventions for Resident #703, Nurse A replied, The wound care nurse does it during the week. No further explanation was provided. An interview was completed with Wound Care Nurse B on 1/3/18 at 11:25 AM. When queried regarding Resident #703's pressure ulcer, Nurse B replied, The treatment is Santyl ([MEDICATION NAME] wound care treatment). With additional inquiry regarding the onset of the pressure ulcer, Nurse B stated, (Resident #703) came with a spine incision (from surgical procedure) but that is healed now and a pressure ulcer. On 1/3/18 at 11:30 AM, Resident #703 was observed in their room. The Resident was lying in their bed, positioned on their back. On 1/3/18 at 11:35 AM, observation occurred of Resident #703's wound care treatment with Nurse B and Nursing Assistant C. A gauze dressing was observed on the Resident's coccyx area. Nurse B proceeded to remove the dressing. A large amount of dark colored, copious drainage was observed on the removed dressing. The pressure ulcer was observed to be irregularly shaped and approximately the size of a quarter. The wound bed was red and white in color with visible slough (non-viable tissue). The wound depth increased towards the middle of the wound and a small pinpoint sized area, bright red in color was noted. After removing the prior dressing, Nurse B removed their gloves, applied hand sanitizer, reapplied gloves prior to cleansing the wound with wound cleanser, applied Santyl and covered the wound with a new dressing. After completion of the dressing change, Resident #703 was positioned on their bed on their back. When queried regarding the Resident's positioning, Nurse B stated, (Resident #703) needs to get out of bed but they (staff) keep putting (the Resident) back in bed. No further explanation was provided. An interview was completed with Nursing Assistant C on 1/3/18 at 11:45 AM. When queried regarding Resident #703's positioning in bed and getting out of bed, Nursing Assistant C stated, I don't work here (area of facility) all the time. On 1/3/18 at 12:30 PM, a record review of Resident #703's skin and wound assessment documentation within the Nursing Admission Assessment, dated 11/27/17 at 6:45 PM, was completed. Record review revealed the Resident had the following alterations in skin integrity at the time of admission to the facility: -1 inch skin tear on left buttocks -Middle of back has bilateral 2 inch length surgical areas Review of the Resident's care plans at this time revealed a care plan entitled, (Resident #703) is at risk for skin breakdown/pressure ulcers or further breakdown r/t (related to) decreased mobility. Resident has a pressure injury stage II left buttocks (Resolved 12/7/17). Resident has a pressure injury stage III coccyx/bilateral buttocks (Date initiated: 11/28/17). The care plan included the following interventions: -Assess for the risk for skin breakdown on admission and quarterly per facility protocol. (Initiated 11/28/17) -Observe skin with showers/care. Notify nurse of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care. (Initiated 11/28/17) -Serve diet as ordered and observe nutritional status. Record intake as needed. (Initiated 11/28/17) -Follow facility policies/ procedures for the prevention/treatment of [REDACTED]. -Provide incontinence care as needed and apply moisture barrier cream/ointment per facility policy/orders. (Initiated 11/28/17) -Dietary consult and/or physician review as needed to make recommendations, for supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. On 1/3/18 at 12:50 PM, a record review of Resident #703's skin and wound assessment documentation was completed with Nurse B. Record review revealed the following: -11/28/17 at 12:02 PM: Skin/Wound Progress Note: Per writer Resident skin was assess and noted with right lower posterior leg bruising, right/left hand and arm bruising, abdomen bruising, abdomen old surgical scars, left parasacral/coccyx cicatrix noted fragile with skin discoloration, upper back right/left side of (spine) resolving surgical incisions (two) 5 cm (centimeters) approximately/ Left incision noted with scant serous drainage. Bilateral buttocks reddened/ blanchable, heels dry and intact. -11/29/17 at 8:56 AM: Skin/Wound Progress Note: Per writer addendum to previous noted upon reassessing Resident Coccyx/ Left Parasacral areas noted with Pressure Injuries stage II pink bases, scant serous drainage . -12/7/17: Physician Wound Progress Note: . (Pressure ulcer) healed . -12/21/17: Physician Wound Progress Note: . [DIAGNOSES REDACTED]. -12/28/17: Physician Wound Progress Note: .Coccyx/ Bilateral Buttocks . Measurements are 1.5 cm length X 1.6 cm width . Diagnosis: [REDACTED]. When queried regarding physician documentation which indicated Resident #703's stage II pressure ulcer was resolved on 12/7/17 and subsequent physician documentation of a stage III pressure ulcer, Nurse B replied, That's because it was a different doctor. Upon the request of additional wound measurements and documentation, Nurse B indicated the only wound measurements were the measurements included in the physician documentation. When queried if the Resident's stage III pressure ulcer was facility acquired, Nurse B replied, Yes. When queried regarding documentation of the Resident's wound/skin during the week of 12/14/17, Nurse B stated, The wound care (doctor) didn't come that week. With further inquiry, Nurse B stated, I think we were having our state annual survey so they didn't come. Nurse B further stated, I think the weather was bad that week too. When asked if there was other documentation of Resident # 703's wound in the medical record, Nurse B reviewed the medical record and stated, No. With further inquiry regarding the Resident's pressure ulcer, Nurse B stated, It did get a little worse. When asked for current wound measurements, Nurse B replied, That is all we have. The wound care (doctor) won't be here until tomorrow. They are the ones that measure (wounds). Resident #703's skin breakdown/pressure ulcer care plan was reviewed with Nurse B at this time. When queried regarding updated interventions to prevent pressure ulcer development and worsening due to the Resident's pressure ulcer status and risk, Nurse B reviewed the care plan and stated, No, it hasn't been updated but we did put a different mattress on their bed. With further inquiry, Nurse B indicated an order for [REDACTED]. With further inquiry regarding why a specialty mattress was not ordered until 12/14/17, Nurse B stated, All our mattresses are pressure relieving. When queried regarding the specific type of mattress on the Resident's bed prior to the Roho mattress, Nurse B stated, They are all pressure relieving. I'm not sure of the name. Information regarding the mattresses and date of placement for the Roho mattress was requested at this time. Nurse B further stated, I will update the care plan. An interview was completed with the facility Administrator on 1/3/18 at 1:30 PM. When queried regarding Resident #703's pressure ulcer and interventions, the Administrator did not provide an explanation. An interview was completed with the Director of Nursing (DON) on 1/3/18 at 4:45 PM. When queried regarding Resident #703's facility acquired pressure ulcer and the care plan not being updated, the DON stated, I thought (Resident #703) was admitted with a pressure ulcer. The DON further stated, I know we need to improve our care plans. No further explanation was provided. When queried regarding the use of hand sanitizer during wound care, the DON stated, No, they (staff) should wash their hands. Record review of facility policy entitled, Skin Management (Revised 7/2016 and 8/2016) on 1/3/17 at 6:30 PM revealed, It is the policy of the facility that a Resident does not develop pressure injury unless clinically unavoidable . Appropriate preventative measures will be implemented on Residents identified at risk and the interventions are documented on the care plan. Residents admitted with skin impairments will have: appropriate interventions implemented to promote healing, a physician's orders [REDACTED].The licensed nurse will document on the Wound/Skin Healing Record . Document weekly until healed . The licensed nurse will monitor, evaluate and document changes regarding skin condition in the medical record. Documentation pertaining to Resident #703's mattress was not received by the conclusion of the survey.

This citation pertains to intake number MI 824 Based on observation, interview and record review, the facility failed to ensure one (#502) of two residents reviewed for falls, from a total of six sampled residents, was not left alone, unsupervised in the bathroom resulting in a fall and left hip fracture that required surgical intervention. Findings include: On 12/30/14 at 9:25 a.m., Resident #502 was observed in her room in bed. When greeted, Resident #502 reported, "I'm not doing too good." When asked about a recent fall, Resident #502 replied, "I know I fell but I don't remember much about the fall." On 12/30/14 at 9:40 a.m. RN "A" who was the first floor unit manager was interviewed about Resident #502's fall and stated, "(Name Resident #502)was in the bathroom and the Aide left her in the bathroom and went off to do something else. We had Xrays done and it showed that her hip was broke. She had to have surgery and the CNA was terminated related to this incident." CNA "H" was unable to be reached for an interview. Included with the facility's investigation was the following documentation, dated 12/04/14: "Employee stated that she placed the resident in the bathroom and left her unattended. Resident care guide shows not to leave the resident unattended. Employee admitted she did not follow the care guide and was not supposed to leave the resident by herself in the bathroom." On 12/30/14 at 10:00 a.m. Resident #502's clinical record and the facility's investigation documents were reviewed. According to the "Incident and Accident Investigation Form" dated 12/4/14, on 12/03/14 at 6:00 p.m., Certified Nursing Assistant (CNA "H") "put Resident #502 on the toilet and gave the resident instructions to use the call light when ready. Resident attempted to self-transfer to wheelchair from toilet without assistance or use of call light. Resident's daughter observed resident on bathroom floor upon arrival to room". Resident #502 was assessed for pain/injury and the physician and family were notified. The physician ordered a hip X-ray. A Radiology Report" dated 12/3/14 was as follows: "...Hip Uni-Lat complete--two views: There is a left subcapital fracture with minimal displacement." The resident was hospitalized and readmitted to the facility on [DATE]. According to the facility's "Admission Record", Resident #502 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed that Resident #502 had moderately impaired cognitive skills for decision making and required extensive physical assistance of staff with bed mobility, transfers, dressing hygiene, bathing and toileting. Two nursing care plans, titled, "At risk for decline in function" dated 5/27/14 and "At risk for Falls" care plan dated 6/16/14 revealed the resident had poor safety awareness and staff were instructed: "Do not leave Resident unattended in the bathroom". On 12/30/14 at 11:56 a.m., during an interview, the Director of Nursing (DON) was queried about Resident #502's fall and reported, Resident #502 "asked to go to the bathroom so CNA "H" helped her. CNA "H" then left the room and that's when the fall happened. The Resident was not to be left alone." The DON provided an untitled document, with Resident #502's name on it that was dated 10/14/14. The document was referred to as the "Care Guide" (a form that provides instructions to CNA's on the needs/care of residents). According to this form, Under the section titled, "Safety", CNA's were instructed: "Do not leave resident unattended in the bathroom". On 12/30/14 at 12:39 p.m., the facility's Administrator was interviewed and reported, "The CNA (CNA "H") acknowledged she know the resident was not to be left alone. She didn't follow the care guide. This could have been avoided if the CNA had not left the resident in the bathroom." The facility's "Fall Management" policy dated 7/2014 documented: "Residents identified at risk for falls will have a care plan developed and implement the appropriate fall prevention interventions..."